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17,900 | Mitral annuloplasty for atrial functional mitral regurgitation in patients with chronic atrial fibrillation. | Surgical ring annuloplasty is generally performed in patients with symptomatic atrial functional mitral regurgitation (MR) caused by long-standing atrial fibrillation (AF). However, its clinical results have not been well reported.</AbstractText>Twenty consecutive patients with atrial functional MR (mean age of 68 ± 9 years) and a left ventricular (LV) ejection fraction (EF) greater than 50% underwent mitral annuloplasty. Concomitant procedures included tricuspid valve surgery in 16 patients, AF ablation in 13 patients, and coronary artery bypass grafting in 2 patients. We reviewed the clinical outcomes of those patients and investigated the specific preoperative echocardiographic findings related to MR recurrence.</AbstractText>At discharge, the mean left atrial (LA) volume index and mean tricuspid regurgitation peak gradient had significantly decreased from 94 ± 59 mL/m 2</sup> to 58 ± 30 mL/m 2</sup> and from 34 ± 11mm Hg to 23 ± 5mm Hg, respectively. During the follow-up period of 28 ± 17 months, the New York Heart Association functional class significantly improved from 2.3 ± 0.6 to 1.3 ± 0.6. Four patients developed recurrent MR, and of those, two required reoperation. Those with recurrent MR had a significantly larger preoperative LV dimension than those without recurrent MR. Preoperative three-dimensional transesophageal echocardiography was performed in 12 patients, revealing a greater degree of leaflet tethering in patients with recurrent MR than that in patients without recurrent MR.</AbstractText>In patients with the combination of atrial functional MR, left ventricular dilatation and excessive leaflet tethering, mitral annuloplasty alone may not be sufficient to achieve long-term correction of MR.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,901 | Novel <i>SCN5A</i> Frameshift Mutation in Brugada Syndrome Associated With Complex Arrhythmic Phenotype. | In this case report, we characterize a novel inherited frameshift mutation c.4700_4701del (p.Phe1567Cysfs<sup>*</sup>221) in a single copy of the <i>SCN5A</i> gene and its association with Brugada syndrome (BrS). The proband experienced a life-threatening ventricular arrhythmia successfully treated with DC-shock and he also suffered from supraventricular tachycardia. Ajmaline test confirmed the BrS diagnosis. No other mutation nor low frequency variants in the other 23 analyzed genes were detected. The same mutation was found in the father and sister, who were both diagnosed with BrS. We hypothesize that this mutation could be responsible for BrS and potentially linked to supraventricular tachycardias. Further studies are needed to confirm this observation and to assess the clinical relevance of this mutation, in terms of risk-stratification. |
17,902 | Long-term left atrial remodeling after ablation of persistent atrial fibrillation: 7-year follow-up by cardiovascular magnetic resonance imaging. | Restoration of sinus rhythm in patients with persistent atrial fibrillation (ps. AF) induces reverse atrial remodeling and improvement of left ventricular function. We evaluated the effect of ablative treatment on cardiac remodeling after a long follow-up period of 7 years by cardiovascular magnetic resonance (CMR).</AbstractText>Patients with symptomatic ps. AF underwent CMR within 7 days prior to the ablation procedure. Left atrial and ventricular volumes were measured. All patients underwent circumferential pulmonary vein isolation. At the end of follow-up (FU), a CMR and 7-day ECG registration were performed.</AbstractText>Forty-two patients (67 ± 9 years) were included. After a FU of 86 ± 13 months, 23 patients had a successful outcome. In these patients, LVEF improved from 56 ± 5 to 62 ± 4% (p = 0.02), but left atrial volume and ejection fraction (LAV, LAEF) remained unchanged (105 ± 25 to 98 ± 34, p = 0.44; 34 ± 10 to 36 ± 11, p = 0.6, respectively). In 14 patients with a BMI < 30 and no left ventricular hypertrophy (LVH), LAV decreased (104 ± 30 to 82 ± 26 ml, p = 0.01) and LAEF improved (33 ± 12 to 40 ± 11%, p = 0.03). In 9 patients with successful outcome and either BMI ≥ 30 or LVH, LAV increased (110 ± 26 to 125 ± 30 ml, p = 0.03) and LAEF deteriorated (35 ± 11 to 31 ± 10%, p = 0.04).</AbstractText>Successful ablative treatment of atrial fibrillation is associated with reverse left atrial remodeling and improvement of left atrial and ventricular function. In patients with a BMI ≥ 30 or left ventricular hypertrophy, further left atrial enlargement occurs despite successful outcome.</AbstractText> |
17,903 | Clinical impact of newly developed atrial fibrillation complicated with longstanding ventricular fibrillation during left ventricular assist device support: A case report. | Continuous-flow left ventricular assist devices (LVADs) improve survival and morbidity in patients with stage D heart failure. Management of LVADs for longer durations is necessary in some clinical settings, and a better understanding of the hemodynamics of patients using LVADs is warranted. Arrhythmia, including atrial (AA) and ventricular (VAs) arrhythmias, is a modifying factor of hemodynamics that is highly prevalent among patients with LVADs. However, the clinical impact of arrhythmias in various clinical settings in patients with LVAD, in which the hemodynamic load is likely to present as worsening of right heart failure, remains to be completely elucidated.</AbstractText>We describe the case of a patient under sustained ventricular fibrillation for extraordinarily long duration who was stabilized using LVAD support and in whom newly developed atrial fibrillation led to a significant worsening of right heart failure while using an LVAD.</AbstractText>This case demonstrates the substantial clinical impact of AAs in the management of right heart failure using an LVAD.</AbstractText> |
17,904 | Combination of a leadless pacemaker and subcutaneous defibrillator with nine effective shock treatments during follow-up of 18 months. | We present a case of combination of a leadless pacemaker (Micra) and a subcutaneous implantable cardioverter-defibrillator (S-ICD). The patient had a total of nine adequate shock treatments of ventricular fibrillation during 18 months of follow-up after the implantation. The shock treatments did not lead to any alteration in the Micra. All three sensing vectors of the S-ICD worked well. After 18 months, the functioning of both Micra and S-ICD continues to be uneventful. This case demonstrates that S-ICD combined with Micra may be a safe and feasible approach to provide pacing and ICD treatment without intracardiac leads. |
17,905 | Usefulness of transesophageal echocardiography before cardioversion in atrial arrhythmias. | Although many thromboembolism risk factors are well defined, formation of thrombus or dense spontaneous contrast (sludge) in the left atrium remains enigmatic and confounding. Exclusion of the thrombus is extremely important with respect to planned reversal of sinus rhythm. Data regarding the routine transesophagal echocardiography (TEE) before cardioversion are inconclusive. The authors focused on analyzing the usefulness of TEE before cardioversion by assessment of factors influencing the risk of thrombus and/or dense spontaneous echo contrast with the intention of extending indications for TEE in the group with a high risk of thrombus or to forgo TEE in the low risk group.</AbstractText>Two hundred sixty-nine consecutive patients with persistent (> 48 h) atrial fibrillation or atrial flutter, in whom a direct current cardioversion was planned, were undergoing TEE for the detection of the left atrial thrombus or dense spontaneous echo contrast. Additional clinical and echocardiographic data were collected. The relationship between both thrombus and dense spontaneous echo contrast and covariates was analyzed with the use of binary logistic regression.</AbstractText>Left atrium (LA) appendage (LAA) thrombus and/or sludge were detected in 79 (29%) patients. Signs of dementia in mini-mental state examination (hazard ratio [HR]: 1.16; p = 0.005), low velocities in LAA (HR: 3.38; p = 0.032); presence of spontaneous echo contrast in LA (HR: 3.38; p = 0,003) consecutive episode of AF (HR: 2.27; p = 0,046); longer duration of atrial fibrillation (HR: 1.009; p = 0.022); were significant predictors of thrombus and/or dense spontaneous echo contrast. None of the patients with a CHA2DS2VASc score ≤ 1 had thrombus or sludge in the LAA. Among patients with a CHA2DS2VASc score > 1, the prevalence of thrombus or sludge in LAA was independent of the CHA2DS2VASc score value.</AbstractText>Amongst many factors, including an established as risk for thromboembolism only a few of them increased the risk for the presence of thrombus in LAA: low velocities in LAA, presence of spontaneous echo contrast, longer duration of arrhythmia, consecutive (not first) arrhythmia episode and signs of dementia from a mini-mental state examination questionnaire. It was believed that there could be a need for an extension of indications of TEE in vast majority of the patients with atrial arrhythmias, due most often to an unpredictable occurrence of thrombus and potentially disastrous thromboembolism. The only exception could have been the group of the patients with a CHA2DS2VASc score ≤ 1.</AbstractText> |
17,906 | Model-Based Quantification of Left Ventricular Diastolic Function in Critically Ill Patients with Atrial Fibrillation from Routine Data: A Feasibility Study. | Left ventricular diastolic dysfunction (LVDD) and atrial fibrillation (AF) are connected by pathophysiology and prevalence. LVDD remains underdiagnosed in critically ill patients despite potentially significant therapeutic implications since direct measurement cannot be performed in routine care at the bedside, and echocardiographic assessment of LVDD in AF is impaired. We propose a novel approach that allows us to infer the diastolic stiffness, β</i>, a key quantitative parameter of diastolic function, from standard monitoring data by solving the nonlinear, ill-posed inverse problem of parameter estimation for a previously described mechanistic, physiological model of diastolic filling. The beat-to-beat variability in AF offers an advantageous setting for this.</AbstractText>By employing a global optimization algorithm, β</i> is inferred from a simple six parameter and an expanded seven parameter model of left ventricular filling. Optimization of all parameters was limited to the interval ]0, 400[ and initialized randomly on large intervals encompassing the support of the likelihood function. Routine ECG and arterial pressure recordings of 17 AF and 3 sinus rhythm (SR) patients from the PhysioNet MGH/MF Database were used as inputs.</AbstractText>Estimation was successful in 15 of 17 AF patients, while in the 3 SR patients, no reliable estimation was possible. For both models, the inferred β</i> (0.065 ± 0.044 ml-1</sup> vs. 0.038 ± 0.033 ml-1</sup> (p</i>=0.02) simple vs. expanded) was compatible with the previously described (patho) physiological range. Aortic compliance, α</i>, inferred from the expanded model (1.46 ± 1.50 ml/mmHg) also compared well with literature values.</AbstractText>The proposed approach successfully inferred β</i> within the physiological range. This is the first report of an approach quantifying LVDF from routine monitoring data in critically ill AF patients. Provided future successful external validation, this approach may offer a tool for minimally invasive online monitoring of this crucial parameter.</AbstractText> |
17,907 | The value of STAF (Score for the Targeting of Atrial Fibrillation) in Patients with Cryptogenic Embolic Stroke. | The aim of the present study was to predict paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients with presumed cryptogenic embolic etiology.</AbstractText>In this retrospective cohort study, demographics, blood tests, data of neuroimaging studies such as non-contrast computed tomography (NCCT), magnetic resonance imaging (MRI), standard 12-lead electrocardigraphy (ECG), 24-hour Holter ECG, echocardiography was collected. The diagnostic work-up to detect atrial fibrillation (AF) was either medical history of the patient or 12-lead ECG or 24-hour Holter ECG or continuous ECG monitoring. Score for the targeting of atrial fibrillation (STAF) was calculated for all patients. Cryptogenic ischemic stroke (CS) patients with and without documented AF were recorded.</AbstractText>Between July 2014 and December 2015, a total of 133 of the 258 patients with CS were included in this study. Overall, 133 patients were enrolled and AF was detected in 30 (22.6%) patients. In univariate analysis gender (p<0.001), age (p=0.001), smoking habit (p=0.004), aortic and mitral valve insufficiency (p=0.014 and p=0.021), left ventricular systolic dysfunction (p=0.04), and left atrial dilatation (p=0.03) were predictors of AF but multivariate analysis showed that only gender and age were independent predictors of AF in patients with presumed cryptogenic ischemic stroke. According to ROC analysis, area under the curve was 70% and the sensitivity and specificity of STAF score of ≥5 was 86% and 71% respectively.</AbstractText>STAF score predicted with fair accuracy, and has a limited use for the risk of PAF in stroke patients.</AbstractText> |
17,908 | Therapeutic hypothermia as a treatment option after out-ofhospital cardiac arrest: our experience. | Aim To examine the effects of therapeutic hypothermia on the outcome of patients with the diagnosis of out-of-hospital cardiac arrest (OHCA). Methods The study included 76 patients who were hospitalised at the Medical Intensive Care Unit (MICU) of the Clinical Centre University of Sarajevo, with the diagnosis of out-of-hospital cardiac arrest, following the return of spontaneous circulation. Therapeutic hypothermia was performed with an average temperature of 33<sup>o</sup>C (32.3 - 34.1<sup>o</sup> C) on the patients who had coma, according to the Glasgow Coma Scale (GCS). Results Multiple organ dysfunction syndrome (MODS) significantly affected survival (p=0.0001), as its presence reduced patients' survival by 96%. In addition, ventricular fibrillation (VF) as the presenting rhythm, also significantly affected survival (p=0.019). A degree of patient's coma, as measured by the GCS, significantly affected survival (p=0.011). For each increasing point on the GCS, the chance for survival increased twice. Moreover, other physiological factors such as the pH and the lactate serum levels significantly affected patients' survival (p=0.012 and p=0.01, respectively). Conclusion In patients with the diagnosis of OHCA who underwent to the treatment with therapeutic hypothermia, verified VF as a presenting rhythm was a positive predictive factor for their outcome. Therefore, therapeutic hypothermia represents an option of therapeutic modality for this type of patients. |
17,909 | Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. | Natriuretic peptide [NP; B-type NP (BNP), N-terminal proBNP (NT-proBNP), and midregional proANP (MR-proANP)] concentrations are quantitative plasma biomarkers for the presence and severity of haemodynamic cardiac stress and heart failure (HF). End-diastolic wall stress, intracardiac filling pressures, and intracardiac volumes seem to be the dominant triggers. This paper details the most important indications for NPs and highlights 11 key principles underlying their clinical use shown below. NPs should always be used in conjunction with all other clinical information. NPs are reasonable surrogates for intracardiac volumes and filling pressures. NPs should be measured in all patients presenting with symptoms suggestive of HF such as dyspnoea and/or fatigue, as their use facilitates the early diagnosis and risk stratification of HF. NPs have very high diagnostic accuracy in discriminating HF from other causes of dyspnoea: the higher the NP, the higher the likelihood that dyspnoea is caused by HF. Optimal NP cut-off concentrations for the diagnosis of acute HF (very high filling pressures) in patients presenting to the emergency department with acute dyspnoea are higher compared with those used in the diagnosis of chronic HF in patients with dyspnoea on exertion (mild increase in filling pressures at rest). Obese patients have lower NP concentrations, mandating the use of lower cut-off concentrations (about 50% lower). In stable HF patients, but also in patients with other cardiac disorders such as myocardial infarction, valvular heart disease, atrial fibrillation or pulmonary embolism, NP concentrations have high prognostic accuracy for death and HF hospitalization. Screening with NPs for the early detection of relevant cardiac disease including left ventricular systolic dysfunction in patients with cardiovascular risk factors may help to identify patients at increased risk, therefore allowing targeted preventive measures to prevent HF. BNP, NT-proBNP and MR-proANP have comparable diagnostic and prognostic accuracy. In patients with shock, NPs cannot be used to identify cause (e.g. cardiogenic vs. septic shock), but remain prognostic. NPs cannot identify the underlying cause of HF and, therefore, if elevated, must always be used in conjunction with cardiac imaging. |
17,910 | First-in-man fully leadless transvenous CRT-P with a transseptal implant of WISE-CRT<sup>®</sup> system and Micra<sup>®</sup> PM. | We describe the world's first fully leadless cardiac resynchronization therapy pacing implant with transseptal approach, in a patient with pacemaker dependency, atrial fibrillation, ischemic hypokinetic cardiomyopathy, and a history of pocket infections. After lead extraction, we implanted a MicraTranscathether Pacing System® (Medtronic, Minneapolis, MN, USA) as the sole right ventricular pacemaker, and the WISECRT system (EBR Systems, Sunnyvale, CA, USA) to provide biventricular pacing. We performed the WISECRT implant procedure using the transseptal approach given the presence of a prosthetic aortic mechanical valve, achieving satisfactory periprocedural results. |
17,911 | Short- and medium-term prognosis of Takotsubo syndrome in a Portuguese population. | Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) systolic dysfunction.</AbstractText>To characterize a Portuguese population with TTS and to determine their short- and medium-term prognosis.</AbstractText>We conducted a multicenter study in Portuguese hospitals that included all patients diagnosed with TTS, initially retrospectively and subsequently prospectively. Short- and medium-term clinical complications and mortality were assessed. Independent predictors of in-hospital complications and prognostic factors were determined.</AbstractText>A total of 234 patients (210 female, age 68±12 years) were included. During hospitalization, 32.9% of patients had complications: acute heart failure (24.4%), atrial fibrillation (9.0%), ventricular arrhythmias (2.6%), complete atrioventricular block (2.1%), stroke/transient ischemic attack (1.7%), and LV thrombus (1.3%). Chronic kidney disease (CKD) (p=0.02), coronary artery disease (CAD) (p=0.027), lower LV ejection fraction (LVEF) on admission (p=0.003), and dyspnea at presentation (p=0.019) were predictors of in-hospital complications. In-hospital mortality was 2.2%. At the mean follow-up of 33±33 months, all-cause mortality was 4.4%, cardiovascular mortality was 0.9% and TTS recurrence was 4.4%. Prolonged QTc interval on admission was associated with complications in follow-up (p=0.001).</AbstractText>TTS has a good short- and medium-term prognosis. However, the rate of in-hospital complications is high and should not be overlooked. Dyspnea at presentation, CKD, CAD and lower LVEF on admission were independent predictors of in-hospital complications. Prolonged QTc on admission was associated with complications in follow-up.</AbstractText>Copyright © 2019 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.</CopyrightInformation> |
17,912 | Quantification of Electromechanical Coupling to Prevent Inappropriate Implantable Cardioverter-Defibrillator Shocks. | This study sought to test specialized processing of laser Doppler signals for discriminating ventricular fibrillation (VF) from common causes of inappropriate therapies.</AbstractText>Inappropriate implantable cardioverter-defibrillator (ICD) therapies remain a clinically important problem associated with morbidity and mortality. Tissue perfusion biomarkers, implemented to assist automated diagnosis of VF, sometimes mistake artifacts and random noise for perfusion, which could lead to shocks being inappropriately withheld.</AbstractText>The study tested a novel processing algorithm that combines electrogram data and laser Doppler perfusion monitoring as a method for assessing circulatory status. Fifty patients undergoing VF induction during ICD implantation were recruited. Noninvasive laser Doppler and continuous electrograms were recorded during both sinus rhythm and VF. Two additional scenarios that might have led to inappropriate shocks were simulated for each patient: ventricular lead fracture and T-wave oversensing. The laser Doppler was analyzed using 3 methods for reducing noise: 1) running mean; 2) oscillatory height; and 3) a novel quantification of electromechanical coupling which gates laser Doppler relative to electrograms. In addition, the algorithm was tested during exercise-induced sinus tachycardia.</AbstractText>Only the electromechanical coupling algorithm found a clear perfusion cut off between sinus rhythm and VF (sensitivity and specificity of 100%). Sensitivity and specificity remained at 100% during simulated lead fracture and electrogram oversensing. (Area under the curve running mean: 0.91; oscillatory height: 0.86; electromechanical coupling: 1.00). Sinus tachycardia did not cause false positive results.</AbstractText>Quantifying the coupling between electrical and perfusion signals increases reliability of discrimination between VF and artifacts that ICDs may interpret as VF. Incorporating such methods into future ICDs may safely permit reductions of inappropriate shocks.</AbstractText>Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,913 | Atrial Remodeling Following Catheter Ablation for Atrial Fibrillation-Mediated Cardiomyopathy: Long-Term Follow-Up of CAMERA-MRI Study. | This study sought to determine the long-term right atrial (RA) electrical and structural changes in a subgroup from the CAMERA-MRI (Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction-Magnetic Resonance Imaging) study.</AbstractText>Catheter ablation (CA) is successful in restoring ventricular function in patients with atrial fibrillation (AF) and otherwise unexplained cardiomyopathy, as demonstrated in the randomized study of CA versus rate control (CAMERA-MRI). It is unknown if this is associated with atrial remodeling.</AbstractText>Detailed electroanatomical (EA) mapping of the RA using CARTO3 and a force sensing catheter was performed at initial CA and electively at least 12 months after CA in patients with >90% reduction in AF burden following ablation. Bipolar voltage, fractionation, and conduction velocity were collected in 4 segments together with echo and cardiac magnetic resonance imaging.</AbstractText>Fifteen patients (mean age 59.1 ± 6.8 years) underwent repeat RA EA mapping. At a mean follow-up of 23.4 ± 11.9 months, left ventricular (LV) ejection fraction improved from 33.6 ± 3.2% to 54.1 ± 3.2% (p = 0.001), RA area decreased from 28.4 ± 2.0 cm2</sup> to 20.8 ± 1.2 cm2</sup> (p < 0.001), and left atrial area decreased from 32.9 ± 2.3 cm2</sup> to 26.8 ± 1.4 cm2</sup> (p = 0.007). On EA mapping, RA bipolar voltage increased from 1.6 ± 0.1 mV to 1.9 ± 0.1 mV (p = 0.04). Tissue voltage increased across all regions, which achieved statistical significance at the posterior (p = 0.002) and septal (p = 0.01) segments. There was a significant decrease in complex fractionated electrograms from 21.7 ± 3.5% to 8.3 ± 1.8% (p = 0.002); however, no significant change occurred in global or regional conduction velocities (p = 0.5).</AbstractText>Recovery of atrial electrical and structural changes was observed following restoration of sinus rhythm and recovery of LV function in patients who underwent CA for persistent AF and LV systolic dysfunction. The randomized CAMERA MRI study demonstrated significant improvement in LV systolic function with AF ablation compared with rate control. The present study demonstrated reverse electrical and structural atrial recovery in concert with recovery of LV systolic function at 2 years post-AF ablation. This may partially explain the long-term success of CA in patients with AF and otherwise unexplained cardiomyopathy.</AbstractText>Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,914 | A Post hoc analysis on rhythm and high intensity interval training in cardiac resynchronization therapy. | <i>Objectives</i>. Evaluate the effects of a 6-month High Intensity Interval Training (HIIT) program on (1) functional capacity and health-related quality of life, (2) multiple blood biomarkers, (3) echocardiographic parameters, and (4) exercise performance, in patients in cardiac resynchronization therapy (CRT) stratified by the presence of atrial fibrillation (AF), targeting the following questions: (1) Does CRT provide similar benefits in patients in AF and sinus rhythm (SR)?; and (2) Does HIIT provides similar benefits in patients in AF and SR? <i>Design.</i> Estimates were available at baseline and 6 months after CRT implantation in 37 patients with heart failure. Patients were randomized after CRT to a 24-week HIIT group or to a usual care group (CON). In this sub-analysis, HIIT (AF = 7; SR = 11) and CON (AF = 9; SR = 10) were stratified by the presence of AF. <i>Results.</i> Patients in AF benefitted to a lesser degree from CRT in functional status than patients in SR (23.8-46.0%). However, HIIT induced superior improvements in patients in AF compared to CON (23.9-61.0%). Decreases in TNF-α (8.5-42.9%), BNP (15.3-34.6%) and left ventricular mass (9.6-26.2%) were only observed in patients in SR, whereas increases in peak oxygen uptake were only observed in patients in AF (19.5-23.2%). HIIT improved exercise capacity (8.8-59.4%) in patients in SR. <i>Conclusions.</i> Patients in AF or SR undergoing CRT demonstrated distinct benefits from device implantation and from HIIT as an adjunctive therapeutic strategy. This suggests that both mainstay and adjunctive therapeutics may need to be managed differently in patients in AF and SR. |
17,915 | Electrocardiogram Characteristics and Their Association With Psychotropic Drugs Among Patients With Schizophrenia. | There are limited data on electrocardiogram (ECG) characteristics and their association with psychotropic drugs in schizophrenia.</AbstractText>Using a cross-sectional design, we included Danish primary care patients with first-time digital ECGs from 2001 to 2015. Patients diagnosed with schizophrenia before ECG recording were matched 1:5 on age, sex, and ECG recording year to controls without psychiatric disease. Multivariable logistic regression was used to compute odds ratios (ORs) with 95% confidence intervals (CIs).</AbstractText>We included 4486 patients with schizophrenia matched with 22 430 controls (median age, 47 years; male, 55%). Between groups, the prevalence of abnormal ECGs was similar (54%, P = .536), but patients with schizophrenia demonstrated higher median heart rate (79 vs 69 beats per minute, P < .001) and Fridericia-corrected QT (QTc) interval (416 vs 412 ms, P < .001) than controls. QTc prolongation was also more prevalent among patients with schizophrenia (3.4% vs 1.1%, P < .001), and so were pathological Q waves (5.3% vs 3.9%, P < .001). Patients with schizophrenia less frequently demonstrated left ventricular hypertrophy (6.1% vs 9.6%, P < .001) and atrial fibrillation or flutter (0.7% vs 1.4%, P < .001). Among patients with schizophrenia only, particularly antipsychotics were associated with abnormal ECGs (OR, 1.20; 95% CI, 1.04-1.39).</AbstractText>Patients with schizophrenia demonstrate a different cardiovascular risk profile than matched controls without psychiatric disease, with higher prevalence of elevated heart rate, QTc prolongation, and pathological Q waves, and lower prevalence of left ventricular hypertrophy and atrial fibrillation or flutter. Particularly antipsychotics were associated with abnormal ECGs. This underscores an integrated care approach when ECG abnormalities are detected in this group.</AbstractText>© The Author(s) 2019. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
17,916 | Evaluation of the diagnostic accuracy of smartphone electrocardiogram recorder compared to standard 12 lead electrocardiography in hospital settings. | To evaluate Smartphone-based Electrocardiogram Recorders (S-ECG-R) diagnostic accuracy compared to standard 12 lead ECG.</AbstractText>A cross-sectional comparative study was conducted in a tertiary cardiac center in Riyadh, Kingdom of Saudi Arabia from December 2017 to February 2018. A total of 403 patients underwent both standard 12 leads ECG and S-ECG-R recordings in the same time. All recordings were checked initially by an electrophysiologist to confirm the accurate diagnosis. Then, the 806 recordings were randomly distributed among 6 certified cardiologists to interpret the rhythms and to evaluate rhythms quality.</AbstractText>In this study 211 (52%) males and 192 (48%) females were included, with a mean age of 52±18 years. Of the included rhythms,149 (37%) were abnormal. The majority of which were atrial fibrillation 46 (11%), sinus tachycardia 35 (9%) and premature ventricular contractions 33 (8%). Analysis revealed an overall similar diagnostic sensitivity and specificity of S-ECG-R to the standard 12 lead ECG recording, sensitivity (97.3% versus (vs) 98%) and specificity (99.6% vs. 99.6%). However, cardiologists were more confident during interpreting standard ECG recordings in 91% of the recordings while in 71% of S-ECG-R recordings. Conclusion: The ECG rhythms produced by smartphone accessory have a good diagnostic accuracy in diagnosing arrhythmias. The utility of using S-ECG-R for out-patient is to be determined.</AbstractText> |
17,917 | In vitro assessment of pacing as therapy for aortic regurgitation. | Clinical evaluation of pacing therapy in mitigating the aortic insufficiency after transchateter aortic valve implantation often gives contradictory outcomes. This study presents an in vitro investigation aimed at clarifying the effect of pacing on paravalvular leakage.</AbstractText>A series of in vitro tests reproducing the heart operating changes clinically obtained by pacing was carried out in a 26 mm Edwards Sapien XT prosthesis with mild paravalvular leakage. The effect of pacing on the regurgitant volumes per cycle and per minute was quantified, and the energy and power consumed by the left ventricle were calculated.</AbstractText>Results indicate that though pacing results in some reduction in the total regurgitation per cycle, the volume of fluid regurgitating per minute increases substantially, causing overload of left ventricle.</AbstractText>Our tests indicate no effective haemodynamic benefit from pacing, suggesting a prudential clinical use of this therapy for the treatment of postoperative aortic regurgitation.</AbstractText> |
17,918 | Outcomes of cardiac resynchronisation therapy in patients with heart failure with atrial fibrillation: a systematic review and meta-analysis of observational studies. | Cardiac resynchronisation therapy (CRT) is beneficial in selected patients with heart failure (HF) in normal sinus rhythm (NSR). We sought to evaluate the impact of CRT with or without atrioventricular junction (AVJ) ablation in patients with HF with concomitant atrial fibrillation (AF).</AbstractText>Literature was searched (inception through 30 August 2017) for observational studies that reported outcomes in patients with HF with CRT and AF that reported all-cause and cardiovascular mortality. Thirty-one studies with 83, 571 patients were included. CRT did not decrease mortality compared with internal cardioverter defibrillator or medical therapy alone in patients with HF and AF with indications for CRT (OR: 0.851, 95% CI 0.616 to 1.176, p=0.328, I2</sup>=86.954). CRT-AF patients had significantly higher all-cause and cardiovascular mortality than CRT-NSR patients ([OR: 1.472, 95% CI 1.301 to 1.664, p=0.000] and [OR: 1.857, 95% CI 1.350 to 2.554, p=0.000] respectively). Change in left ventricular ejection fraction was not different between CRT patients with and without AF (p=0.705). AVJ ablation, however, improved all-cause mortality in CRT-AF patients when compared with CRT-AF patients without AVJ ablation (OR: 0.485, 95% CI 0.247 to 0.952, p=0.035). With AVJ ablation, there was no difference in all-cause mortality in CRT-AF patients compared with CRT-NSR patients (OR: 1.245, 95% CI 0.914 to 1.696, p=0.165).</AbstractText>The results of our meta-analysis suggest that AF was associated with decreased CRT benefits in patients with HF. CRT, however, benefits patients with AF with AVJ ablation.</AbstractText> |
17,919 | Associations between common ECG abnormalities and out-of-hospital cardiac arrest. | Out-of-hospital cardiac arrest (OHCA) is often the first manifestation of unrecognised cardiac disease. ECG abnormalities encountered in primary care settings may be warning signs of OHCA.</AbstractText>We examined the association between common ECG abnormalities and OHCA in a primary care setting.</AbstractText>We cross-linked individuals who had an ECG recording between 2001 and 2011 in a primary care setting with the Danish Cardiac Arrest Registry and identified OHCAs of presumed cardiac cause.</AbstractText>A total of 326 227 individuals were included and 2667 (0,8%) suffered an OHCA. In Cox regression analyses, adjusted for age and sex, the following ECG findings were strongly associated with OHCA: ST-depression without concomitant atrial fibrillation (HR 2.79; 95% CI 2.45 to 3.18), left bundle branch block (LBBB; HR 3.44; 95% CI 2.85 to 4.14) and non-specific intraventricular block (NSIB; HR 3.15; 95% CI 2.58 to 3.83). Also associated with OHCA were atrial fibrillation (HR 1.89; 95% CI 1.63 to 2.18), Q-wave (HR 1.75; 95% CI 1.57 to 1.95), Cornell and Sokolow-Lyon criteria for left ventricular hypertrophy (HR 1.56; 95% CI 1.33 to 1.82 and HR 1.27; 95% CI 1.12 to 1.45, respectively), ST-elevation (HR 1.40; 95% CI 1.09 to 1.54) and right bundle branch block (HR 1.29; 95% CI 1.09 to 1.54). The association between ST-depression and OHCA diminished with concomitant atrial fibrillation (HR 1.79; 95% CI 1.42 to 2.24, p < 0.01 for interaction). Among patients suffering from OHCA, without a known cardiac disease at the time of the cardiac arrest, 14.2 % had LBBB, NSIB or ST-depression.</AbstractText>Several common ECG findings obtained from a primary care setting are associated with OHCA.</AbstractText> |
17,920 | Heart failure with preserved ejection fraction in the elderly: pathophysiology, diagnostic and therapeutic approach. | Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by symptoms and sings of heart failure with elevated left ventricular filling pressures at rest or during exercise. It is the most common type of heart failure in the elderly and its prevalence increases with age and is higher in females at any given age. HFpEF is frequently accompanied of comorbid conditions such as diabetes mellitus, obesity, atrial fibrillation and renal dysfunction. The diagnosis relies in the integration of clinical information, laboratory data and interpretation of cardiac imaging and hemodynamic findings at rest and during exercise. Conditions that have a specific treatment such as coronary artery disease, valvular disease, cardiac amyloidosis and constrictive pericarditis should be considered and evaluated as appropriate. Aggressive management of comorbidities, optimization of blood pressure control and volume status using diuretics as needed are among the current treatment recommendations. There are no specific therapies that have shown to decrease mortality in HFpEF. In symptomatic patients with history of hospital admission for decompensated heart failure, the implantation of a wireless pulmonary artery pressure monitor should be considered. Finally, given the high mortality of this condition, goals of care discussion should be initiated early and involvement of palliative care medicine should be considered. |
17,921 | Junctophilin-2 expression rescues atrial dysfunction through polyadic junctional membrane complex biogenesis. | Atrial dysfunction is highly prevalent and associated with increased severity of heart failure. While rapid excitation-contraction coupling depends on axial junctions in atrial myocytes, the molecular basis of atrial loss of function remains unclear. We identified approximately 5-fold lower junctophilin-2 levels in atrial compared with ventricular tissue in mouse and human hearts. In atrial myocytes, this resulted in subcellular expression of large junctophilin-2 clusters at axial junctions, together with highly phosphorylated ryanodine receptor (RyR2) channels. To investigate the contribution of junctophilin-2 to atrial pathology in adult hearts, we developed a cardiomyocyte-selective junctophilin-2-knockdown model with 0 mortality. Junctophilin-2 knockdown in mice disrupted atrial RyR2 clustering and contractility without hypertrophy or interstitial fibrosis. In contrast, aortic pressure overload resulted in left atrial hypertrophy with decreased junctophilin-2 and RyR2 expression, disrupted axial junctions, and atrial fibrosis. Whereas pressure overload accrued atrial dysfunction and heart failure with 40% mortality, additional junctophilin-2 knockdown greatly exacerbated atrial dysfunction with 100% mortality. Strikingly, transgenic junctophilin-2 overexpression restored atrial contractility and survival through de novo biogenesis of polyadic junctional membrane complexes maintained after pressure overload. Our data show a central role of junctophilin-2 cluster disruption in atrial hypertrophy and identify transgenic augmentation of junctophilin-2 as a disease-mitigating rationale to improve atrial dysfunction and prevent heart failure deterioration. |
17,922 | Inevitable high-dose irradiation to lead of implantable cardioverter defibrillator in small cell lung cancer: a case report. | Radiotherapy has been shown to cause malfunction of implantable cardioverter-defibrillators, and there are few studies of implantable cardioverter-defibrillators and radiotherapy. We report an unusual case of small cell lung cancer in a patient with an implantable cardioverter-defibrillator in whom direct irradiation to the electrode and lead could not be avoided.</AbstractText>We report a case of radiotherapy in a 72-year-old Korean man with a limited stage of small cell lung cancer who had undergone insertion of an implantable cardioverter-defibrillator because of ventricular fibrillation. The radiation dose was 60 Gy in 30 fractions to the thorax. The mean dose and maximum dose estimated at the body of the implantable cardioverter-defibrillator were 0.89 Gy and 2.23 Gy, respectively. The mean and maximum doses of the lead and electrode were 17.12 Gy and 55.72 Gy in the lead and 1.81 Gy and 7.10 Gy in the electrode, respectively, because part of the lead and electrode was inevitably in the irradiated fields. The function of the patient's implantable cardioverter-defibrillator was checked daily, and no change in implantable cardioverter-defibrillator function was observed for the duration of radiotherapy. The patient was tolerated the treatment well without severe complications. Computed tomography performed at 4 weeks after radiotherapy showed a good response with regression of the tumor. The patient was alive with complete remission of the tumor and without any implantable cardioverter-defibrillator dysfunction more than 36 months after the end of treatment.</AbstractText>This case demonstrates that radiotherapy may be a safe and effective treatment modality through careful monitoring of implantable cardioverter-defibrillators in patients with lung cancer who have implantable cardioverter-defibrillators.</AbstractText> |
17,923 | Targeting Noninducible Clinical Ventricular Tachycardias in Patients With Prior Myocardial Infarctions Based on Stored Electrograms. | Ablation of postinfarction ventricular tachycardia (VT) has been shown to reduce VT recurrence and decrease mortality. However, VT recurrence can occur despite extensive ablation procedures. The lack of inducibility of clinical VTs during ablation procedures remains problematic and may be in part responsible for VT recurrences. In this prospective study, we targeted documented but noninducible clinical VTs based on stored implantable cardioverter-defibrillator (ICD) electrograms.</AbstractText>Radiofrequency ablation was performed in a consecutive group of 66 postinfarction patients (mean age, 67.5±9.2 years; men, 61; mean left ventricular ejection fraction, 25.1±10.8%) in whom clinical VTs were not inducible during an ablation procedure. In the first 33 patients (control group), only inducible VTs were targeted, and in the second 33 patients, noninducible clinical VTs were also targeted by pace-mapping based on stored ICD-electrograms (ICD-electrogram-guided ablation group). Procedural and clinical outcomes were compared at 24 months post-ablation.</AbstractText>VT recurred in 5 patients (15%) in whom the ICD-electrogram-guided approach was performed and in 13 patients (39%) in the control group. Freedom from recurrent VT was higher (log-rank P=0.04) in the ICD-electrogram-guided group, but there was no difference in ventricular fibrillation or in total mortality between both groups.</AbstractText>Ablation guided by pace-mapping of noninducible postinfarction clinical VTs based on ICD-electrograms is feasible and reduces the risk of recurrent VT.</AbstractText> |
17,924 | Machine Learning Prediction of Response to Cardiac Resynchronization Therapy: Improvement Versus Current Guidelines. | Cardiac resynchronization therapy (CRT) has significant nonresponse rates. We assessed whether machine learning (ML) could predict CRT response beyond current guidelines.</AbstractText>We analyzed CRT patients from Cleveland Clinic and Johns Hopkins. A training cohort was created from all Johns Hopkins patients and an equal number of randomly sampled Cleveland Clinic patients. All remaining patients comprised the testing cohort. Response was defined as ≥10% increase in left ventricular ejection fraction. ML models were developed to predict CRT response using different combinations of classification algorithms and clinical variable sets on the training cohort. The model with the highest area under the curve was evaluated on the testing cohort. Probability of response was used to predict survival free from a composite end point of death, heart transplant, or placement of left ventricular assist device. Predictions were compared with current guidelines.</AbstractText>Nine hundred twenty-five patients were included. On the training cohort (n=470: 235, Johns Hopkins; 235, Cleveland Clinic), the best ML model was a naive Bayes classifier including 9 variables (QRS morphology, QRS duration, New York Heart Association classification, left ventricular ejection fraction and end-diastolic diameter, sex, ischemic cardiomyopathy, atrial fibrillation, and epicardial left ventricular lead). On the testing cohort (n=455, Cleveland Clinic), ML demonstrated better response prediction than guidelines (area under the curve, 0.70 versus 0.65; P=0.012) and greater discrimination of event-free survival (concordance index, 0.61 versus 0.56; P<0.001). The fourth quartile of the ML model had the greatest risk of reaching the composite end point, whereas the first quartile had the least (hazard ratio, 0.34; P<0.001).</AbstractText>ML with 9 variables incrementally improved prediction of echocardiographic CRT response and survival beyond guidelines. Performance was not improved by incorporating more variables. The model offers potential for improved shared decision-making in CRT (online calculator: http://riskcalc.org:3838/CRTResponseScore ). Significant remaining limitations confirm the need to identify better variables to predict CRT response.</AbstractText> |
17,925 | Genomics-First Evaluation of Heart Disease Associated With Titin-Truncating Variants. | Truncating variants in the Titin gene (TTNtvs) are common in individuals with idiopathic dilated cardiomyopathy (DCM). However, a comprehensive genomics-first evaluation of the impact of TTNtvs in different clinical contexts, and the evaluation of modifiers such as genetic ancestry, has not been performed.</AbstractText>We reviewed whole exome sequence data for >71 000 individuals (61 040 from the Geisinger MyCode Community Health Initiative (2007 to present) and 10 273 from the PennMedicine BioBank (2013 to present) to identify anyone with TTNtvs. We further selected individuals with TTNtvs in exons highly expressed in the heart (proportion spliced in [PSI] >0.9). Using linked electronic health records, we evaluated associations of TTNtvs with diagnoses and quantitative echocardiographic measures, including subanalyses for individuals with and without DCM diagnoses. We also reviewed data from the Jackson Heart Study to validate specific analyses for individuals of African ancestry.</AbstractText>Identified with a TTNtv in a highly expressed exon (hiPSI) were 1.2% individuals in PennMedicine BioBank and 0.6% at Geisinger. The presence of a hiPSI TTNtv was associated with increased odds of DCM in individuals of European ancestry (odds ratio [95% CI]: 18.7 [9.1-39.4] {PennMedicine BioBank} and 10.8 [7.0-16.0] {Geisinger}). hiPSI TTNtvs were not associated with DCM in individuals of African ancestry, despite a high DCM prevalence (odds ratio, 1.8 [0.2-13.7]; P=0.57). Among 244 individuals of European ancestry with DCM in PennMedicine BioBank, hiPSI TTNtv carriers had lower left ventricular ejection fraction (β=-12%, P=3×10-7</sup>), and increased left ventricular diameter (β=0.65 cm, P=9×10-3</sup>). In the Geisinger cohort, hiPSI TTNtv carriers without a cardiomyopathy diagnosis had more atrial fibrillation (odds ratio, 2.4 [1.6-3.6]) and heart failure (odds ratio, 3.8 [2.4-6.0]), and lower left ventricular ejection fraction (β=-3.4%, P=1×10-7</sup>).</AbstractText>Individuals of European ancestry with hiPSI TTNtv have an abnormal cardiac phenotype characterized by lower left ventricular ejection fraction, irrespective of the clinical manifestation of cardiomyopathy. Associations with arrhythmias, including atrial fibrillation, were observed even when controlling for cardiomyopathy diagnosis. In contrast, no association between hiPSI TTNtvs and DCM was discerned among individuals of African ancestry. Given these findings, clinical identification of hiPSI TTNtv carriers may alter clinical management strategies.</AbstractText> |
17,926 | Reference database and performance evaluation of methods for extraction of atrial fibrillatory waves in the ECG. | This study proposes a reference database, composed of a large number of simulated ECG signals in atrial fibrillation (AF), for investigating the performance of methods for extraction of atrial fibrillatory waves (f-waves).</AbstractText>The simulated signals are produced using a recently published and validated model of 12-lead ECGs in AF. The database is composed of eight signal sets together accounting for a wide range of characteristics known to represent major challenges in f-wave extraction, including high heart rates, high morphological QRST variability, and the presence of ventricular premature beats. Each set contains 30 5 min signals with different f-wave amplitudes. The database is used for the purpose of investigating the statistical association between different indices, designed for use with either real or simulated signals.</AbstractText>Using the database, available at the PhysioNet repository of physiological signals, the performance indices unnormalized ventricular residue (uVR), designed for real signals, and the root mean square error, designed for simulated signals, were found to exhibit the strongest association, leading to the recommendation that uVR should be used when characterizing performance in real signals.</AbstractText>The proposed database facilitates comparison of the performance of different f-wave extraction methods and makes it possible to express performance in terms of the error between simulated and extracted f-wave signals.</AbstractText> |
17,927 | Atrial ectopy after pulmonary vein isolation and left heart reverse remodeling in patients with atrial fibrillation. | Maintenance of sinus rhythm after pulmonary vein isolation (PVI) for atrial fibrillation (AF) is associated with left atrial (LA) and ventricular (LV) reverse remodeling, although the degree varies among individuals. We hypothesized that frequent premature atrial complex (PAC) after PVI may attenuate the left heart reverse remodeling benefited from maintenance of sinus rhythm.</AbstractText>We included 82 AF patients who underwent first-time PVI and 24-h Holter recordings at 6 months after PVI. All patients had no AF recurrence before this time. The number of PAC was categorized into tertiles: <90, 90-488 and >488 PACs/day. All patients underwent two-dimensional echocardiography and serum plasma B-type natriuretic peptide (BNP) measurement before and 6 months after PVI. LA reverse remodeling was defined as ≥15% decrease in LA volume index.</AbstractText>There was no significant difference in the baseline characteristics among the PAC tertiles except for sex. Six months after PVI, LA volume index, LV mass index, and serum BNP levels were significantly decreased in lower and middle PAC tertiles (all P < .05), whereas no significant changes were observed in upper PAC tertile. Frequency of LA reverse remodeling was significantly lower in upper tertile of PAC compared with middle and lower tertiles (22.2%, 57.1%, and 59.3%, P < .001). Baseline LA volume index, changes in LV mass index, and the frequency of PAC were independently associated with LA reverse remodeling (all P < .05).</AbstractText>Frequent PAC after PVI was associated with less left heart reverse remodeling in AF patients even without AF recurrence.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,928 | Unusual Cause of Bidirectional Ventricular Rhythm. | Bidirectional ventricular tachycardia (BDVT), a rare ventricular arrhythmia, is commonly caused by digitalis toxicity or channelopathies and is rarely caused by aconite toxicity, myocarditis, infarction, or sarcoidosis. This paper describes a patient with BDVT, recurrent syncope, myocardial disarray, and interstitial fibrosis on histology but normal results on echocardiography with variants in the <i>TTN</i>, <i>KCNH2</i>, and <i>GATA4</i> genes. (<b>Level of Difficulty: Advanced.</b>). |
17,929 | [A Rare Cause of Acute Coronary Occlusion with Inferior ST-Elevation Myocardial Infarction and Out of Hospital Cardiac Arrest]. | The 59-year old female was successfully resuscitated after out of hospital cardiac arrest due to ventricular fibrillation. The ECG after return of spontaneous circulation showed elevated ST-segments in the inferior leads.</AbstractText>Acute coronary angiography confirmed a complete occlusion of the right coronary artery without collateral flow. However, a few seconds after intracoronary administration of nitroglycerin complete reperfusion was achieved without persistent relevant stenosis.</AbstractText>Stenting of the vessel was withheld. After controlled hypothermia and 68 h on respirator therapy the patient was extubated and showed no persistent neurological disorders. On day 6 she received an implantable cardioverter-defibrillator. Two weeks after the index event the patient could be discharged in good condition. Routine intracoronary administration of nitroglycerin before balloon dilatation or stenting is therefore highly recommended, also in the setting of acute coronary syndromes. Because of the high risk of recurrence, patients resuscitated from lethal cardiac arrhythmia, caused by coronary spasm should receive a cardioverter-defibrillator.</AbstractText>© Georg Thieme Verlag KG Stuttgart · New York.</CopyrightInformation> |
17,930 | Impact of defibrillation threshold testing on burden of heart failure hospitalizations. | <b>Background:</b> Defibrillation threshold testing (DT) following implantable cardioverter defibrillator (ICD) implantation has not shown to improve mortality. However, the impact of DT on burden of heart failure (HF) hospitalisations has not been well defined.<b>Methods:</b> We studied retrospectively consecutive patients who underwent ICD implantation or generator change between 2008 and 2014. Primary outcome was burden of HF hospitalisations within 30 days following implantation. Secondary outcomes were mortality, stroke, and ICD shock within 30 days and one-year mortality.<b>Results:</b> Three hundred and eleven of 501 patients (62%) were in DT+ group versus 190 (38%) were in DT- group. The percentage of new implantations was higher in DT+ group than in DT- group (69% vs 39%, <i>p</i> < .001) but the distributions of NYHA function classes were similar between two groups. The burden of HF hospitalisations at 30-days was significantly higher in DT+ group than in DT- group (17.4% vs 4.7%, HR 0.842, 95% CI 0.774-0.915, <i>p</i> < .0001). No difference in mortality, stroke or ICD shocks was found between two groups at 30 days and mortality at 1 year.<b>Conclusions:</b> DT after new ICD or generator replacement was associated with increased HF hospitalisation rates at 30 days after ICD implant in a non-trial HF population. However, there was no association between DT and mortality, stroke and ICD shocks at 30 days or mortality at 1 year. The increased burden of HF hospitalisation in this observational study requires validation by randomised studies. |
17,931 | A 'Natural' thyroid storm! | Over the counter supplements are often taken for granted during medication reconciliation in the emergency department. Supplements are not regulated by FDA, and some can be potentially dangerous.</AbstractText>We report a case of thyrotoxicosis secondary to over the counter bovine thyroid supplements. Our patient presented with atrial fibrillation with rapid ventricular response refractory to calcium channel blockers. Had we not known about the supplement, the course of treatment would have been different with potential adverse outcome.</AbstractText>Natural thyroid supplements are marketed as over the counter products and are largely unregulated. Thyroid extracts have been found to have disparaging inconsistencies in composition, delivering anywhere from non-existent to supratherapeutic doses. Thyroid supplements should be regulated considering the potential side effects.</AbstractText>© 2019 John Wiley & Sons Ltd.</CopyrightInformation> |
17,932 | Safety and Efficacy Outcomes of Combined Leadless Pacemaker and Atrioventricular Nodal Ablation for Atrial Fibrillation Using a Single Femoral Puncture Approach. | Atrioventricular nodal (AVN) ablation with permanent pacemaker (PPM) insertion is indicated for rate control in patients with atrial fibrillation (AF) who remain unresponsive to rate or rhythm control strategies. The leadless PPM (Micra Transcatheter Pacing System [TPS], Medtronic, Minneapolis, MN, USA) has the advantage of eliminating transvenous lead and pacemaker pocket-related complications. The aim of this case series was to determine the outcomes of patients who had undergone combined Micra TPS and AVN ablation, performed via a single femoral approach.</AbstractText>A retrospective review was undertaken on patients who had undergone concurrent procedures, across two major hospitals in Perth, Western Australia. Procedural details were obtained from a cardiac devices database whilst patient demographics and clinical information were determined from medical records.</AbstractText>Fourteen (14) patients underwent concurrent Micra TPS insertion and AVN ablation for symptomatic AF. The average age was 73±9.2 years, and 43% of them were males. There was no acute procedural/device related complication. Over a median follow-up duration of 9 months (36% completing 12-month follow-up), there was no incidence of device complications, in particular device dislodgement, malfunction or infection. One patient had a resuscitated ventricular fibrillation (VF) arrest event with new onset cardiomyopathy during follow-up and required Micra TPS removal. One patient died at 33 days post procedure from a non-cardiac cause. Device performance was excellent with stable sensing and pacing thresholds during the follow-up period.</AbstractText>Our study has shown that combined leadless PPM (Micra TPS) implantation and AVN ablation using a single femoral approach is feasible, with good safety and efficacy profile in the short-medium term. Long-term data involving larger cohorts is needed to confirm the findings of this study and determine the clinical usefulness of this combined approach.</AbstractText>Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,933 | Out-of-hospital cardiac arrest and survival in a patient with Noonan syndrome and multiple lentigines: a case report. | A 9-year-old Arabic boy attending middle school presented with an out-of-hospital cardiac arrest due to ventricular fibrillation recorded by Holter electrocardiographic monitoring. He had a background history of Noonan syndrome with multiple lentigines (also known as LEOPARD syndrome), a rare condition of autosomal dominant inheritance with approximately 200 cases reported worldwide.</AbstractText>Apart from characteristic features, the boy was known to have asymmetric septal hypertrophy with a maximum wall thickness of 24 mm measured by cardiovascular magnetic resonance imaging. A day prior to the event, he attended cardiology follow-up at our institution, and Holter monitoring was commenced. Following cardiopulmonary resuscitation by bystanders and paramedics, he reverted back into sinus rhythm after a total downtime of 24 min. He was initially treated in the intensive care unit and underwent implantable cardioverter defibrillator implantation. He has made a full recovery and remains at the top of his class.</AbstractText>This case demonstrates that sudden cardiac arrest in patients with secondary forms of hypertrophic cardiomyopathy is not necessarily protected by apparently favorable phenotypes and that events may be preceded by non-sustained ventricular tachycardia observed by Holter monitoring. Implantable cardioverter defibrillator implantation plays a critical role in both primary and secondary prevention in patients at high risk of out-of-hospital cardiac arrest.</AbstractText> |
17,934 | Arrhythmic episodes in patients implanted with a cardioverter-defibrillator - results from the Prospective Study on Predictive Quality with Preferencing PainFree ATP therapies (4P). | Little is known about the ICD performance using enhanced detection algorithms in unselected, non-trial patients. Performance of recent generation ICD equipped with SmartShock™ technology (SST) for detection and conversion of ventricular tachyarrhythmias (VTA) was investigated.</AbstractText>4P was a prospective, multicenter, observational study conducted in 10 Swiss implanting centers. Patients with a Class I indication according to international guidelines were included and received an ICD with SST. ICD discrimination capability was assessed by evaluating SST performance; therapy efficacy was assessed by rate of VTA conversions by ATP and by rescue shocks.</AbstractText>Overall, 196 patients were included in the analysis with a mean duration of follow-up of 27.7 months (452 patient-years of observation). Patient-specific rather than recommended programming was preferred. Device-detected episodes were frequent (5147 episodes in 146 patients, 74.5%). In 44 patients (22.4%), 1274 episodes were categorized as VTA; only 215 episodes were symptomatic. ATP was the first-line therapy and highly effective (99.9% success rate at the episode level, 100.0% at the patient level). Rescue shocks were rare (66 episodes in 28 patients); 7 shocks in 5 patients (2.6%) were inappropriate. Death and hospitalization rates were low.</AbstractText>In a cohort of non-trial, unselected ICD patients, VTA episodes were frequent. The 4P results confirm the robustness of VTA detection by SST and the effectiveness of ATP treatment, hence limiting overall ICD shock burden.</AbstractText> |
17,935 | Achievement of target SBP without attention to decrease in DBP can increase cardiovascular morbidity in treated arterial hypertension: the Campania Salute Network. | Results of the SPRINT study have influenced recent guidelines on arterial hypertension, in the identification of target SBP, but scarce attention has been paid to the consequences on DBP. However, there is evidence that reducing DBP too much can be harmful.</AbstractText>We analyzed outcome in 4005 treated hypertensive patients (22% obesity, 8% diabetes and 21% current smoking habit) with target attended office SBP less than 140 mmHg, in relation to quintiles of DBP, cardiovascular risk profile and target organ damage (LV hypertrophy, carotid plaque and left atrial dilatation). Composite fatal and nonfatal cardiovascular event was the outcome variable in this analysis (stroke and myocardial infarction, sudden cardiac death, heart failure requiring hospitalization, transient ischemic attack, myocardial revascularization, de novo angina, carotid stenting and atrial fibrillation).</AbstractText>Lower DBP was associated with greater proportion of women and diabetes, older age, decline in kidney function and greater values of LV mass index and left atrial volume and greater prevalence of carotid plaque (all 0.04 < P < 0.0001). The lowest quintile of DBP (74.1 ± 3.7 mmHg) was associated with 1.49 higher hazard of composite cardiovascular events, independently of significant effect of older age, female sex, LV hypertrophy and borderline effect of left atrial dilatation (0.04 < P < 0.001).</AbstractText>Increased risk associated with aggressive reduction of DBP should be balanced with the advantage of reducing aggressively SBP to predict the net benefit of antihypertensive treatment, especially in the oldest old individuals.</AbstractText> |
17,936 | Microvolt T-wave alternans complemented with electrophysiologic study for prediction of ventricular tachyarrhythmias in patients with arrhythmogenic right ventricular cardiomyopathy: a long-term follow-up study. | The long-term predicted value of microvolt T-wave alternans (MTWA) for ventricular tachyarrhythmia in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) remains unclear. Our study explored the characteristics of MTWA and its prognostic value when combined with an electrophysiologic study (EPS) in patients with ARVC.</AbstractText>All patients underwent non-invasive MTWA examination with modified moving average (MMA) analysis and an EPS. A positive event was defined as the first occurrence of sudden cardiac death, documented sustained ventricular tachycardia (VT), ventricular fibrillation, or the administration of appropriate implantable cardioverter defibrillator therapy including shock or anti-tachycardia pacing.</AbstractText>Thirty-five patients with ARVC (age 38.6 ± 11.0 years; 28 males) with preserved left ventricular (LV) function were recruited. The maximal TWA value (MaxValt) was 17.0 (11.0-27.0) μV. Sustained VT was induced in 22 patients by the EPS. During a median follow-up of 99.9 ± 7.7 months, 15 patients had positive clinical events. When inducible VT was combined with the MaxValt, the area under the curve improved from 0.739 to 0.797. The receiver operating characteristic curve showed that a MaxValt of 23.5 μV was the optimal cutoff value to identify positive events. The multivariate Cox regression model for survival showed that MTWA (MaxValt, hazard ratio [HR], 1.06; 95% confidence interval [CI], 1.01-1.11; P = 0.01) and inducible VT (HR, 5.98; 95% CI, 1.33-26.8; P = 0.01) independently predicted positive events in patients with ARVC.</AbstractText>MTWA assessment with MMA analysis complemented by an EPS might provide improved prognostic ability in patients with ARVC with preserved LV function during long-term follow-up.</AbstractText> |
17,937 | Looking back on 15 years of ultrasound-guided alcohol septal ablation for hypertrophic obstructive cardiomyopathy. | <b>Background:</b> Septal reduction remains an important target of current therapeutic modalities in hypertrophic obstructive cardiomyopathy (HOCM). Surgical septal myectomy has long been considered the gold standard in pharmacotherapy-refractory severely symptomatic patients with marked left ventricular outflow tract (LVOT) obstruction. In recent years, percutaneous alcohol septal ablation (ASA) has matured into the preferred strategy for patients with favourable anatomy and no other coexisting surgically amenable disease.<b>Methods:</b> We discuss 26 HOCM patients with persistent dyspnoea, angina or syncope despite optimal medical treatment. Baseline septal wall thickness was 20 ± 3 mm, with peak resting/provoked LVOT gradients of 53 ± 35/112 ± 40 mmHg. Guided by echocardiography, alcohol injection could be restricted to the first septal coronary artery in 85% of patients, provoking basal septal infarction with average troponin rise of 3.0 ng/ml.<b>Results:</b> Eighty-six per cent of patients experienced sustained clinical improvement, associated with a reduction of septal wall thickness to 15 ± 3 mm and resting LVOT gradient to 21 ± 15 mmHg. One of the two non-responders underwent additional septal myectomy 11 years after ASA. Notable adverse events during the follow-up of 7.2 ± 4.7 years included: persistent conduction disturbances (65%) necessitating early postprocedural permanent pacemaker implantation (15%); atrial fibrillation (32%); ventricular tachycardia (4%) and aortic stenosis (14%). Six patients died, of which only 1 cardiac death.<b>Conclusions:</b> Our case series underscores the efficacy of ASA at relieving LVOT obstruction and improving symptoms in properly selected HOCM patients, with acceptably low procedural and long term mortality and morbidity. |
17,938 | Public-Access Defibrillation and Survival of Out-of-Hospital Cardiac Arrest in Public vs. Residential Locations in Japan. | This study assessed whether the dissemination of public-access defibrillation (PAD) at the population level is associated with an increase in neurologically favorable outcomes among patients experiencing ventricular fibrillation (VF) in public vs. residential locations in Japan.Methods and Results:We enrolled adult patients with bystander-witnessed VF between 2013 and 2015. The primary outcome measure was 1-month neurologically favorable outcome defined by cerebral performance category 1 or 2. The number of survivors with neurologically favorable outcome attributed to PAD after VF arrest was estimated by location of arrest. A total of 16,252 adult patients with bystander-witnessed VF arrest were analyzed. In public locations, 29.3% (2,334/7,973) of out-of-hospital cardiac arrest (OHCA) patients received PAD, whereas 1.1% (89/8,279) of OHCA patients received PAD in residential locations. OHCA patients with PAD had significantly better neurological outcomes compared with those without PAD in public locations (51.8% vs. 25.5%, P<0.001), whereas there were no significant differences in neurologically favorable outcome between patients with or without PAD in residential locations (22.5% vs. 18.6%, P=0.357). The total number of patients with neurologically favorable outcomes attributed to PAD was estimated at 615 in public locations, but only 3 in residential locations.</AbstractText>In Japan, when compared with residential locations, PAD works more successfully in public locations for adults with bystander-witnessed VF arrest.</AbstractText> |
17,939 | Single-dose cardioplegia protects myocardium as well as traditional repetitive dosing: A noninferiority randomized study. | The present prospective noninferiority randomized trial was designed to demonstrate the safety and efficacy of a single dose of Custodiol histidine-tryptophan-ketoglutarate compared with repetitive cold-blood cardioplegia.</AbstractText>From October 2012 to May 2014, 110 patients were randomly assigned to 1 of 2 groups: Group 1 (55 patients) received repetitive cold-blood cardioplegia, and group 2 (55 patients) received single-dose Custodiol histidine-tryptophan-ketoglutarate. Isolated aortic valve replacement, isolated mitral valve replacement, and multivalve procedures represented the most frequent operations, with 39 cases (71%) in group 1 and 49 cases (89%) in group 2. There was no difference in cardiopulmonary bypass time (102 ± 26 minutes vs 99 ± 19 minutes, P = .70) or aortic crossclamp time (77 ± 19 minutes vs 74 ± 17 minutes, P = .33). All patients underwent preoperative electrocardiogram and determination of creatine kinase-MB, troponin I, left ventricular ejection fraction, and regional wall motion. Postoperative cardiac biomarkers were checked at 7, 24, and 48 hours, and an echocardiogram was obtained to check for left ventricular function abnormalities.</AbstractText>There was no difference in cardiac biomarkers release between the 2 groups at baseline and 7, 24, and 48 hours postoperatively (creatine kinase, P = .18, troponin P = .23). Left ventricular function was similar between groups preoperatively and at 24 hours after surgery. No death or myocardial infarction was observed in either group. There were no differences in intensive care unit length of stay, incidence of atrial fibrillation, use of inotropes or vasopressors support, time of intubation, or creatinine levels.</AbstractText>A single dose of Custodiol histidine-tryptophan-ketoglutarate cardioplegia is not inferior to repeated cold-blood cardioplegia during elective cardiac surgery.</AbstractText>Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,940 | Comparison of Electrophysiologic Profiles in Pediatric Patients with Incidentally Identified Pre-Excitation Compared with Wolff-Parkinson-White Syndrome. | The rising utilization of screening electrocardiograms has resulted in increased incidental identification of ventricular pre-excitation in pediatric patients. We compared accessory pathways of incidentally identified pre-excitation to Wolff-Parkinson-White Syndrome (WPW) with the aim to identify factors important in preprocedural counseling and planning. This single-center, retrospective study of patients ≤18 years without congenital heart disease identified 227 patients diagnosed with pre-excitation and referred for invasive electrophysiology study between 2008 and 2017. WPW Syndrome was diagnosed in 178 patients, while 49 patients had incidental identification of pre-excitation. Anterograde conduction of incidentally identified accessory pathways was not clinically different between the two cohorts at baseline or upon isoproterenol infusion. However, the proportion of accessory pathways meeting high-risk criteria was significantly lower than in patients diagnosed with WPW, 12% versus 28% (p < 0.05). Retrograde conduction at baseline of incidentally diagnosed accessory pathways was slower with a median block cycle length 365 milliseconds (IQR 260 to 450) versus 290 milliseconds (IQR 260 to 330, p < 0.01). In the incidentally identified cohort, right-sided, paraHisian, and fascicular pathways were more common with fewer attempted ablations (71% vs 94%, p < 0.001) and lower success rate (91% vs 97%, p < 0.001). A binomial logistic regression analysis further indicated patients incidentally identified with pre-excitation were associated with having lower rates of inducible supraventricular tachycardia, atrial fibrillation, and ablations performed, in addition, to having right-sided pathways. In conclusion, as patients with incidentally identified pre-excitation present more frequently for consideration of invasive electrophysiology study, these results impact procedural approaches, technical considerations, patient counseling, and outcome expectations. |
17,941 | Monocyte Chemoattractant Protein-1-Induced Protein in Age-Related Atrial Fibrillation and Its Association with Circulating Fibrosis Biomarkers. | Atrial fibrillation (AF), for which age is an independent risk factor, is the most common persistent arrhythmia. Monocyte chemoattractant protein-1-induced protein (MCPIP), a transcription factor that induces a series of inflammation and cell death procedures, has been indicated to cause cardiomyocyte death in ischemic cardiomyopathy. The objective of this research was to investigate the relationship between age-related AF and MCPIP.</AbstractText>A total of 1,084 participants were included in this study, including 542 AF patients and 542 non-AF controls. Their medical histories were collected and analyzed. Moreover, blood samples were collected, and ELISA tests for expression of the inflammatory factor MCPIP and the fibrosis biomarkers pro-collagen type III N-terminal peptide (PIIINP) and type I collagen C-terminal telopeptide (ICTP) were conducted. Finally, a correlation analysis of these inflammatory factors and biomarkers was performed based on the ELISA results.</AbstractText>We compared the echocardiography results of AF patients and found that the left ventricular ejection fraction and left atrial appendage velocity decreased with age (p < 0.05). Moreover, ELISA analysis of these samples showed that the expression of MCPIP was the highest in elderly patients with AF (p < 0.05), and there was no significant difference in expression between adult AF patients and elderly controls (p > 0.05). Finally, the correlation analysis demonstrated that the expressions of MCPIP, PIIINP, and ICTP were positively correlated in the elderly AF patient group, the adult AF group, and the elderly control group (p < 0.05).</AbstractText>MCPIP expression was higher in age-related AF than in the other patient groups and it was associated with AF-induced fibrosis.</AbstractText>© 2019 S. Karger AG, Basel.</CopyrightInformation> |
17,942 | Epicardial adipose tissue thickness as an independent predictor of ventricular tachycardia recurrence following ablation. | Although several investigations have shown a relationship between increased epicardial adipose tissue (EAT) and atrial fibrillation (AF), the association between EAT and ventricular tachycardia (VT) has not been evaluated.</AbstractText>We investigated the association between EAT and postablation VT recurrence.</AbstractText>Sixty-one consecutive patients (mean age = 62.0 ± 13.9 years) undergoing VT ablation with preprocedural cardiovascular magnetic resonance imaging (CMR) were recruited. EAT thickness was measured using CMR in the right and left atrioventricular grooves (AVGs), right ventricular free wall, and anterior, inferior, and superior interventricular grooves.</AbstractText>During a mean follow-up period of 392.9 ± 180.2 days, postablation VT recurrence occurred in 15 (24.6%) patients. EAT thickness was significantly higher in the VT recurrence group than in the nonrecurrent VT group at the right (18.7 ± 5.7 mm vs 14.1 ± 4.4 mm; P = .012) and left (13.3 ± 3.9 mm vs 10.4 ± 4.1 mm; P = .020) AVGs. The best cut-off points for predicting VT recurrence were calculated as 15.5 mm for the right AVG (area under receiver operating characteristic [ROC] curve = 0.74) and 11.5 mm for the left AVG (area under ROC curve = 0.72). Multivariate Cox regression analysis showed that preprocedural right AVG-EAT (hazard ratio: 1.2; 95% confidence interval: [1.06-1.39], P = .004) was the only independent predictor of VT recurrence after adjustment for covariates. Kaplan-Meier analysis showed a difference for postablation VT recurrence between the 2 groups, with right AVG-EAT thickness cut-off value of <15.5 mm vs ≥15.5 mm (log-rank, P = .003).</AbstractText>We suggested a new possible imaging marker for risk stratification of postablation VT recurrence. A higher EAT may be associated with VT recurrence after catheter ablation of VTs.</AbstractText>Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,943 | Prognostic Value of Global Longitudinal Strain and Etiology After Surgery for Primary Mitral Regurgitation. | This study sought to investigate whether left ventricular (LV) global longitudinal strain (GLS) is associated with long-term outcome after mitral valve (MV) surgery for primary mitral regurgitation (MR) and assess the differences in outcome according to MR etiology: Barlow's disease (BD), fibroelastic deficiency (FED), and forme fruste (FF).</AbstractText>Appropriate timing of MV surgery for primary MR is still challenging and may differ according to the etiology. In these patients, LV-GLS has been proposed as more sensitive measure to detect subtle LV dysfunction as compared with LV ejection fraction.</AbstractText>Echocardiography was performed in 593 patients (64% men, age 65 ± 12 years) with severe primary MR who underwent MV surgery, including assessment of LV-GLS. The etiology (BD, FED, or FF) was defined based on surgical observation. During follow-up, primary endpoint was all-cause mortality and a secondary endpoint included cardiovascular death, heart failure hospitalizations, and cerebrovascular accidents.</AbstractText>During a median follow-up of 6.4 (interquartile range: 3.6 to 10.4) years, 146 patients died (16 within 30 days after surgery), 46 patients were hospitalized for heart failure, and 13 patients had a cerebrovascular accident. Age (hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 1.05 to 1.11; p < 0.001) and LV-GLS (HR: 1.13; 95% CI: 1.06 to 1.21; p < 0.001) were independently associated with all-cause mortality. Patients with LV-GLS >-20.6% (more impaired) showed significant worse survival than did patients with LV-GLS ≤-20.6%; of interest, patients with BD showed similar prognosis compared with FED and FF. In addition, previous atrial fibrillation (HR: 1.70; 95% CI: 1.01 to 2.86; p = 0.045) and LV-GLS (HR: 1.01; 95% CI: 1.01 to 1.15; p = 0.019) were independently associated with the secondary endpoint.</AbstractText>LV-GLS is independently associated with all-cause mortality and cardiovascular events after MV surgery for primary MR and might be helpful to guide surgical timing. Importantly, patients with BD showed similar prognosis when corrected for age, compared with patients with FED or FF.</AbstractText>Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,944 | The neuropeptide GsMTx4 inhibits a mechanosensitive BK channel through the voltage-dependent modification specific to mechano-gating. | The cardiac mechanosensitive BK (Slo1) channels are gated by Ca<sup>2+</sup>, voltage, and membrane stretch. The neuropeptide GsMTx4 is a selective inhibitor of mechanosensitive (MS) channels. It has been reported to suppress stretch-induced cardiac fibrillation in the heart, but the mechanism underlying the specificity and even the targeting channel(s) in the heart remain elusive. Here, we report that GsMTx4 inhibits a stretch-activated BK channel (SAKcaC) in the heart through a modulation specific to mechano-gating. We show that membrane stretching increases while GsMTx4 decreases the open probability (<i>P</i><sub>o</sub>) of SAKcaC. These effects were mostly abolished by the deletion of the STREX axis-regulated (STREX) exon located between RCK1 and RCK2 domains in BK channels. Single-channel kinetics analysis revealed that membrane stretch activates SAKcaC by prolonging the open-time duration (τ<sub>O</sub>) and shortening the closed-time constant (τ<sub>C</sub>). In contrast, GsMTx4 reversed the effects of membrane stretch, suggesting that GsMTx4 inhibits SAKcaC activity by interfering with mechano-gating of the channel. Moreover, GsMTx4 exerted stronger efficacy on SAKcaC under membrane-hyperpolarized/resting conditions. Molecular dynamics simulation study revealed that GsMTx4 appeared to have the ability to penetrate deeply within the bilayer, thus generating strong membrane deformation under the hyperpolarizing/resting conditions. Immunostaining results indicate that BK variants containing STREX are also expressed in mouse ventricular cardiomyocytes. Our results provide common mechanisms of peptide actions on MS channels and may give clues to therapeutic suppression of cardiac arrhythmias caused by excitatory currents through MS channels under hyper-mechanical stress in the heart. |
17,945 | Association Between Time to Defibrillation and Neurologic Outcome in Patients With In-Hospital Cardiac Arrest. | The influence of time to defibrillation in patients with shockable in-hospital cardiac arrest (IHCA) has not been fully assessed. This study investigated the association between time to defibrillation and neurologic outcome in shockable IHCA survivors.</AbstractText>A 7-year retrospective cohort study was conducted using a prospectively collected registry of adult IHCA patients. Patients whose first documented rhythm was pulseless ventricular tachycardia or ventricular fibrillation and who received defibrillation within 5 minutes were included.</AbstractText>Among 1,683 IHCA patients, 261 patients were included. At 28 days, a good neurologic outcome (Cerebral Performance Category score 1 or 2) according to time to defibrillation was seen in 49.0%, 21.1%, 13.4% and 16.5% of patients treated at <2 minutes (n = 128), 2-3 minutes (n = 55), 3-4 minutes (n = 35) and 4-5 minutes (n = 43) after IHCA, respectively. After adjusting for clinical characteristics, a graded inverse association was found after 3 minutes.</AbstractText>A graded inverse association between time to defibrillation and neurologic outcome was observed beyond 3 minutes following cardiac arrest. A target time to defibrillation of <3 minutes may be a practical target goal in resource-limited hospitals.</AbstractText>Copyright © 2019 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,946 | Novel approaches to the management of chronic systolic heart failure: future directions and unanswered questions. | Despite improvements in outcomes in the last few decades for heart failure (HF) with reduced ejection fraction (HFrEF), there still remains a need for novel therapies as many patients incompletely recover with existing therapies and progress to advanced HF. In this review, we will discuss recent advances in the management of HFrEF with a focus on upcoming therapies that hold the greatest promise for clinical use. We will discuss novel pharmacological therapies and areas of uncertainty with existing therapies. We will also discuss the potential utility and controversy surrounding novel interventions for HF such as percutaneous mitral valve repair, atrial fibrillation ablation, and other emerging interventions with positive signals for benefit in HFrEF. Finally, we will summarize the current state of stem cell and gene therapy for HFrEF and future directions. |
17,947 | Study of the effect of obesity on QT-interval among adults. | Obesity affects the different organ systems of human body and has been recognized as a risk factor for the development of many diseases. Most of the cardiovascular diseases develop due to obesity which reflects alterations in either cardiac morphology or conduction defects. These abnormalities are reflected in ECG as prolongation of various intervals. Prolongation of QT-interval has been found to be associated with ventricular arrhythmia and sudden cardiac death.</AbstractText>The aim of the study was to investigate the effect of obesity on QT-interval to assess the risk of development of cardiovascular diseases in early stage.</AbstractText>A cross-sectional study was conducted on 80 cases and 80 controls, which included adults of 18-40 years age groups from both sexes. The cases were obese [body mass index (BMI) >30 kg/m2</sup>] and the controls were nonobese (BMI < 25 kg/m2</sup>). ECG of the cases and controls was recorded and their QT-intervals were calculated and analyzed with BMI by independent samples test.</AbstractText>We found significantly higher QT-intervals in obese group in comparison to that of nonobese group (P</i> = 0.000).</AbstractText>Obesity was found to be associated with prolongation of QT-interval among young obese adults. This prolongation of QT-interval duration increases the possibility of left ventricular enlargement and ventricular fibrillation. Hence the present study helps in creating awareness among obese people so that they can change their lifestyle in order to prevent the onset of the deleterious effects of obesity on their health.</AbstractText> |
17,948 | Management of monomorphic ventricular tachycardia electrical storm in structural heart disease. | Electrical storm (ES) is a life-threatening condition that is defined by three or more episodes of sustained ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate shocks from an implantable cardioverter defibrillator (ICD) within 24 hours. The most common form of ES is monomorphic VT. It carries poor outcome despite all available intervention therapies. The therapies include rapid recognition of the condition, treatment of the reversible causes, ICD-reprogramming, antiarrhythmic drugs, sedation, and catheter ablation (CA). The first line antiarrhythmic drugs are amiodarone and β-blockers with superiority of propranolol over the others. The long-term use of the antiarrhythmic drugs is limited due to their adverse effects and drug-related proarrhythmic effect. The basic mechanism of monomorphic VT is re-entry pathway which can be targeted by CA. CA should be considered in drug refractory ES and patients should be referred in early course of disease. There are reported studies which showed the superiority of CA over the medical treatment in reducing the arrythmia burden and ICD appropriate shock. The survival benefit has been reported after successful ablation of ES in case series but to date no randomized control trial shows mortality benefit. |
17,949 | Utility of <sup>99 m</sup>Tc-Pyrophosphate Scintigraphy in Diagnosing Transthyretin Cardiac Amyloidosis in Real-World Practice. | <b><i>Background:</i></b> Amyloid transthyretin (ATTR) cardiac amyloidosis has now been recognized as one of the major causes of heart failure, especially in elderly patients. The purpose of the present study was to validate the usefulness of technetium-99 m (<sup>99 m</sup>Tc)-pyrophosphate (<sup>99 m</sup>Tc-PYP) scintigraphy in the screening diagnosis for ATTR amyloidosis in daily clinical practice. <b><i>Methods and Results:</i></b> Ninety-eight patients underwent <sup>99 m</sup>Tc-PYP scintigraphy in the previous 3 years (PYP positive/negative, 18/80), of whom 29 underwent concomitant endomyocardial biopsy (ATTR positive/negative, 9/20). The sensitivity and specificity of <sup>99 m</sup>Tc-PYP scintigraphy for the diagnosis of biopsy-proven ATTR amyloidosis were 0.889 and 0.950, respectively. Age, gender, N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level, or electrocardiogram findings did not differ significantly between PYP-positive and PYP-negative patients. Left ventricular (LV) wall thickness was significantly greater in PYP-positive than in PYP-negative patients, but LV ejection fraction or prevalence of atrial fibrillation was similar between groups. In the PYP-positive patients, higher uptake of PYP correlated with younger age and lower NT-proBNP. <b><i>Conclusions:</i></b> <sup>99 m</sup>Tc-PYP scintigraphy was useful, with high sensitivity and specificity in the screening diagnosis for ATTR cardiac amyloidosis, which is difficult to diagnose on clinical characteristics alone. <sup>99 m</sup>Tc-PYP scintigraphy should be considered to elucidate the underlying causes of heart failure, especially in elderly patients based on the higher prevalence of ATTR cardiac amyloidosis in this population. |
17,950 | Corrected QT Interval Prolongation in Pediatric and Young Adult Patients on Methadone for Cancer-Related Pain. | Methadone has been reported to prolong the corrected QT (QTc) interval and increase the risk of torsades de pointes.</AbstractText>Our study examined the frequency of QTc prolongation among pediatric and young adult patients starting methadone for cancer pain.</AbstractText>All patients followed a standardized protocol. Electrocardiograms (ECGs) were obtained at baseline (methadone starting day to 14 days prior), 1-2 weeks, and 4-6 weeks later. QTc values were manually calculated using the Bazett formula. QTc prolongation was defined as ≥460 milliseconds (ms) for prepubertal children, ≥470 ms for pubertal males, and ≥480 ms for pubertal females.</AbstractText>Baseline ECGs were completed in 42 patients. Follow-up ECGs were completed in 38 of 42 (91%) and 31 of 42 (74%) patients at 1-2 weeks and 4-6 weeks, respectively. No patients had prolongation of the QTc at baseline, and 1 of 38 (3%) patients had a prolonged QTc at weeks 1-2. This patient had a history of prolonged QTc that the family did not initially report. No patients had prolongation of the QTc at weeks 4-6. No patients had torsades de pointes or ventricular fibrillation, and none died suddenly. Median (interquartile range [IQR]) baseline QTc was 391 (377-400) ms; median (IQR) 1-2 week follow-up QTc was 399 (374-411) ms (P = .05), and median (IQR) 4-6 week follow-up QTc was 393 (379-423) ms (P = .01).</AbstractText>Clinically significant prolongation of the QTc interval occurred only in one patient who had a history of prolonged QTc. Prolonged QTc is rare in this population.</AbstractText>Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,951 | Remote monitoring: Doomed to let down or an attractive promise? | Device interrogation and management are time consuming, representing a relevant burden for pacing centers. In several situations, patients' management requires additional follow up visits. Remote Monitoring (RM) allows an optimal recall management and a rapid diagnosis of device or lead failure, without the need of additional in office visits. Further it allows a significant delay reduction between the adverse event and the reaction to the alarm, shortening the time needed to make a clinical decision. A role in risk-predicting patient-related outcomes has also been shown. RM permits detection of the arrhythmia from 1 to 5 months in advance compared to in-office visits. Importantly, by using specific algorithms with multiparametric analysis, RM has been studied as a potential instrument to identify early patients on risk of worsening HF using specific algorithms. Although the use of RM in HF setting remains controversial, it has been proposed to improve HF clinical outcomes and survival in clinical trials. In this sense, RM success could require a standardization of process within a management model, that may involve different health care professionals. In this review, we examine recent advances of RM providing an update of this tool through different clinical scenarios. |
17,952 | Early transient recurrence of ventricular fibrillation after catheter ablation of premature ventricular contraction from Purkinje fibers in two patients with myocardial infarction. | Catheter ablation (CA) targeting premature ventricular contraction (PVC) from Purkinje fibers can be an effective therapy for refractory ventricular fibrillation (VF) after myocardial infarction (MI). We experienced two cases in which catheter ablation targeting PVC initiating VF after percutaneous coronary intervention (PCI) in post-MI patients was effective despite transient early recurrences of VF. The first patient (a 68-year-old woman with MI) developed drug-refractory VF 3 days after PCI to the left anterior descending artery (LAD) and left circumflex artery. CA targeting Purkinje potential preceding PVC at the infarcted area eliminated both the PVCs and VF. Three days after the procedure, the VF attacks relapsed by a different type of PVC. However, the VF responded to conventional treatments and disappeared thereafter. In the second patient (an 83-year-old woman with old MI), refractory VF attacks occurred after PCI to the LAD. CA targeting Purkinje potential preceding two distinct types of PVC successfully suppressed the VF. Although the VF relapsed 2 days after CA, it was suppressed by conventional treatment and disappeared the next day. <<b>Learning objective:</b> We report two patients with MI in whom VF attacks were treated by CA targeting triggering PVCs, and these completely disappeared after the process of transient early VF recurrences. Two cases demonstrate that additional CA may not always be necessary even if VF has relapsed within several days after PVC elimination. When recurrences of VF attacks after the first CA are not so frequent, we will be able to observe patient for several days without performing additional CA.>. |
17,953 | Short coupled Torsade de pointes with myocardial injury: A possible sequela of myocarditis. | A 44-year-old woman with previous myocarditis underwent several syncopal events due to self-terminated ventricular fibrillation (VF) with hypokalemia. Electrocardiogram showed a normal QT duration and premature ventricular contraction with a short coupling interval (280 ms), and the R-on-T phenomenon induced Torsade de pointes (TdP) that deteriorated into VF, a condition known as short coupled TdP (ScTdP). Cardiac magnetic resonance imaging showed left ventricular dilatation and diffuse high T2 signal intensity, and endomyocardial biopsy exhibited a failing myocardium. This is a rare case of ScTdP accompanied by a failing myocardium. Some instances of ScTdP may be associated not only with an electrical disorder but also with a structural myocardial disorder. <<b>Leaning Objective:</b> Any cases with short coupled Torsade de pointes (ScTdP) have not reported structural disorders, and ScTdP has been categorized as an idiopathic arrhythmia. This is the first case of ScTdP accompanied by a failing myocardium, which was identified by cardiac magnetic resonance imaging and both light and electron microscopic examination. According to this case, some cases of ScTdP may be associated not only with electrical disorders, but also structural myocardial abnormalities.>. |
17,954 | [The wearable cardioverter defibrillator - temporary protection against sudden cardiac death]. | Ventricular tachycardia or ventricular fibrillation can be terminated by defibrillation and implantable cardioverter defibrillators (ICDs) prevent sudden cardiac death. Since 2001 the wearable cardioverter defibrillator (WCD) has been available to provide temporary protection; it safely and effectively detects and terminates ventricular tachyarrhythmias. VEST (published in 2018) compared the effect of WCD in patients with ejection fraction ≤35 percent following myocardial infarction. Total mortality was reduced but sudden cardiac death did not reach statistical significance. According to European guidelines a WCD could be used to protect patients during the time they are evaluated for ICD; for example, during the three-month period with optimal medical therapy awaiting recovery of a low ejection fraction. It could also be considered during the period following extraction due to endocarditis before reimplantation of ICD or during the waiting period for heart transplant. |
17,955 | Post-cardioversion Improvement in LV Function Defined by 4D Flow Patterns and Energetics in Patients With Atrial Fibrillation. | Atrial fibrillation (AF) is a prevalent cause of cardiovascular morbidity, including thromboembolism and heart failure. Left ventricular dysfunction (LVD) detected in AF patients may be either precursor or consequence of the arrythmia. Successful cardioversion of chronic AF is often followed by a transient period of left atrial (LA) stunning, where depressed mechanical atrial contraction persists despite reinstitution of sinus rhythm. To determine if AF-associated LVD would improve with resolution of LA dysfunction, AF patients were examined immediately and 4 weeks after cardioversion to sinus rhythm. 4D flow cardiovascular magnetic resonance (CMR) assesses ventricular function according to the volumes and energetics of functional components of the LV volume. Previously, described 4D CMR markers of LVD include decreased volume and end-diastolic kinetic energy (KE) of the Direct flow</i>, which is the portion of LV volume that passes directly from inflow to outflow in a single cycle. We hypothesize that impaired LV flow patterns and energetics will be found immediately after cardioversion during atrial stunning, and that those parameters will improve as atrial function returns.</AbstractText>Ten patients with a history of AF underwent CMR 2-3 h (Time-1) and 4 weeks (Time-2), following electrical cardioversion to sinus rhythm. 4D phase-contrast velocity data and morphological images were acquired at a 3T CMR system. Using a previously evaluated method, pathlines were emitted from the LV end diastolic volume (LVEDV) and traced forward and backward in time until end-systole. The LVEDV was automatically separated into four functional flow components whose volume and KE were calculated.</AbstractText>Left atrial fractional area change increased over the follow-up period (P</i> = 0.001), indicating recovery of LA mechanical function. LVEF increased between Time-1 and Time-2 (P</i> = 0.003); LVEDVI did not change (P</i> = 0.319). Over that interval, the ratios of Direct flow</i>/LVEDV volume and KE increased (P</i> = 0.001 and P</i> = 0.003, respectively), while the ratios of Residual volume</i>/LVEDV volume and KE decreased (P</i> = 0.001 and P</i> = 0.005, respectively).</AbstractText>Post-cardioversion recovery of LA function was associated with improvements in conventional and 4D CMR markers of LV function. Flow-specific measures demonstrate the negative but potentially reversible impact of LA dysfunction on volume and energetic aspects of LV function.</AbstractText> |
17,956 | Impact of coronary artery disease and revascularization on recurrence of atrial fibrillation after catheter ablation: Importance of ischemia in managing atrial fibrillation. | There are few studies analyzing the association between the presence of coronary artery disease (CAD) and recurrence of atrial fibrillation (AF). This study evaluated the clinical impact of concomitant CAD and coronary revascularization on the recurrence of AF after catheter ablation.</AbstractText>From April 2008 to December 2015, 700 consecutive patients were treated with pulmonary vein isolation for AF as the initial procedure. Of those, 681 patients who simultaneously underwent coronary angiography were investigated. Patients with at least one coronary stenosis (≥70%) were classified as having obstructive CAD. Of 681 patients, 90 patients had CAD and 42 patients underwent percutaneous coronary intervention (PCI) for lesions with perfusion abnormalities on single-photon emission tomography. The recurrence of AF was significantly more frequent in patients with CAD (56%) than in those without CAD (39%) (P = .0011). On multivariable analysis, the predictors of AF recurrence were persistent or long-standing persistent AF [hazard ratio (HR): 1.36; 95% confidence interval (CI): 1.04-1.77; P = .023], left atrial diameter (HR: 1.04; 95% CI: 1.02-1.06; P < .0001), and concomitant CAD (HR: 1.45; 95% CI: 1.05-1.97; P = .024). The recurrence of AF in patients with PCI (38%) was significantly lower than in those without PCI (72%) (P = .0006), and E/E' significantly improved in patients with PCI (71%) than in those without PCI (42%; P = .001). Performing PCI for concomitant CAD significantly reduced AF recurrence (HR: 0.39; 95% CI: 0.20-0.72; P = .002).</AbstractText>Patients with CAD had a significantly higher rate of AF recurrence than those without CAD. Coronary revascularization may reduce the recurrence of AF with improvement of left ventricular diastolic function.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,957 | Catheter ablation of atrial fibrillation in patients with heart failure with reduced ejection fraction: Real world experience from six European centers. | Catheter ablation of atrial fibrillation (AF) has been recently shown to have an impact on the outcome of patients with heart failure and reduced LV ejection fraction (LVEF). We aimed to assess patients with reduced LVEF referred to catheter ablation of AF, and the efficacy and safety of this procedure compared with healthier patients.</AbstractText>2083 consecutive procedures of catheter ablation of AF in six centers were divided into two groups on the basis of LVEF (≤ vs >35%) and comparisons were performed regarding procedural safety and efficacy.</AbstractText>Only 51 (2.4%) of patients had low LVEF. Complication rate was comparable: 8.0% vs 6.9% (P = .760). Low LVEF patients are more frequently in persistent AF at the time of the procedure, have a higher degree of left atrial dilation, and higher CHA2</sub> DS2</sub> VASc score. The rate of atrial arrhythmia relapse post-blanking period in the first 12 months was higher in the low LVEF group: 58.0% vs 37.6% (P < .001). During a median follow-up of 14 months (IQR 5-24), after adjusting for all baseline differences, AF duration, paroxysmal AF, CHA2</sub> DS2</sub> VASc score, BMI, and indexed LA volume were independent predictors of relapse. LVEF and LVEF ≤ 35% were not identified as predictors of relapse.</AbstractText>Patients with reduced LVEF account for only a minority of patients undergoing catheter ablation of AF. However, ablation appears to be as safe as for the general population, and albeit the efficacy seems lower, this appears to be driven by other comorbidities or features, which are more frequent in this population.</AbstractText>© 2019 Wiley Periodicals, Inc.</CopyrightInformation> |
17,958 | Digitalis Therapy and Risk of Recurrent Ventricular Tachyarrhythmias and ICD Therapies in Atrial Fibrillation and Heart Failure. | This study sought to assess the impact of treatment with digitalis on recurrences of ventricular tachyarrhythmias in implantable cardioverter defibrillator (ICD) recipients with atrial fibrillation (AF) and heart failure (HF).</AbstractText>The data regarding outcomes of digitalis therapy in ICD recipients are limited.</AbstractText>A large retrospective registry was used, including consecutive ICD recipients with episodes of ventricular tachyarrhythmia between 2002 and 2016. Patients treated with digitalis were compared to patients without digitalis treatment. The primary prognostic outcome was first recurrence of ventricular tachyarrhythmia at 5 years. Kaplan-Meier and multivariable Cox regression analyses were applied.</AbstractText>A total of 394 ICD recipients with AF and/or HF was included (26% with digitalis treatment and 74% without). Digitalis treatment was associated with decreased freedom from recurrent ventricular tachy-arrhythmias (HR = 1.423; 95% CI 1.047-1.934; p = 0.023). Accordingly, digitalis treatment was associated with decreased freedom from appropriate ICD therapies (HR = 1.622; 95% CI 1.166-2.256; p = 0.004) and, moreover, higher rates of rehospitalization (38 vs. 21%; p = 0.001) and all-cause mortality (33 vs. 20%; p = 0.011).</AbstractText>Among ICD recipients suffering from AF and HF, treatment with digitalis was associated with increased rates of recurrent ventricular tachyarrhythmias and ICD therapies. However, the endpoints may also have been driven by interactions between digitalis, AF, and HF.</AbstractText>© 2019 S. Karger AG, Basel.</CopyrightInformation> |
17,959 | Transforming Growth Factor Beta 1 and Vascular Risk in Alcoholics. | Transforming growth factor beta-1 (TGF-β1) is a pleiotropic cytokine. Its relationship with atherosclerosis is debatable, protective or deleterious effects have been described. Alcoholics are at increased vascular risk. Although TGF-β1 is increased in alcoholics, its role on vascular risk factors has not been analyzed. This is the objective of this study.</AbstractText>79 heavy alcoholics and 34 controls were included. Calcium deposition in the aortic arch was assessed in the plain thorax X-ray film. Ankle-brachial index was recorded in 48 patients. All the patients underwent complete laboratory evaluation, including serum levels of TGF-β1, tumor necrosis factor (TNF)-α, interleukin (IL)-4, IL-6, and interferon-γ (IFN-γ).We analyzed the relationships between TGF-β1 and vascular risk factors by both univariate (parametric or non parametric tests), or multivariate analysis to discern on which variables TGF-β1 levels depend.</AbstractText>Serum TGF-β1 levels were higher among patients (t = 2.73; P = 0.008), but no differences exist among cirrhotics (17246 ± 11,021 pg/mL) and non-cirrhotics (21,340 ± 12,442 pg/mL). TGF-β1 showed significant correlations with total cholesterol (r = 0.28; P = 0.017) and HDL- cholesterol (r = 0.25; P = 0.042), and inverse correlations with body mass index (BMI; ρ = -0.37; P = 0.004), IL-4 (ρ = -0.31; P = 0.009), INF-γ (ρ = -0.28; P = 0.001), and IL-6 (ρ = -0.38; P = 0.001). By multivariate analysis, only BMI, IL-6 and HDL-cholesterol showed independent relationships with TGF-β1. No relationships were observed with ankle-brachial index or calcium in the aortic arch, hypertension, diabetes, left ventricular hypertrophy or atrial fibrillation.</AbstractText>TGF-β1 levels are increased in alcoholics, but are unrelated to vessel wall calcification or arterial stiffness.</AbstractText>© The Author(s) 2019. Medical Council on Alcohol and Oxford University Press. All rights reserved.</CopyrightInformation> |
17,960 | Effects of Aortic Valve Replacement on Left Ventricular Diastolic Function in Patients With Aortic Valve Stenosis. | The afterload increase imposed by severe aortic valve stenosis (AS) creates concentric left ventricular (LV) remodeling and diastolic dysfunction (DD), which are both markers of poor clinical outcome. Ideally, a correctly timed surgery for isolated AS can reverse the LV remodeling. However, data on LV DD after aortic valve replacement (AVR) are sparse and contrasting. Aims of the study are to define the markers of a favorable evolution of the DD at follow-up. Patients with severe isolated AS, scheduled for AVR were prospectively enrolled. Transthoracic echocardiography with DD assessment was performed before surgery, and at 12 months after surgery. Global LV longitudinal and circumferential strain, peak atrial longitudinal and contraction strain (PALS, PACS) were obtained at baseline. LV septal biopsy to assess fibrosis was performed at the time of AVR. Sixty-seven patients were enrolled, age 72 ± 8 years, 66% female, ejection fraction 61 ± 8%, E/e' 13 ± 6, PALS 23 ± 7%. Normal estimated left atrial pressure was detected in 19/67 (28%) versus 43/67 (64%) at follow-up (p <0.0001). In the 37 patients with biopsy available, fibrosis was 24 ± 12%. PALS and AS severity were correlated with LV fibrosis (R<sup>2</sup> = 0.19; p = 0.006, and R<sup>2</sup> = 0.15; p = 0.02, respectively). PALS (odds ratio: 1.19 [1.05 to 1.41], p = 0.02) and PACS (odds ratio: 1.24 [1.06 to 1.50], p = 0.006) were the only baseline noninvasive parameters independently associated with normal left atrial pressure at follow-up. Mean follow-up time was 791 ± 245 days, and 8 (12%) patients had cardiovascular events (death, hospital admission due to heart failure or ischemic disease, and onset of atrial fibrillation). Myocardial fibrosis (p = 0.05), baseline PALS (p = 0.004), and PACS (p = 0.03) were associated with cardiovascular events. In conclusion, LV diastolic function generally improves after AVR for severe AS. Baseline PALS, PACS, and LV fibrosis were related to the DD and clinical outcome at follow-up; these parameters might cue a better diastolic response to the afterload correction. |
17,961 | Early recurrent arrhythmias after out-of-hospital cardiac arrest associated with obstructive coronary artery disease: Analysis of the PROCAT registry. | After out-of-hospital cardiac arrest (OHCA) associated with obstructive coronary artery disease (CAD), the risk of recurrence during the early period is unclear and the indication for anti-arrhythmic treatment is debated. We assessed the incidence and predisposing factors for severe cardiac arrhythmias in this population.</AbstractText>Retrospective study in a cardiac arrest center.</AbstractText>The primary endpoint was the occurrence of major cardiac arrhythmias from hospital admission to intensive care unit (ICU) discharge in patients admitted after an OHCA associated with obstructive CAD. A major arrhythmia was defined as any arrhythmic event (auricular or ventricular) associated with cardiac arrest recurrence and/or severe arterial hypotension. Secondary outcomes were time from ICU admission to arrhythmia occurrence and all-cause in-ICU mortality. Risk factors for recurrence of a major arrhythmia were assessed using multivariate analysis.</AbstractText>We included all consecutive OHCA patients resuscitated from ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as initial rhythm associated with obstructive CAD, and who had a successful primary percutaneous coronary intervention.</AbstractText>None.</AbstractText>Among 256 patients, a major arrhythmia occurred in 29 (11.3%), within the first 24 h in 79.3% of cases and were mostly VF (44.8%). Mortality rate was significantly increased in patients with major arrhythmia recurrence (69% vs 41%; p = 0.006). Factor significantly associated with recurrence of severe arrhythmia was male gender (OR 0.32 [0.12-0.92]; p = 0.034). Treatment with prophylactic anti-arrhythmic in the ICU was not associated with a change in the risk of recurrence (OR 0.85 [0.21-3.65], p = 0.82).</AbstractText>An early recurrence of major arrhythmia was observed in more than 10% of post-cardiac arrest patients. These events happened mostly within the first 24 h. The interest of prophylactic anti-arrhythmic treatment remains to be evaluated in this population.</AbstractText>Copyright © 2019 Elsevier B.V. All rights reserved.</CopyrightInformation> |
17,962 | Duration of cardiac arrest requires different ventilation volumes during cardiopulmonary resuscitation in a pig model. | There are few studies examining the ventilation strategies recommended by current CPR guidelines. We investigated the influence of different minute volume applying to untreated cardiac arrest with different duration, on resuscitation effects in a pig model. 32 Landrace pigs with 4 or 8 min (16 pigs each) ventricular fibrillation (VF) randomly received two ventilation strategies during CPR. "Guideline" groups received mechanical ventilation with a tidal volume of 7 ml/kg and a frequency of 10/min, while "Baseline" groups received a tidal volume (10 ml/kg) and a frequency used at baseline to maintain an end-tidal PCO<sub>2</sub> (P<sub>ET</sub>CO<sub>2</sub>) between 35 and 40 mmHg before VF. Mean airway pressures and intrathoracic pressures (P<sub>IT</sub>) in the Baseline-4 min group were significantly higher than those in the Guideline-4 min group (all P < 0.05). Similar results were observed in the 8 min pigs, except for no significant difference in minimal P<sub>IT</sub> and P<sub>ET</sub>CO<sub>2</sub> during 10 min of CPR. Venous pH and venous oxygen saturation were significantly higher in the Baseline-8 min group compared to the Guideline-8 min group (all P < 0.05). Aortic pressure in the Baseline-8 min group was higher than in the Guideline-8 min group. Seven pigs in each subgroup of 4 min VF models achieved the return of spontaneous circulation (ROSC). Higher ROSC was observed in the Baseline-8 min group than in the Guideline-8 min group (87.5% vs. 37.5%, P = 0.039). For 4 min VF but not 8 min VF, a guideline-recommended ventilation strategy had satisfactory results during CPR. A higher minute ventilation resulted in better outcomes for subjects with 8 min of untreated VF through thoracic pump. |
17,963 | A Case of Left Ventricular Noncompaction Presenting as Atrial Fibrillation. | Ventricular noncompaction is a rare congenital cardiomyopathy resulting from failure in cardiac embryogenesis. Both left and right ventricular involvement has been reported in nature. We present a case of a 69-year-old male presenting with atrial fibrillation complicated with in-hospital cardiac arrest in the setting of left ventricular noncompaction (LVNC). Our case demonstrates the fatal nature of this disease entity thus demanding a high index of suspicion for early detection and treatment. |
17,964 | An illustrative case of endocardial fibroelastosis and recalcitrant intracardiac thrombosis: a case report. | Endocardial Fibroelastosis is diffuse, accentuated proliferation of ventricular endocardium causing a rare form of restrictive cardiomyopathy in both children and adults. It is an incompletely understood cause of heart failure predominantly in Sub-Saharan Africa associated with high morbidity and mortality. Atrial fibrillation and thrombus formation are common accompanying complications and portend a poor prognosis. Due to rarity of the condition in the developed countries and lack of evidence based options, the optimal strategy for anticoagulation is unclear.</AbstractText>Herein, we describe a relatively asymptomatic patient with endocardial fibroelastosis who has been found to have atrial fibrillation and a large thrombus in the right atrium. Currently, there is no evidence-based strategy in the management of endocardial fibroelastosis-associated intracardiac thrombus. This case report illustrates a scenario by which the use of apixaban potentially benefited or prevented the thrombus formation compared with warfarin as demonstrated by imaging findings.</AbstractText>The patients with endocardial fibroelastosis are at risk of developing intracardiac thrombus due to sticky substrate lining cardiac chambers while being relatively asymptomatic. No directed therapy is known for the management of heart failure and any complications of subsequent arrhythmias. The general recommendations follow those of same conditions in other hosts. Novel oral anticoagulant agents can be considered in the treatment of atrial thrombus in the appropriate settings.</AbstractText> |
17,965 | The Effect of Bronchial Asthma on Interatrial Electromechanical Delay Coupling Obtained Using Tissue Doppler Imaging. | Asthma is a predisposing factor for the development of atrial fibrillation. Asthma disturbs the electrophysiology in the right and left atrium. The aim of this study was to evaluate atrial electromechanical delay by coupling obtained from tissue Doppler imaging (TDI) in children.</AbstractText>A cross-sectional study was conducted on 50 patients with Bronchial Asthma, compared with 50 healthy children. The intra-right atrial conduction time (IRCT), intra-left atrial conduction time (ILCT), and interatrial conduction time (IACT) were calculated. The function of systolic and diastolic right ventricular (RV) was assessed by TDI, conventional echocardiography, and pulse Doppler wave. The pulmonary function test was carried out for all the subjects by spirometry. We used an independent Student's t</i> test and Pearson's correlation test for analyzing the data.</AbstractText>The findings revealed normal shape in both atrial between the two groups. The diastolic RV function was not significantly different between the subjects as measured by the pulse wave Doppler in the tricuspid flow. Patients in the experimental group had significantly higher intra and interatrial electromechanical delays (P=0.007) than the control group. This difference was statistically significant with regard to IRCT (P=0.0001) and IACT (P=0.005). IRCT/IACT and myocardia performance index (r=0.35, P=0.004; and r=0.52, P=0.008) correlated with isovolumetric relaxation time (r=0.46, P=0.003; and r=0.58, P=0.008).</AbstractText>We found that IRCT and IACT prolonged in pediatrics with asthma. Also, it was found that there was a correlation between IRCT and IACT, on one hand, and RV myocardial performance index, on the other hand, but they were not related to TDI diastolic parameters.</AbstractText> |
17,966 | Outcomes following cardiopulmonary resuscitation in an emergency department of a low- and middle-income country. | Cardiopulmonary resuscitation (CPR) is a key component of emergency care following cardiac arrest. A better understanding of factors that influence CPR outcomes and their prognostic implications would help guide care. A retrospective analysis of 800 adult patients that sustained an in- or out-of-hospital cardiac arrest and underwent CPR in the emergency department of a tertiary care facility in Karachi, Pakistan, between 2008 and 15 was conducted.</AbstractText>Patient demographics, clinical history, and CPR characteristics data were collected. Logistic regression model was applied to assess predictors of return of spontaneous circulation and survival to discharge. Analysis was conducted using SPSS v.21.0.</AbstractText>Four hundred sixty-eight patients met the study's inclusion criteria, and overall return of spontaneous circulation and survival to discharge were achieved in 128 (27.4%) and 35 (7.5%) patients respectively. Mean age of patients sustaining return of spontaneous circulation was 52 years and that of survival to discharge was 49 years. The independent predictors of return of spontaneous circulation included age ≤ 49 years, witnessed arrest, ≤ 30 min interval between collapse-to-start, and 1-4 shocks given during CPR (aOR (95% CI) 2.2 (1.3-3.6), 1.9 (1.0-3.7), 14.6 (4.9-43.4), and 3.0 (1.4-6.4) respectively), whereas, age ≤ 52 years, bystander resuscitation, and initial rhythm documented (pulseless electrical activity and ventricular fibrillation) were independent predictors of survival to discharge (aOR (95% CI) 2.5 (0.9-6.5), 1.4 (0.5-3.8), 5.3 (1.5-18.4), and 3.1 (1.0-10.2) respectively).</AbstractText>Our study notes that while the majority of arrests occur out of the hospital, only a small proportion of those arrests receive on-site CPR, which is a key contributor to unfavorable outcomes in this group. It is recommended that effective pre-hospital emergency care systems be established in developing countries which could potentially improve post-arrest outcomes. Younger patients, CPR initiation soon after arrest, presenting rhythm of pulseless ventricular tachycardia and ventricular fibrillation, and those requiring up to four shocks to revive are more likely to achieve favorable outcomes.</AbstractText> |
17,967 | Commotio cordis and L-type calcium channel mutation: Is there a link? | Commotio cordis is a rare phenomenon when ventricular fibrillation and sudden death occurs with a blunt, nonpenetrating blow to the chest. Individual susceptibility to commotio cordis has been demonstrated in swine models, and might be present in humans as well. We report a case of commotio cordis in an adolescent with a heterozygous mutation on the gene CACNA1C, encoding for an L-type calcium channel expressed in the heart. This genetic mutation has been previously associated with a phenotype of long-QT syndrome; however, this was not demonstrated in our patient despite extensive investigations. To the best of our knowledge, this is the first report of commotio cordis in which an ion-channel gene mutation involved in repolarization abnormalities has been documented. This finding might corroborate the hypothesis that a genetic predisposition plays a role in the individual susceptibility to this rare cause of cardiac arrest. |
17,968 | Prediction of ventricular arrhythmias in patients with a spontaneous Brugada type 1 pattern: the key is in the electrocardiogram. | There is currently no reliable tool to quantify the risks of ventricular fibrillation or sudden cardiac arrest (VF/SCA) in patients with spontaneous Brugada type 1 pattern (BrT1). Previous studies showed that electrocardiographic (ECG) markers of depolarization or repolarization disorders might indicate elevated risk. We aimed to design a VF/SCA risk prediction model based on ECG analyses for adult patients with spontaneous BrT1.</AbstractText>This retrospective multicentre international study analysed ECG data from 115 patients (mean age 45.1 ± 12.8 years, 105 males) with spontaneous BrT1. Of these, 45 patients had experienced VF/SCA and 70 patients did not experience VF/SCA. Among 10 ECG markers, a univariate analysis showed significant associations between VF/SCA and maximum corrected Tpeak-Tend intervals ≥100 ms in precordial leads (LMaxTpec) (P < 0.001), BrT1 in a peripheral lead (pT1) (P = 0.004), early repolarization in inferolateral leads (ER) (P < 0.001), and QRS duration ≥120 ms in lead V2 (P = 0.002). The Cox multivariate analysis revealed four predictors of VF/SCA: the LMaxTpec [hazard ratio (HR) 8.3, 95% confidence interval (CI) 2.4-28.5; P < 0.001], LMaxTpec + ER (HR 14.9, 95% CI 4.2-53.1; P < 0.001), LMaxTpec + pT1 (HR 17.2, 95% CI 4.1-72; P < 0.001), and LMaxTpec + pT1 + ER (HR 23.5, 95% CI 6-93; P < 0.001). Our multidimensional penalized spline model predicted the 1-year risk of VF/SCA, based on age and these markers.</AbstractText>LMaxTpec and its association with pT1 and/or ER indicated elevated VF/SCA risk in adult patients with spontaneous BrT1. We successfully developed a simple risk prediction model based on age and these ECG markers.</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> |
17,969 | Action Potential Triangulation Explains Acute Proarrhythmic Effect of Aliskiren in a Whole-Heart Model of Atrial Fibrillation. | Recent experimental studies showed a protective effect of the renin inhibitor aliskiren regarding atrial structural remodeling. Purpose of this study was to assess acute electrophysiologic effects of aliskiren in a whole-heart model of atrial fibrillation (AF) and to investigate its impact on the ventricle. Twelve rabbit hearts were excised, retrogradely perfused, and paced at different cycle lengths. To enhance atrial vulnerability, a combination of acetylcholine (ACh) and isoproterenol (Iso) was infused and significantly reduced atrial action potential duration (aAPD<sub>90</sub>) and atrial effective refractory period (aERP). Additional infusion of aliskiren prolonged aAPD<sub>90</sub> but did not alter aERP. A triangulation of action potential with ACh/Iso and a further triangulation after treatment with aliskiren were noted. Vulnerability to AF was tested by employing trains of burst pacing. Administration of ACh/Iso provoked more episodes of AF (baseline: 26 episodes, Iso/Ach: 48 episodes). Additional treatment with aliskiren induced AF significantly more often (108 episodes). Another nine hearts were perfused with aliskiren to examine its ventricular effects. Infusion with aliskiren abbreviated ventricular APD<sub>90</sub> and ERP. Utilizing programmed ventricular stimulation, a trend towards more ventricular arrhythmias in aliskiren-treated hearts was observed. Though aliskiren did not reduce aAPD<sub>90</sub> or aERP, acute treatment with aliskiren promoted AF. Triangulation of atrial action potentials, which is an established risk factor for ventricular proarrhythmia, may contribute to the increased atrial vulnerability. This effect may interfere with its recently demonstrated beneficial properties in atrial remodeling. Of note, aliskiren might have a proarrhythmic effect on the ventricular level. |
17,970 | Coronary arteriovenous malformation in a dog with a complex arrhythmia and hypothyroidism. | A four-year-old Japanese Akita was referred for investigation of lethargy, exercise intolerance, and an irregular heart rhythm. He was diagnosed with atrial fibrillation, a complex ventricular arrhythmia, and hypothyroidism. Echocardiography identified a nest of anomalous vessels surrounding the heart and shunting into the pulmonary artery. Computed tomography confirmed a coronary arteriovenous malformation consisting of a coronary-to-pulmonary arterial communication and an associated complex nest of tortuous vessels, which was thought to be an incidental finding. Clinical signs improved with levothyroxine and antiarrhythmic treatment. Describing an unusual coronary artery anomaly as well, this case serves as a reminder to critically evaluate the hemodynamic significance of structural cardiac disease and to screen for systemic disease in patients with arrhythmias. |
17,971 | Spironolactone and perioperative atrial fibrillation occurrence in cardiac surgery patients: Rationale and design of the ALDOCURE trial. | After artery bypass grafting (CABG), the presence of perioperative AF (POAF) is associated with greater short- and long-term cardiovascular morbidity. Underlying POAF mechanisms are complex and include the presence of an arrhythmogenic substrate, cardiac fibrosis and electrical remodeling. Aldosterone is a key component in this process. We hypothesize that perioperative mineralocorticoid receptor (MR) blockade may decrease the POAF incidence in patients with a left ventricular ejection fraction (LVEF) ≥50% who are referred for CABG with or without aortic valve replacement (AVR).</AbstractText>The ALDOCURE trial (NCT03551548) will be a multicenter, randomized, double-blind, placebo-controlled trial testing the superiority of a low-cost MR antagonist (MRA, spironolactone) on POAF in 1500 adults referred for on-pump elective CABG surgery with or without AVR, without any history of heart failure or atrial arrhythmia. The primary efficacy end point is the occurrence of POAF from randomization to within 5 days after surgery, assessed in a standardized manner. The main secondary efficacy end points include the following: postoperative AF occurring within 5 days after cardiac surgery, perioperative myocardial injury, major cardiovascular events and death occurring within 30 days of surgery, hospital and intensive care unit length of stay, need for readmission, LVEF at discharge and significant ventricular arrhythmias within 5 days after surgery. Safety end points, including blood pressure, serum potassium levels and renal function, will be monitored regularly throughout the trial duration.</AbstractText>The ALDOCURE trial will assess the effectiveness of spironolactone in addition to standard therapy for reducing POAF in patients undergoing CABG.</AbstractText>NCT03551548.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,972 | A de novo gain-of-function KCND3 mutation in early repolarization syndrome. | Early repolarization syndrome (ERS) is characterized by J-point elevation on electrocardiograms and ventricular fibrillation (VF). Early repolarization arises from augmentation of the transmural electrical gradient in the cardiac action potential; therefore, the transient outward potassium current (Ito</sub>) has been regarded as a key candidate current for elucidating the mechanism of ERS. KCND3 encoding Kv4.3, an α-subunit of the Ito</sub> channel, is considered as one of target genes.</AbstractText>The purpose of this study was to search for novel KCND3 mutations associated with ERS and to clarify the pathogenesis.</AbstractText>We performed genetic screening for 11 unrelated probands with ERS and analyzed the electrophysiological properties of detected mutations by patch-clamp methods.</AbstractText>A novel de novo KCND3 heterozygous mutation, Gly306Ala (c.917g>c), was found in 1 proband. The proband was a 12-year-old boy, who suffered VF storm and showed significant J-point elevation in multiple leads. Intravenous isoproterenol and subsequent administration of quinidine were effective in preventing VF recurrence and restored the J-point elevation. In electrophysiological analysis, cultured cells expressing mutant Kv4.3 showed significantly increased current densities, slow inactivation, and slow recovery from inactivation compared to wild type. Extracellular application of quinidine significantly restored the inactivation time course in mutant Kv4.3. A simulation study confirmed the relationship between the novel KCND3 mutation and early repolarization on electrocardiograms.</AbstractText>A novel KCND3 heterozygous mutation was found to be associated with ERS. The pathogenesis can be explained by the increased Ito</sub>. Genetic screening for KCND3 could be useful for understanding the pathogenesis and selecting effective treatment.</AbstractText>Copyright © 2019. Published by Elsevier Inc.</CopyrightInformation> |
17,973 | Changing the management of refractory ventricular fibrillation: The consideration of earlier utilization of dual sequential defibrillation. | Dual Sequential Defibrillation (DSD) has shown promise in the management of refractory ventricular fibrillation (RVF). In the recent past, there have been a number of reports on the topic with varying results. Some studies have concluded that DSD provides no benefit over standard defibrillation therapy of RVF in terms of survival and neurological outcome. In fact, termination of RVF and achieving return of spontaneous circulation (ROSC) are achieved quite frequently in patients with DSD. Unfortunately, DSD has been utilized very late in the course of resuscitation, likely masking a great deal of its potential benefit. Interventions at this later phase of resuscitation are much less likely to produce a beneficial outcome, regardless of their ability to impact the course of events. It is suggested that earlier use of DSD can potentially improve ROSC, ultimate survival, and neurological outcome. After a review of the existing literature on the topic, we will propose that DSD be considered for use at a much earlier time in the resuscitation of patients with RVF. In addition to the consideration of its use in resuscitation, clinicians and device manufacturers must also address the impact on the two defibrillation devices employed in DSD due to the potential for damage and resultant defibrillator dysfunction. |
17,974 | Propensity-Matched Comparison of Oral Anticoagulation Versus Antiplatelet Therapy After Left Atrial Appendage Closure With WATCHMAN. | In this propensity-matched analysis of post-left atrial appendage closure antithrombotic therapy, the safety and effectiveness of oral anticoagulation (OAC) and antiplatelet therapy (APT) were compared.</AbstractText>Left atrial appendage closure with the WATCHMAN device is an alternative to OAC in patients with nonvalvular atrial fibrillation, who are at high bleeding risk. Initial trials included 45 days of post-implantation OAC, but registry data suggest that APT may suffice.</AbstractText>Patients from the PROTECT-AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation), PREVAIL (Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy), CAP (Continued Access to PROTECT-AF), CAP2 (Continued Access to PREVAIL), ASAP (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology), and EWOLUTION (Registry on WATCHMAN Outcomes in Real-Life Utilization) trials receiving either OAC or APT post-implantation were matched and compared for nonprocedural bleeding and stroke or systemic thromboembolism over 6 months following implantation. Each patient on APT was matched with 2 patients on OAC, with propensity scores derived from age, sex, congestive heart failure, hypertension, diabetes, prior transient ischemic attack or stroke, peripheral vascular disease, left ventricular ejection fraction, renal impairment, and different atrial fibrillation subtypes.</AbstractText>The cohort on OAC (n = 1,018; 95% receiving warfarin and 5% receiving nonwarfarin OAC) was prescribed 45-day OAC post-implantation (92% also received single APT), followed by 6-month single or dual APT. The cohort on APT (n = 509; 91% receiving dual APT and 9% receiving single APT) received APT for variable durations. Six-month freedom from nonprocedural major bleeding was similar (OAC, 95.7%; APT, 95.5%; p = 0.775) despite more early bleeds with OAC. Freedom from thromboembolism beyond 7 days was similar between groups (OAC, 98.8%; APT, 99.4%; p = 0.089). However, device-related thrombosis was more frequent with APT (OAC, 1.4%; APT, 3.1%; p = 0.018).</AbstractText>After left atrial appendage closure with the WATCHMAN, although device-related thrombosis was more common with APT, both APT and OAC strategies resulted in similar safety and efficacy endpoints.</AbstractText>Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,975 | Calmodulin mutations and life-threatening cardiac arrhythmias: insights from the International Calmodulinopathy Registry. | Calmodulinopathies are rare life-threatening arrhythmia syndromes which affect mostly young individuals and are, caused by mutations in any of the three genes (CALM 1-3) that encode identical calmodulin proteins. We established the International Calmodulinopathy Registry (ICalmR) to understand the natural history, clinical features, and response to therapy of patients with a CALM-mediated arrhythmia syndrome.</AbstractText>A dedicated Case Report File was created to collect demographic, clinical, and genetic information. ICalmR has enrolled 74 subjects, with a variant in the CALM1 (n = 36), CALM2 (n = 23), or CALM3 (n = 15) genes. Sixty-four (86.5%) were symptomatic and the 10-year cumulative mortality was 27%. The two prevalent phenotypes are long QT syndrome (LQTS; CALM-LQTS, n = 36, 49%) and catecholaminergic polymorphic ventricular tachycardia (CPVT; CALM-CPVT, n = 21, 28%). CALM-LQTS patients have extremely prolonged QTc intervals (594 ± 73 ms), high prevalence (78%) of life-threatening arrhythmias with median age at onset of 1.5 years [interquartile range (IQR) 0.1-5.5 years] and poor response to therapies. Most electrocardiograms (ECGs) show late onset peaked T waves. All CALM-CPVT patients were symptomatic with median age of onset of 6.0 years (IQR 3.0-8.5 years). Basal ECG frequently shows prominent U waves. Other CALM-related phenotypes are idiopathic ventricular fibrillation (IVF, n = 7), sudden unexplained death (SUD, n = 4), overlapping features of CPVT/LQTS (n = 3), and predominant neurological phenotype (n = 1). Cardiac structural abnormalities and neurological features were present in 18 and 13 patients, respectively.</AbstractText>Calmodulinopathies are largely characterized by adrenergically-induced life-threatening arrhythmias. Available therapies are disquietingly insufficient, especially in CALM-LQTS. Combination therapy with drugs, sympathectomy, and devices should be considered.</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> |
17,976 | Treatment with verapamil for restoration of sinus rhythm in atrial fibrillation with rapid ventricular response: A case report. | Atrial fibrillation (AF) is a common arrhythmia disease that can cause thromboembolic disease and/or heart failure, resulting in increased mortality. Propafenone, amiodarone, and flecainide are recommended for converting AF to sinus rhythm. Beta blockers, verapamil, diltiazem, and digoxin are recommended for controlling AF with fast ventricular rate (VR). In this case report, we found that verapamil successfully converted AF into sinus rhythm.</AbstractText>A 92-year-old woman presented with fast VR AF with a history of coronary heart disease, hypertension, and diabetes.</AbstractText>Verapamil can successfully convert AF into sinus rhythm.</AbstractText>The patient was treated with amiodarone or propafenone, yet still had AF. After stopping amiodarone and propafenone, the patient was given verapamil to control the VR, and following 9 days of treatment the patient switched to sinus rhythm. When verapamil treatment was stopped, the patient experienced AF recurrence. Upon receiving verapamil again, the AF again converted into sinus rhythm.</AbstractText>For the treatment of AF, nondihydropyridine calcium antagonists can be tried in the absence of antiarrhythmic drugs.</AbstractText> |
17,977 | Sex and Heart Failure with Preserved Ejection Fraction: From Pathophysiology to Clinical Studies. | Heart failure with preserved ejection fraction (HFpEF) represents the most frequent form of heart failure in women, with almost two-fold higher prevalence than in men. Studies have revealed sex-specific HFpEF pathophysiology, and suggested the possibility of a sex-specific therapeutic approach in these patients. Some cardiovascular risk factors, such as arterial hypertension, obesity, diabetes mellitus, coronary artery disease, atrial fibrillation, and race, show specific features that might be responsible for the development of HFpEF in women. These risk factors are related to specific cardiovascular changes-left ventricular diastolic dysfunction and hypertrophy, ventricular-vascular coupling, and impaired functional capacity-that are related to specific cardiac phenotype and HFpEF development. However, there is no agreement regarding outcomes in women with HFpEF. For HFpEF, most studies have found higher hospitalization rates for women than for men. Mortality rates are usually not different. Pharmacological treatment in HFpEF is challenging, along with many unresolved issues and questions raised. Available data on medical therapy in patients with HFpEF show no difference in outcomes between the sexes. Further investigations are necessary to better understand the pathophysiology and mechanisms of HFpEF, as well as to improve and eventually develop sex-specific therapy for HFpEF. |
17,978 | Effect of Heart Structure on Ventricular Fibrillation in the Rabbit: A Simulation Study. | Ventricular fibrillation (VF) is a lethal condition that affects millions worldwide. The mechanism underlying VF is unstable reentrant electrical waves rotating around lines called filaments. These complex spatio-temporal patterns can be studied using both experimental and numerical methods. Computer simulations provide unique insights including high resolution dynamics throughout the heart and systematic control of quantities such as fiber orientation and cellular kinetics that are not feasible experimentally. Here we study filament dynamics using two bi-ventricular 3-D high-resolution rabbit heart geometries, one with detailed fine structure and another without fine structure. We studied filament dynamics using anisotropic and isotropic conductivities, and with four cellular action potential models with different recovery kinetics. Spiral wave dynamics observed in isotropic two-dimensional sheets were not predictive of the behavior in the whole heart. In 2-D the four cell models exhibited stable reentry, meandering spiral waves, and spiral-wave breakup. In the whole heart with fine structure, all simulation results exhibited complex dynamics reminiscent of fibrillation observed experimentally. In the whole heart without fine structure, anisotropy acted to destabilize filament dynamics although the number of filaments was reduced compared to the heart with structure. In addition, in isotropic hearts without structure the two cell models that exhibited meandering spiral waves in 2-D, stabilized into figure-of-eight surface patterns. We also studied the sensitivity of filament dynamics to computer system configuration and initial conditions. After large simulation times, different macroscopic results sometimes occurred across different system configurations, likely due to a lack of bitwise reproducibility. The study conclusions were insensitive to initial condition perturbations, however, the exact number of filaments over time and their trends were altered by these changes. In summary, we present the following new results. First, we provide a new cell model that resembles the surface patterns of VF in the rabbit heart both qualitatively and quantitatively. Second, filament dynamics in the whole heart cannot be predicted from spiral wave dynamics in 2-D and we identified anisotropy as one destabilizing factor. Third, the exact dynamics of filaments are sensitive to a variety of factors, so we suggest caution in their interpretation and their quantitative analyses. |
17,979 | Propafenone-associated Gross Hematuria: A Case Report and Review of the Literature. | Propafenone hydrochloride has been widely used for the treatment of supraventricular and ventricular arrhythmias. We present a case report of an 81-year-old patient with propafenone-associated gross hematuria.</AbstractText>The Naranjo Adverse Drug Reaction Probability Scale was used to assess causality. We also performed a literature search to find publications that report propafenone-associated gross hematuria.</AbstractText>The Naranjo scale generated a score of 6, suggesting a probable association between gross hematuria and propafenone therapy. Thirteen publications that reported an association between gross hematuria and propafenone administration were found.</AbstractText>A probable association exists between gross hematuria and propafenone.</AbstractText>Copyright © 2019 Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,980 | High-Power (40-50 W) Radiofrequency Ablation Guided by Unipolar Signal Modification for Pulmonary Vein Isolation: Experimental Findings and Clinical Results. | Background Although proposed to facilitate pulmonary vein isolation (PVI), high-power ablation may favor extracardiac damage. Negative component abolition of the unipolar signal reflects lesion transmurality. The present study sought to evaluate the safety and efficacy of high-power ablation using unipolar signal modification as a local end point. Methods High power and standard power were compared in 4 swine and 100 consecutive patients referred for PVI. The first 50 patients were included in the control group (25-30 W) and the last 50 patients in the study group (40-50 W). Atrial radiofrequency applications were stopped 2 s (study group and swine) or 5 s (control group) after unipolar signal modification. Ventricular radiofrequency applications of 500 J (25 W·20 s versus 50 W·10 s) were performed at the swine epicardium. Results Swine gross necropsy did not show any extracardiac damage related to atrial lesions. At equal energy of 500 J, 50 W lesions were deeper (3±0.9 versus 2.6±1.1 mm; P=0.03) and wider (6.2±2 versus 5±2.3 mm; P=0.006) than 25 W lesions. No complications occurred during the clinical study, whatever the power output used for PVI. For a similar sinus rhythm maintenance at 12 months (90% versus 88%; P=0.75), the study group displayed higher first-pass PVI (92% versus 73%; P<0.001), lower acute pulmonary vein reconnection (2% versus 17%; P<0.001), reduced procedure time (73.1±18.2 versus 107.4±21.2 min; P<0.001), and ablation time (13±2.9 versus 30.3±8.8 min; P<0.001). Conclusions High-power PVI guided by unipolar signal modification safely decreases procedural burden while ensuring robust 12-month outcomes. |
17,981 | Characteristics and periodicity of sustained ventricular tachyarrhythmia events in a population of military veterans with implantable cardioverter defibrillator. | Circadian patterns of ventricular tachyarrhythmias (VTAs) in ICD patients from SCD-HeFT and MADIT-CRT have yielded differing results. The aim was to investigate VTA patterns in a large population of military veterans with ICD.</AbstractText>This retrospective study analyzed biorhythm periodicity of sustained VTAs (≤ 300 ms). Findings were derived from the Veterans Affairs (VA) National Cardiac Device Surveillance database encompassing January 1, 2005, to December 31, 2017.</AbstractText>The patient population comprised 1559 consecutive patients with 17,039 VTAs. There were 763 patients with clinical information with the mean age of 67.8 ± 9 years old and 99% male. An hourly non-uniform VTA distribution with a bimodal pattern and a predominant afternoon peak was seen (χ2</sup> = 5057, P < 0.0001). VTAs treated successfully by anti-tachycardia pacing (ATP) showed a bimodal pattern with even distributions. VTAs treated by ICD shocks showed a bimodal pattern with a predominant afternoon peak. The duration of VTA peaks was increased from 13.5 to 17 h with increasing daylight time from 9.9 to 14.5 h. The weekly VTA distribution showed a significant septadian pattern with lowest frequency on weekend and highest on weekdays (χ2</sup> = 4840, P < 0.0001). No annual periodicity and monthly periodicity were seen.</AbstractText>Sustained VTA events exhibited a circadian rhythm in a large population of military veterans with ICD/CRT-D; specifically, a bimodal pattern with a predominant afternoon peak was observed. Further, the majority of VTA episodes treated by ICD shock occurred in the afternoon, and the duration of VTA peak lengthened with increased duration of daylight time.</AbstractText> |
17,982 | Left atrial myocardial dysfunction in patients with primary aldosteronism as assessed by speckle-tracking echocardiography. | We investigated the left atrial myocardial deformation in patients with primary aldosteronism using the speckle-tracking echocardiographic (STE) strain imaging technique.</AbstractText>Our study included 107 primary aldosteronism patients [52 aldosterone-producing adenoma (APA) and 55 idiopathic hyperaldosteronism (IHA)] and 50 primary hypertensive patients. We performed conventional echocardiography to measure left atrial volume and ejection fraction, and STE to estimate left atrial myocardial deformation including peak velocity, strain and strain rate and calculate the ratio of E/e' to left atrial strain during left ventricular systole as the left atrial stiffness index.</AbstractText>Patients with APA, compared with those with IHA and primary hypertension had a significantly (P < 0.001) lower serum potassium concentration and higher 24-h urinary aldosterone excretion and plasma aldosterone-to-renin ratio. Patients with APA had a significantly (P < 0.01) larger maximal, precontraction, and minimal left atrial volumes and lower total, active and passive left atrial emptying fractions than those with IHA and primary hypertension. Among the three groups, patients with APA showed lowest left atrial velocity, strain, and strain rate during ventricular systole, early diastole and late diastole (P < 0.05) and highest left atrial stiffness index (P < 0.001). In unadjusted analysis, the left atrial strain, strain rate and stiffness index were significantly (P < 0.05) associated with plasma aldosterone concentration and urinary aldosterone excretion. After adjustment for various confounding factors, these associations remained statistically significant for urinary aldosterone excretion (P < 0.05) but not plasma aldosterone concentration (P ≥ 0.05).</AbstractText>Patients with primary aldosteronism, especially APA, had impaired left atrial deformation mechanics and increased left atrial stiffness, providing a promising insight into early detection of subclinical left atrial dysfunction by strain echocardiography.</AbstractText> |
17,983 | Rapid improvement in left ventricular function after sinus rhythm restoration in patients with idiopathic cardiomyopathy and atrial fibrillation. | Sinus rhythm restoration (SRR) in patients with atrial fibrillation (AF) and heart failure may improve systolic function and impact on consecutive clinical management, but time course and potential predictors of response to SRR are uncertain.</AbstractText>We prospectively studied 50 consecutive patients who presented in heart failure with reduced ejection fraction (EF) and concomitant AF. After exclusion of valvular and coronary artery disease patients underwent electrical cardioversion. Serial echocardiography, cardiac magnetic resonance imaging (cMRI), and 24-h electrocardiograms were performed at baseline, and on Days 3 and 40 following SRR. Baseline left ventricular EF of the study population (76% male, age 69 ± 11 years) was 30 ± 7%. Sustained SRR (≥3 days) significantly improved EF (Day 3: 43 ± 7%, n = 46; Day 40: 53 ± 9%, n = 34; P < 0.001) as quantified by echocardiography. Comparable results were obtained using cMRI (baseline: 29 ± 8%; Day 3: 42 ± 9%). Three patients showed no response to SRR (EF improvement <15%). The percentage of patients meeting current criteria for implantable cardioverter-defibrillator (ICD) implantation for primary prevention dropped from 76% (n = 38) to 11% (n = 3) on Day 40 following SRR. No specific clinical or echocardiographic factor predicting improved EF after SRR could be identified.</AbstractText>The majority of patients presenting with non-ischaemic, non-valvular heart failure with reduced EF and concomitant AF show a significant and rapid improvement in EF following SRR. An attempt at SRR and reassessment of the need for ICD implantation after 40 days may be warranted in all such patients.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
17,984 | Cardiac resynchronization therapy pacemaker or cardiac resynchronization therapy defibrillator: what determines the choice?-findings from the ESC CRT Survey II. | The decision to implant a cardiac resynchronization therapy pacemaker (CRT-P) or a cardiac resynchronization therapy defibrillator (CRT-D) may be challenging. There are no clear guideline recommendations as no randomized study of cardiac resynchronization therapy (CRT) has been designed to compare the effects of CRT-P with those of CRT-D on patients' outcomes. In the CRT Survey II, we studied patient and implantation centre characteristics associated with the choice of CRT-P vs. CRT-D.</AbstractText>Clinical practice data from 10 692 patients undergoing CRT implantation of whom 7467 (70%) patients received a CRT-D and 3225 (30%) received a CRT-P across 42 ESC countries were collected and analysed between October 2015 and January 2017. Factors favouring the selection of CRT-P implantation included age >75 years, female gender, non-ischaemic heart failure (HF) aetiology, New York Heart Association functional Class III/IV symptoms, left ventricular ejection fraction >25%, atrial fibrillation, atrioventricular (AV) block II/III, and implantation in a university hospital.</AbstractText>In a large cohort from the CRT Survey II, we found that patients allocated to receive CRT-P exhibited particular phenotypes with more symptomatic HF, more frequent comorbidities, advanced age, female gender, non-ischaemic HF aetiology, atrial fibrillation, and evidence of AV block. There were substantial differences in the proportion of patients allocated to receive CRT-P vs. CRT-D between countries.</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> |
17,985 | Optimization with levosimendan improves outcomes after left ventricular assist device implantation. | The aim of this study was to examine the haemodynamic effects of preoperative levosimendan infusion in patients who underwent left ventricular assist device implantation and evaluate the prognoses.</AbstractText>Between May 2013 and October 2018, 85 adult patients who underwent left ventricular assist device implantation were included; 44 and 41 patients suffered from dilated cardiomyopathy and ischaemic cardiomyopathy, respectively. Patients were divided into 2 groups: group A (58 patients) included those who received levosimendan infusion in addition to other inotropes and group B (27 patients) included those who received inotropic agents other than levosimendan. Levosimendan infusion was started at a dose of 0.1 µg⋅kg-1⋅min-1 for a maximum of 48 h without a bolus. The primary outcome was early right ventricular failure (RVF). The secondary outcomes were in-hospital mortality, need for right ventricular assist device, late RVF and recovery of end-organ functions. The safety end points of levosimendan included hypotension, atrial fibrillation, ventricular tachycardia or fibrillation and resuscitated cardiac arrest.</AbstractText>Patient characteristics were similar in both groups. No significant differences between groups were observed in the rates of early mortality, RVF, need for right ventricular assist device, cardiopulmonary bypass time and intensive care unit stay. Survival rates at 30 days, 1 year and 3 years and freedom from late RVF were similar between the groups. Administration of levosimendan was safe, generally well-tolerated and not interrupted because of side effects.</AbstractText>Levosimendan therapy was well-tolerated in patients who received permanent left ventricular assist devices. Combined preoperative therapy with inotropes and levosimendan significantly improves end-organ functions.</AbstractText>© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.</CopyrightInformation> |
17,986 | Trend and risk factors of recurrence and complications after arrhythmias radiofrequency catheter ablation: a nation-wide observational study in Taiwan. | This study determined the recurrence and complication rates after radiofrequency catheter ablation (RFCA) for those with paroxysmal supraventricular tachycardia (PSVT), Wolff-Parkinson-White syndrome (WPW), atrial flutter (AFL), atrial fibrillation (AF) and ventricular tachycardia (VT).</AbstractText>This retrospective study included RFCAs for 2001-2010 in the Taiwan National Health Insurance Research Database. Primary outcomes included perioperative complications (pericardial effusion and new-onset stroke), RFCA recurrence and long-term outcomes (high-grade atrioventricular block (AVB) and pacemaker implantation).</AbstractText>Of 19,475 patients who underwent RFCA, prevalence rates were 56.7% for PSVT, 13.5% for WPW, 9.5% for AFL, 5.1% for AF and 2.7% for VT. Prevalence rates increased in AF, AFL and VT over the study years. During an average follow-up period of 4.3 years (SD: 2.8 years), recurrence rates for PSVT, WPW, VT, AFL and AF were 2.0%, 4.9%, 5.7%, 5.8% and 16.1%, respectively. Compared with the PSVT group, the WPW and AF groups had significantly higher risk of pericardial effusion during admission (adjusted OR (aOR) 2.98, 95% CI (CI) 1.24 to 7.15; aOR 4.09, 95% CI 1.90 to 8.79, respectively); the AFL group had a higher risk of new-onset stroke during admission (aOR 4.07, 95% CI 1.39 to 11.91); the WPW group had a lower risk of high-grade AVB during follow-up (adjusted HR (aHR) 0.37, 95% CI 0.19 to 0.71) while the AFL group had a greater risk (aHR 1.74, 95% CI 1.17 to 2.60); and the AFL group had a higher risk of permanent pacemaker (aHR 2.14, 95% CI 1.27 to 3.62).</AbstractText>The RFCA rate increased rapidly during 2001-2010 for AF, AFL and VT. Recurrence was associated with congenital heart disease in PSVT and WPW, and with age in AF and AFL. AFL had a higher risk of permanent pacemaker implantation and new stroke. AF had a higher risk of life-threatening pericardial effusion.</AbstractText>© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
17,987 | Evaluation of Atrial Electromechanical Delay in Children with Obesity. | Background and Objective</i>: Childhood obesity is one of the worldwide health problems with an increasing prevalence and accompanied by severe morbidity and mortality. It is a serious predisposing risk factor especially for the development of cardiovascular diseases and arrhythmias. Electromechanical delay (EMD) is known to be a predictor for the development of atrial fibrillation (AF). Our study aims to investigate whether EMD, which is a predictor of AF, prolongs in obese children or not.</AbstractText>The study included 59 obese patients aged between 8-18 years and 38 healthy patients as the control group with a similar age and gender. All the individuals underwent transthoracic echo and tissue Doppler echocardiography. Systolic and diastolic left ventricular (LV) functions, inter- and intra-atrial electromechanical delay were measured by tissue Doppler imaging (TDI) and conventional echocardiography.</AbstractText>Obese patients had significantly lengthened P-wave on surface ECG to the beginning of the late diastolic wave (PA) lateral, PA septum, intra- and inter-atrial electromechanical delays when compared with the control group (p</i> <</i> 0.001, p</i> = 0.001, p</i> < 0.001 and p</i> < 0.001, respectively) Inter-atrial EMD and intra-atrial EMD correlated positively with body mass index (BMI) values (r</i> = 0.484, p</i> < 0.001 and r</i> = 0.376, p</i> = 0.001; respectively) BMI was significantly related with inter-atrial EMD (β</i> = 0.473, p</i> < 0.001) However, there was no relationship between inter-atrial EMD and serum glucose and platelet count.</AbstractText>In our study, we declared that electromechanical delay was increased in obese children when compared to the control group and intra- and inter-atrial electromechanical delay was in correlation with body mass index. Furthermore, we discovered that BMI is an independent predictor of the inter-atrial EMD in obese children.</AbstractText> |
17,988 | Frequency Variation of Ventricular Fibrillation May Help Predict Successful Defibrillation in a Rat Model of Cardiac Arrest. | To evaluate whether the frequency variation of ventricular fibrillation (VF) helps to predict successful defibrillation in a rat model of cardiac arrest.</AbstractText>VF was induced in rats followed by cardiopulmonary resuscitation and then defibrillation. The electrocardiographic signals of 30 rats with first-shock success were obtained from our previous animal experiments, and 300 rats without first-shock success were selected as control. The VF waveform immediately before the first defibrillation was analyzed.</AbstractText>Eighty-eight percentages of the frequency variations of an electrocardiogram (ECG) record falling in the range -9.5-9.5 Hz was selected with sensitivity of 0.8, specificity of 0.583, and area under curve (AUC) of 0.708. Compared with amplitude spectrum area (AMSA) (sensitivity = 0.767, specificity= 0.547, and AUC = 0.678), combining frequency variation and AMSA significantly increases the predictability with sensitivity of 0.933, specificity of 0.493, and AUC of 0.732 (p</i> = 0.005).</AbstractText>The frequency variation of VF may serve a useful parameter to predict defibrillation success.</AbstractText>Copyright © 2019 by Taiwan Society of Emergency Medicine & Ainosco Press. All Rights Reserved.</CopyrightInformation> |
17,989 | Subcutaneous nerve stimulation for rate control in ambulatory dogs with persistent atrial fibrillation. | Subcutaneous nerve stimulation (ScNS) damages the stellate ganglion and improves rhythm control of atrial fibrillation (AF) in ambulatory dogs.</AbstractText>The purpose of this study was to test the hypothesis that thoracic ScNS can improve rate control in persistent AF.</AbstractText>We created persistent AF in 13 dogs and randomly assigned them to ScNS (n = 6) and sham control (n = 7) groups. 18</sup>F-2-Fluoro-2-deoxyglucose positron emission tomography/magnetic resonance imaging of the brain stem was performed at baseline and at the end of the study.</AbstractText>The average stellate ganglion nerve activity reduced from 4.00 ± 1.68 μV after the induction of persistent AF to 1.72 ± 0.42 μV (P = .032) after ScNS. In contrast, the average stellate ganglion nerve activity increased from 3.01 ± 1.26 μV during AF to 5.52 ± 2.69 μV after sham stimulation (P = .023). The mean ventricular rate during persistent AF reduced from 149 ± 36 to 84 ± 16 beats/min (P = .011) in the ScNS group, but no changes were observed in the sham control group. The left ventricular ejection fraction remained unchanged in the ScNS group but reduced significantly in the sham control group. Immunostaining showed damaged ganglion cells in bilateral stellate ganglia and increased brain stem glial cell reaction in the ScNS group but not in the control group. The 18</sup>F-2-fluoro-2-deoxyglucose uptake in the pons and medulla was significantly (P = .011) higher in the ScNS group than the sham control group at the end of the study.</AbstractText>Thoracic ScNS causes neural remodeling in the brain stem and stellate ganglia, controls the ventricular rate, and preserves the left ventricular ejection fraction in ambulatory dogs with persistent AF.</AbstractText>Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,990 | Time to therapy delivery and effectiveness of the subcutaneous implantable cardioverter-defibrillator. | At the time of subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, successful termination of ventricular fibrillation (VF) is confirmed. A previous study reported cases of prolonged time to therapy during defibrillation testing.</AbstractText>We sought to evaluate the time to therapy, identify possible predictors of delay, and investigate the impact of delayed therapy on VF conversion.</AbstractText>We analyzed consecutive patients with S-ICDs who underwent initial conversion testing at a shock energy of 65 J in 53 Italian centers.</AbstractText>We analyzed 570 patients (467 [82%] male; mean age 48 ± 15 years; mean body mass index 25 ± 6 kg/m2</sup>; mean ejection fraction 47% ± 17%). General anesthesia was used in 165 (29%) of patients, with sub- or intermuscular positioning of the generator in (422; 74%). Cardioversion was successful at 65 J in 557 (97.7%) of patients. In 12 patients (2.1%) the shock did not convert VF, and in 1 patient the shock was not delivered because of noise from entrapped subcutaneous air. All failures were successfully managed by reprogramming or repositioning the device. The mean time to therapy was 15 ± 3 seconds, and it exceeded 18 seconds in 51 patients (9%). Independent predictors of delayed therapy (18 seconds) were ejection fraction (odds ratio [OR] 0.98; 95% confidence interval [CI] 0.96-0.99; P = .016) and a 2× gain programmed (OR 3.66; 95% CI 1.44-9.30; P = .006). Effectiveness at 65 J was not associated with time to therapy (OR 1.13; 95% CI 0.97-1.32; P = .122).</AbstractText>In this analysis of a large population of patients with S-ICDs, delayed therapy during defibrillation testing occurred less frequently than previously reported and had no effect on VF conversion success. Delayed therapies seemed more common when a vector with a 2× gain was programmed.</AbstractText>Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
17,991 | COMPARISON OF CARDIAC ARRHYTHMIA TYPES BETWEEN HYPERTHYROID PATIENTS WITH GRAVES' DISEASE AND TOXIC NODULAR GOITER. | Previous studies have demonstrated the relationship between hyperthyroidism and increased risk of cardiac arrhythmias. The most common causes of hyperthyroidism are Graves' disease (GD) and toxic nodular goiter (TNG). The aim of our study was to demonstrate if the underlying mechanism of hyperthyroidism, in other words autoimmunity, has an impact on the type of cardiac arrhythmias accompanying hyperthyroidism.</AbstractText>Twenty patients with TNG and 16 patients with GD who had overt hyperthyroidism were included in the study. Age, sex, thyroid hormone levels, thyroid autoantibody positivity, thyroid ultrasonography and scintigraphy results were recorded. 24-hour Holter ECG monitoring was performed in all patients.</AbstractText>Mean age was significantly higher in the TNG group compared to the GD group (62.9±11.5 vs</i>. 48.9±8.6 years, p=0.001). Free T3 was significantly higher (7.87±3.90 vs</i>. 5.21±1.53 pg/mL, p=0.033) in the GD group while free T4 and TSH levels were similar between the two groups. In 24-hour Holter ECG recordings nonsustained ventricular tachycardia (VT) rates were significantly higher in the GD group than in TNG group [18.75% (n=3/16) vs</i>. 0% (n=0/20), respectively, (p=0.043)]. Paroxysmal atrial fibrillation (AF) rates were significantly higher in the TNG group compared to GD group [(30% (n=6/20) vs</i>. 0% (n=0/16), respectively, (p=0.016)].</AbstractText>Although free T3 levels were lower, paroxysmal AF rates were found significantly higher in the TNG group which may be associated with significantly higher age of this group. On the other hand, higher rate of nonsustained VT in the GD group may be related to either significantly higher free T3 levels or autoimmunity.</AbstractText> |
17,992 | Sudden death in heart failure with preserved ejection fraction and beyond: an elusive target. | Heart failure (HF) with preserved ejection fraction (HFpEF) represents half of HF patients, who are more likely older, women, and hypertensive. Mortality rates in HFpEF are higher compared with age- and comorbidity-matched non-HF controls and lower than in HF with reduced ejection fraction (HFrEF); the majority (50-70%) are cardiovascular (CV) deaths. Among CV deaths, sudden death (SD) (~ 35%) and HF-death (~ 20%) are the leading cardiac modes of death; however, proportionally, CV deaths, SD, and HF-deaths are lower in HFpEF, while non-CV deaths constitute a higher proportion of deaths in HFpEF (30-40%) than in HFrEF (~ 15%). Importantly, the underlying mechanism of SD has not been clearly elucidated and non-arrhythmic SD may be more prominent in HFpEF than in HFrEF. Furthermore, there is no specific strategy for identifying high-risk patients, probably due to wide heterogeneity in presentation and pathophysiology of HFpEF and a plethora of comorbidities in this population. Thus, the management of HFpEF remains problematic due to paucity of data on the clinical benefits of current therapies, which focus on symptom relief and reduction of HF-hospitalization by controlling fluid retention and managing risk-factors and comorbidities. Matching a specific pathophysiology or mode of death with available and novel therapies may improve outcomes in HFpEF. However, this still remains an elusive target, as we need more information on determinants of SD. Implantable cardioverter-defibrillators (ICDs) have changed the landscape of SD prevention in HFrEF; if ICDs are to be applied to HFpEF, there must be a coordinated effort to identify and select high-risk patients. |
17,993 | Heart Failure and Atrial Fibrillation, Like Fire and Fury. | Heart failure and atrial fibrillation are 2 common cardiovascular disorders that frequently complicate one another and exert a significant detrimental effect on cardiovascular health and well-being. Both heart failure and atrial fibrillation continue to increase in prevalence as the risk factors underlying each condition become more common. This review encompasses what is currently known about the epidemiology and pathophysiology of these comorbidities along with incorporation of landmark trials that have contributed to current guidelines. The focus is on clinically relevant considerations, including the contribution of inflammation in the pathophysiology of atrial fibrillation and heart failure. We explore the emerging role of catheter ablation relative to medical therapy in the management of heart failure with reduced ejection fraction, along with indications for biventricular pacing modalities in cardiac resynchronization therapy. We discuss current guideline-directed therapies and how practice models and national recommendations will likely change based on the most recent randomized controlled trials. |
17,994 | An integrated overview of AV node physiology. | The atrioventricular (AV) node generates half of the AV delay needed for blood pumping and filters atrial impulses that could otherwise induce life-threatening ventricular arrhythmias. It is also a pacemaker and a key target in the treatment of cardiac arrhythmias. The special roles of the AV node primarily arise from its slow conduction, long refractory period, and cellular automaticity. However, efforts to establish the dynamics of these properties and their interaction led to many controversies. In fact, the AV node's behavior is so complex that it seems to escape broadly applicable rules. This review summarizes progresses made in resolving these issues and in integrating the multiple roles of the AV node within a common functional model. Presented evidence shows that the rate-dependent conduction and refractory properties of the AV node can be reliably characterized and reconciled from nodal responses to S<sub>1</sub> S<sub>2</sub> S<sub>3</sub> protocols. It also supports the concept that dual pathways constitute a feature of the normal AV node and account for its overall conduction and refractory properties. In this model, the posterior extension and compact node provide the core of the slow and fast pathway, respectively. The transitional tissues and lower nodal bundle provide a common proximal and distal pathway, respectively. These pathways would also support bidirectional conduction. The dual pathway involvement can also be extended to widely variable AV nodal responses, such as Wenckebach cycles, hysteresis, and ventricular response to atrial fibrillation. In brief, the intricate AV nodal behavior may obey a limited set of accessible and definable rules. |
17,995 | Atrial Fibrillation in Heart Failure-Diagnostic, Therapeutic, and Prognostic Relevance. | Atrial fibrillation (AF) and heart failure (HF) commonly coexist and are associated with an increased risk of hospitalization, morbidity, and mortality. Both conditions develop into epidemics due to the ageing of the population and lead to poorer prognosis for the individual patients. Therapeutic strategies include treatment with oral anticoagulation, and rate and rhythm control concepts to prevent stroke and improve the cardiovascular outcome.</AbstractText>Especially in HF patients, data suggest that catheter ablation of AF is superior to medical treatment. In patients with both AF and HF undergoing catheter ablation, significant increases in left ventricular ejection fraction and quality of life and decreases in related symptoms and major adverse cardiac events are reported. In addition, catheter ablation has been shown to reduce mortality and HF hospitalization in the medium term. For patients with AF and HF, an effective individualized therapeutic strategy to minimize potential complications and improve clinical outcomes is needed. Catheter ablation of AF seems to provide advantages in HF patients with AF. However, results of further long-term studies are awaited.</AbstractText> |
17,996 | Late onset left ventricular dysfunction and cardiomyopathy induced with ibrutinib. | Ibrutinib, an oral inhibitor of Bruton's tyrosine kinase, has altered the treatment perspective of chronic lymphocytic leukemia and showed modest activity against several types of non-Hodgkin's lymphomas. According to phase studies and real-world data, reported serious adverse effects included atrial fibrillation, diarrhea, and bleeding diathesis. However, heart failure was not reported to be a probable adverse effect linked with ibrutinib.</AbstractText>In this paper, we present a 66-year-old female chronic lymphocytic leukemia patient who developed significant and symptomatic left ventricular dysfunction at the 13th month of ibrutinib treatment.</AbstractText>Following cessation of ibrutinib, ejection fraction and clinical findings of the left ventricular dysfunction alleviated.</AbstractText>Although the use of ibrutinib is generally well tolerated, cardiac functions should be monitored occasionally in all patients.</AbstractText> |
17,997 | Association between atrial fibrillation and heart failure with different ejection fraction categories and its influence on outcomes. | <b>Background:</b> The important role of atrial fibrillation (AF) in different types of heart failure (HF) according to ejection fraction (EF) is much less explored. In this study, we compared AF in HF with preserved (HFpEF), mid-range (HFmrEF) and reduced (HFrEF) EF with regard to prevalence, association, and prognostic role.<b>Methods and results:</b> A total of 405 inpatients with HF between February 2014 and June 2016 were prospectively analysed in this study. Patients were divided into three groups: HFrEF group (<i>n</i> = 109, 26.9%), HFmrEF group (<i>n</i> = 94, 23.2%), and HFpEF group (<i>n</i> = 202, 49.8%). There was a higher prevalence of AF in patients in the HFpEF and HFmrEF groups than in patients in the HFrEF. Several baseline variables were found to be independently associated with AF, including age, coronary heart disease, heart rate, left atrial diameter, and left ventricular (LV) end-diastolic diameter, regardless of EF category after multivariable adjustment. In addition, AF was found to be a more powerful predictor of all-cause mortality, HF rehospitalisation, and the composite event of all-cause mortality or rehospitalisation in HFpEF and HFmrEF patients, but not in HFrEF patients.<b>Conclusions:</b> HFmrEF resembled HFpEF rather than HFrEF with regard to both a higher prevalence of AF and a greater risk of all-cause mortality, HF rehospitalisation, and the composite event of all-cause mortality or rehospitalisation. |
17,998 | Ventricular fibrillation in a patient with Wolff-Parkinson-White syndrome unrelated to pre-excited atrial fibrillation. | A 52-year-old man was admitted due to out-hospital cardiac arrest. Recurrent ventricular fibrillation (VF) occurred under therapeutic hypothermia thereafter. Previously inadverted full pre-excitation was documented exclusively and immediately prior to 4 out of the 5 VF relapses. Coronary vasospasm and early repolarization were also documented. An electrophysiological study demonstrated poor anterograde conduction over a left-sided accessory pathway. We theorize that maximum pre-excitation favored in-hospital VF by augmenting the repolarization vulnerability induced by therapeutic hypothermia, with coronary vasospasm accounting as the probable cause of out-hospital VF. A plausible VF mechanism in WPW syndrome unrelated to pre-excited atrial fibrillation is discussed. |
17,999 | Remodelling in atrial fibrillation: the impact of amiodarone. | Atrial fibrillation (AF) is a common heart rhythm disorder with a prevalence of up to 2.9% in the general population. Its mechanism involves a particular electrophysiological profile as well as structural and biohumoral changes that are often irreversible. With the recent advances in pharmacology, amiodarone remains the cornerstone for the treatment of AF. Although it is one of the most controversial anti-arrhythmic agents due to the multitude of side effects, it is further recognised as the most effective drug available for the conversion and maintenance of sinus rhythm in the case of significant left ventricular dysfunction or severe aortic stenosis. This quality is provided by its multivalent profile, with a complex electrophysiological activity overlapped with an anti-inflammatory and vasodilatory effect. This review aims to outline the main structural and functional changes in AF and the multisite impact of amiodarone on its treatment. |
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