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18,700 | Left Ventricular Ejection Fraction Predicts Poststroke Cardiovascular Events and Mortality in Patients without Atrial Fibrillation and Coronary Heart Disease. | It is controversial that decreased left ventricular function could predict poststroke outcomes. The purpose of this study is to elucidate whether left ventricular ejection fraction (LVEF) can predict cardiovascular events and mortality in acute ischemic stroke (AIS) without atrial fibrillation (AF) and coronary heart disease (CHD).</AbstractText>Transthoracic echocardiography was conducted consecutively in patients with AIS or transient ischemic attack at Soonchunhyang University Hospital between January 2008 and July 2016. The clinical data and echocardiographic LVEF of 1,465 patients were reviewed after excluding AF and CHD. Poststroke disability, major adverse cardiac events (MACE; nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) and all-cause mortality during 1 year after index stroke were prospectively captured. Cox proportional hazards regressions analysis were applied adjusting traditional risk factors and potential determinants.</AbstractText>The mean follow-up time was 259.9±148.8 days with a total of 29 non-fatal strokes, 3 myocardial infarctions, 33 cardiovascular deaths, and 53 all-cause mortality. The cumulative incidence of MACE and all-cause mortality were significantly higher in the lowest LVEF (<55) group compared with the others (p=0.022 and 0.009). In prediction models, LVEF (per 10%) had hazards ratios of 0.54 (95% confidence interval [CI], 0.36-0.80, p=0.002) for MACE and 0.61 (95% CI, 0.39-0.97, p=0.037) for all-cause mortality.</AbstractText>LVEF could be an independent predictor of cardiovascular events and mortality after AIS in the absence of AF and CHD.</AbstractText>Copyright © 2018. The Korean Society of Cardiology.</CopyrightInformation> |
18,701 | Mapping the potential of community first responders to increase cardiac arrest survival. | Resuscitation from out-of-hospital cardiac arrest (OHCA) is largely determined by the availability of cardiopulmonary resuscitation (CPR) and defibrillation within 5-10 min of collapse. The potential contribution of organised groups of volunteers to delivery of CPR and defibrillation in their communities has been little studied. Ireland has extensive networks of such volunteers; this study develops and tests a model to examine the potential impact at national level of these networks on early delivery of care.</AbstractText>A geographical information systems study considering all statutory ambulance resource locations and all centre point locations for community first responder (CFR) schemes that operate in Ireland were undertaken. ESRI ArcGIS Desktop 10.4 was used to map CFR and ambulance base locations. ArcGIS Online proximity analysis function was used to model 5-10 min drive time response areas under sample peak and off-peak conditions. Response areas were linked to Irish population census data so as to establish the proportion of the population that have the potential to receive a timely cardiac arrest emergency response.</AbstractText>This study found that CFRs are present in many communities throughout Ireland and have the potential to reach a million additional citizens before the ambulance service and within a timeframe where CPR and defibrillation are likely to be effective treatments.</AbstractText>CFRs have significant potential to contribute to survival following OHCA in Ireland. Further research that examines the processes, experiences and outcomes of CFR involvement in OHCA resuscitation should be a scientific priority.</AbstractText> |
18,702 | Left Ventricular Ejection Fraction and Clinically Defined Heart Failure to Predict 90-Day Functional Outcome After Ischemic Stroke. | Heart failure (HF) is a risk factor for atrial fibrillation (AF), stroke, and post-stroke disability. However, differing definitions and application of HF-criteria may impact model prediction. We compared the predictive ability of left ventricular ejection fraction (LVEF), a readily available objective echocardiographic index, with clinical HF definitions for functional disability and AF in stroke patients.</AbstractText>We retrospectively analyzed ischemic stroke patients evaluated between January 2013 and May 2015. Outcomes of interest were: (a) 90-day functional disability (modified Rankin score 3-6) and (b) AF. We compared: (1) LVEF (continuous variable), (2) left ventricular systolic dysfunction (LVSD)-categories (absent to severe), (3) clinical history of HF, and (4) HF/LVSD-categories: (i) HF absent without LVSD, (ii) HF absent with LVSD, (iii) HF with preserved ejection fraction (HFpEF), and (iv) HF with reduced ejection fraction (HFrEF). Multivariable logistic regression was used to determine the predictive ability for 90-day disability and AF, respectively.</AbstractText>Six hundred eighty five consecutive patients (44.5% female) fulfilled the study criteria and were included. After adjustment, the LVEF was independently associated with 90-day disability (OR .98, 95% CI .96-.99, P = .011) with similar predictive ability (area under the curve [AUC] = .85) to models including the LVSD-categories (AUC = .85), clinically define HF (AUC = .86), and HF/LVSD-categories (AUC = .86). The LVEF, HF, LVSD-, and HF/LVSD-categories were independently associated with AF (P < .01, each) with similar predictive ability (AUC = .74, .74, .73, and .75, respectively).</AbstractText>Compared to commonly defined HF definitions, the objectively determined LVEF possesses comparable predictive ability for 90-day disability and AF in stroke patients.</AbstractText>Copyright © 2018. Published by Elsevier Inc.</CopyrightInformation> |
18,703 | Right atrial pathology in arrhythmogenic right ventricular dysplasia. | Atrial fibrillation (AF) is the most common atrial arrhythmia in arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVD). Considering the histologic changes known in the right ventricular (RV) in ARVD, the aim of the present study was to examine right atrial (RA) pathology in patients with ARVD.</AbstractText>Histology of RA and RV was assessed from autopsy material in 3 patients with ARVD without persistent atrial arrhythmia. RA histology in 3 patients with permanent AF without ARVD and 5 patients without cardiovascular disease was also studied. Staining with hematoxylin phloxine saffron was performed for the ARVD patients to identify fibrosis, and hematoxylin-eosin for identification of lymphocytes. Masson's trichrome staining was performed for control groups taken from a collection of standard glass slides.</AbstractText>In all 3 ARVD cases, RA anomalies were observed that revealed a reduction of cardiomyocytes, the presence of adipocytes, some of them inside the mediomural atrial layer and interstitial fibrosis. In 2 ARVD cases, interstitial fibrosis was also associated with a focus of replacement fibrosis, which was also observed in patients with permanent AF without ARVD. The histologic specimen of the RA and RV from the control group without cardiovascular disease did not display any evidence of fat or fibrosis with a preserved cardiomyocyte architecture.</AbstractText>A similar histopathological substrate, as can be observed in the RV of patients with ARVD can also be seen in the RA of these patients. This may explain the high prevalence of atrial arrhythmias, particularly AF, in patients with ARVD.</AbstractText> |
18,704 | Impact of gender on in-hospital outcomes in patients with Takotsubo syndrome: A nationwide analysis from 2006 to 2014. | Takotsubo syndrome (TTS) is characterized by acute, transient systolic dysfunction of the left ventricle not attributed to coronary artery disease (CAD).</AbstractText>There are differences in hospital outcomes in patients admitted with TTS based on their gender.</AbstractText>The National Inpatient Sample database was searched for patients admitted with a principal diagnosis of TTS from 2006 to 2014 using the ICD9-CM code 429.83. Using Pearson's χ2</sup> and Student's t test analyses, the P-value was calculated for differences among baseline characteristics of patients. Multivariate regression models were then created to adjust for potential confounders.</AbstractText>A total of 39 662 admissions with TTS were identified, 91.7% female and 8.3% male with mean age of 66.5 and 61.6 years, respectively. The incidence of TTS increased progressively from 2006 to 2014. Female patients were more likely to have hypertension, hypothyroidism, or depression. Males were more likely to use tobacco, or have known CAD. Males had almost 4-fold higher probability of in-hospital mortality compared to females (3.7% vs 1.1%; P<0.001). Certain complications including cardiogenic shock, ventricular fibrillation/tachycardia, and acute kidney injury were more common in males.</AbstractText>There are distinct gender differences in clinical characteristics of patients admitted with TTS. Although TTS is more common in females, it is associated with higher morbidity and mortality in males.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,705 | Implantable cardioverter-defibrillator in hypertrophic cardiomyopathy. | Sudden cardiac death (SCD) is the most devastating complication in hypertrophic cardiomyopathy (HCM). The implantable cardioverter-defibrillator (ICD) has proven to be effective in SCD prevention in several clinical scenarios. In HCM population, it has demonstrated to successfully abort life-threatening ventricular arrhythmias despite the extreme morphology characteristic of HCM, often with massive degrees of left ventricular hypertrophy and/or LV outflow tract obstruction. Studies showed a high rate of appropriate intervention in secondary prevention and in primary prevention of patients considered at high risk. This appropriate intervention rate is even more significant considering the young and otherwise healthy patients that compose HCM population. Since SCD incidence in HCM is relatively low, optimal identification of patients at high risk is crucial. Classical strategy of risk stratification based on clinical risk factors has several limitations and has proven to overestimate risk. A new risk prediction model that provides individual 5-year estimated risk appears to be superior to traditional models based on bivariate risk factors. Perioperative complications seem to be similar to those related to the implant of other cardiac devices, while long-term complications have been traditionally in the spotlight. HCM patients are considered more vulnerable to ICD-related complications and inappropriate ICD therapy because of their young age at implant and increased prevalence of atrial fibrillation, but long-term follow-up data on ICD-related complications in general practice is limited. The subcutaneous implantable cardioverter defibrillator seems to be a safe and effective alternative in HCM, although long-term data are scarce. |
18,706 | Clinical Influence and Predictors of Pacing-Induced Mechanical Asynchrony in Patients with Normal Cardiac Function with Ventricular Lead Placed in Non-Apical Position. | Right ventricular apical (RVA) pacing often causes left ventricular (LV) mechanical asynchrony, which is enhanced by impaired cardiac contraction and intrinsic conduction abnormality. However, data on patients with normal cardiac function and under RV non-apical (non-RVA) pacing are limited.We retrospectively investigated 97 consecutive patients with normal ejection fraction who received pacemaker implantation for atrioventricular block with the ventricular lead placed in a non-RVA position. We defined mechanical asynchrony as discoordinate contraction between opposing regions of the LV wall evaluated by echocardiography. Asynchrony was detected in 9 (9%) patients at baseline and in 38 (39%) under non-RVA pacing (P < 0.001). Asynchrony at baseline was significantly associated with complete left bundle branch block (CLBBB) [odds ratio (OR) = 20.8, P < 0.001]. Asynchrony under non-RVA pacing was significantly associated with left anterior fascicular block (LAFB) (OR = 7.14, P < 0.001) and CLBBB (OR = 13.3, P = 0.002) at baseline. New occurrence of asynchrony was significantly associated with LAFB at baseline (OR = 5.88, P = 0.001). During a median follow-up period of 4.8 years, the incidence of device-detected atrial fibrillation (AF) was more frequent in patients who developed asynchrony than in those who did not (53.3% versus 27.5%, hazard ratio = 2.17, 95% confidence interval = 1.02-4.61, P = 0.03).In patients with normal cardiac function, LAFB at baseline was significantly associated with new occurrence of mechanical asynchrony under non-RVA pacing. Abnormal contraction had a significant influence on the incidence of device-detected AF. |
18,707 | Pharmacological Therapy for Ventricular Arrhythmias: A State-of-the Art Review. | While implantable cardioverter defibrillators decrease mortality in high risk groups of patients who have ventricular arrhythmias, antiarrhythmic drugs are still required to reduce the burden of both benign and life-threatening arrhythmias. This review will address the available medical therapy for ventricular arrhythmias in Australia and their use in different clinical situations. |
18,708 | Depolarization versus repolarization abnormality underlying inferolateral J-wave syndromes: New concepts in sudden cardiac death with apparently normal hearts. | Early repolarization indicates a distinct electrocardiographic phenotype affecting the junction between the QRS complex and the ST segment in inferolateral leads (inferolateral J-wave syndromes). It has been considered a benign electrocardiographic variant for decades, but recent clinical studies have demonstrated its arrhythmogenicity in a small subset, supported by experimental studies showing transmural dispersion of repolarization. Here we review the current knowledge and the issues of risk stratification that limit clinical management. In addition, we report on new mapping data of patients refractory to pharmacologic treatment using high-density electrogram mapping at the time of inscription of J wave. These data demonstrate that distinct substrates, delayed depolarization, and abnormal early repolarization underlie inferolateral J-wave syndromes, with significant implications. Finally, based on these data, we propose a new simplified mechanistic classification of sudden cardiac deaths without apparent structural heart disease. |
18,709 | Survival in pulmonary hypertension due to chronic lung disease: Influence of low diffusion capacity of the lungs for carbon monoxide. | Patients with pulmonary hypertension (PH) due to chronic lung disease (Group 3 PH) have poor long-term outcomes. However, predictors of survival in Group 3 PH are not well described.</AbstractText>We performed a cohort study of Group 3 PH patients (n = 143; mean age 65 ± 12 years, 52% female) evaluated at the University of Minnesota. The Kaplan-Meier method and Cox regression analysis were used to assess survival and predictors of mortality, respectively. The clinical characteristics and survival were compared in patients categorized by PH severity based on the World Health Organization (WHO) classification and lung disease etiology.</AbstractText>After a median follow-up of 1.4 years, there were 69 (48%) deaths. The 1-, 3-, and 5-year survival rates were 79%, 48%, and 31%. Age, coronary artery disease, atrial fibrillation, Charlson comorbidity index, serum N-terminal pro‒brain natriuretic peptide (NT-proBNP), creatinine, diffusion capacity of carbon monoxide (DLCO), total lung capacity, left ventricular ejection fraction, right atrial and right ventricular enlargement on echocardiography, cardiac index, and pulmonary vascular resistance (PVR) were univariate predictors of survival. On multivariable analysis, DLCO was the only predictor of mortality (adjusted hazard ratio [HR] for every 10% decrease in predicted value: 1.31 [95% confidence interval 1.12 to 1.47]; p = 0.003). The 1-/5-year survival by tertiles of DLCO was 84%/56%, 82%/44%, and 63%/14% (p = 0.01), respectively. On receiver-operating characteristic curve analysis, DLCO <32% of predicted had the highest sensitivity and specificity for predicting survival. The 1- and 5-year survival in patients with a DLCO ≥32% predicted was 84% and 60% vs 68% and 13% in patients with a DLCO <32% predicted (adjusted HR: 2.5 [95% confidence interval 1.3 to 5.0]; p = 0.007). Lung volumes and DLCO were not related, but higher PVR was strongly associated with reduced DLCO. There was increased mortality in interstitial lung disease‒PH as compared with chronic obstructive pulmonary disease‒PH, but PH severity based on the WHO classification did not alter survival.</AbstractText>Low DLCO is a predictor of mortality and should be used to risk-stratify Group 3 PH patients.</AbstractText>Copyright © 2018 Elsevier Ltd. All rights reserved.</CopyrightInformation> |
18,710 | P-wave terminal force in lead V1 is a predictive indicator for the diagnosis of tuberculous constrictive pericarditis. | The purpose of this study is to explore the value of P-wave terminal force in lead V1 (PTFV1) in the clinical diagnosis of tuberculous constrictive pericarditis (TCP).</AbstractText>A total of 53 patients with TCP and 64 patients with tuberculous exudative pericarditis were enrolled in this retrospective study. The demographic and clinical characteristics were collected, including gender, age, the course of disease and New York Heart Association (NYHA) classification. Besides, echocardiography data also were obtained, including left atrial diameter, left ventricular end-diastolic diameter and left ventricular ejection fraction. In addition, the parameters of electrocardiogram (ECG) were obtained, such as heart rate, the time from the corrected ORS wave origin to T-wave terminal, atrial fibrillation, right bundle branch block, atrial premature beat, and PTFV1 value.</AbstractText>No significant differences were found in age, gender, the course of disease, echocardiography results, ECG parameters (in addition to PTFV1) between patients with TCP and patients with tuberculous exudative pericarditis. The percentage of patients located in NYHA class IV in the patients with TCP was significantly higher than those of patients with tuberculous exudative pericarditis (p = 0.041). Moreover, the incidence rate of abnormal PTFV1 (≤ -0.04 mm·s) was obviously higher in patients with TCP than those of patients with tuberculous exudative pericarditis (64.2% vs 9.4%, p < 0.001).</AbstractText>Abnormal PTFV1 (≤ -0.04 mm·s) is associated with TCP, and PTFV1 may be a potential novel diagnostic indicator for TCP diagnosis.</AbstractText>Copyright © 2018 Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,711 | Left ventricular remodeling in hypertrophic cardiomyopathy patients with atrial fibrillation. | Atrial fibrillation (AF) is the most common complication in hypertrophic cardiomyopathy (HCM). The mechanisms of AF is associated with left atrial (LA) structural remodeling in HCM patients. However, the impact of left ventricular (LV) remodeling on the presence of AF in HCM patients has not been evaluated yet. We sought to investigate effect of LV remodeling on the presence of AF assessed by cardiovascular magnetic resonance (CMR) in HCM patients.</AbstractText>A total of 394 HCM patients were enrolled into this study, including HOCM patients (n = 293) and NOHCM patients (n = 101). Patients were divided into HCM with AF (50) and HCM without AF (n = 344). Data were collected from hospital records.</AbstractText>LA diameter and LV remodeling index (LVRI) were significantly higher in HCM patients with AF than that of HCM patients without AF (46.6 ± 7.4 mm versus 39.9 ± 8.0 mm, p < 0.001, and 1.46 ± 0.6 versus 1.2 ± 0.4, p = 0.002, respectively). HCM patients with AF were older than HCM patients without AF (53.6 ± 11.7 years versus 47.7 ± 13.6 years, p = 0.002). Additionally, LVRI positively correlated to LA size (r = 0.12, p = 0.02). In a multivariable logistic regression analysis, when adjusting for age and LV end diastolic mass index, LVRI and LA size remained an independent determinant of AF in HCM patients (OR = 4.7, p = 0.001 and OR = 1.13, P < 0.001).</AbstractText>HCM patients with AF showed significantly more LA diameter, LVRI and age than HCM patients without AF. LVRI and LA size were strong independent predictor of AF in HCM, suggesting LV remodeling may contribute to the occurrence of AF in HCM patients.</AbstractText> |
18,712 | Upstream therapeutic strategies of valsartan and fluvastatin on hypertensive patients with non-permanent atrial fibrillation. | To investigate the upstream therapeutic effects of fluvastatin and valsartan on hypertensive patients with non-permanent atrial fibrillation (AF).</AbstractText>A total of 189 patients who were admitted to outpatient and inpatient department from eight medical centers in China, diagnosed as hypertension with non-permanent AF, were divided into four groups randomly: the CCBs group (group A, n = 45); CCB + fluvastatin group (group B, n = 48); valsartan group (group C, n = 46); valsartan + fluvastatin group (group D, n = 50). The four groups were followed up for 24 months. The blood routine, biochemical examination, echocardiography, high sensitive C-reactive protein (hs-CRP), N-terminal pro-brain natriuretic peptide (NT-proBNP), the maintenance rate of sinus rhythm, and the recurrence of paroxysmal AF or persistent AF incidence were observed in these groups before and after 24 months' treatment.</AbstractText>After 24 months of follow-up, there were 178 cases of patients who have completed the study. (a) There was no significant difference in blood routine, liver, and renal function in each group (P > 0.05). (b) The blood lipids level in groups B and D was significantly reduced after treatment (P < 0.01). There was no significant difference of hs-CRP level in group A (P > 0.05). The left ventricular remodeling was significantly alleviated in group C and group D (P < 0.05). The NT-ProBNP level was significantly decreased in group D (P < 0.05). (c) The sinus rhythm maintenance rate of group B, group C, and group D was higher than group A (77.78%, 70.45%, 79.17% vs 43.90%), the occurrence of persistent AF was significantly lower than group A (11.11%, 14.29%, 8.33% vs 31.71%; P < 0.05).</AbstractText>CCB plus fluvastatin and valsartan can reduce the recurrence rate of non-permanent AF and to delay the progression from non-permanent AF to permanent AF in patients with hypertension. The combined application of valsartan and fluvastatin is more effective than valsartan or CCB alone in the upstream therapies of AF.</AbstractText>© 2018 John Wiley & Sons Ltd.</CopyrightInformation> |
18,713 | Competitive athletes with implantable cardioverter-defibrillators-How to program? Data from the Implantable Cardioverter-Defibrillator Sports Registry. | Athletes with an implantable cardioverter-defibrillator (ICD) may require unique optimal device-based tachycardia programming.</AbstractText>The purpose of this study was to assess the association of tachycardia programming characteristics of ICDs with occurrence of shocks, transient loss-of-consciousness, and death among athletes.</AbstractText>A subanalysis of a prospective, observational, international registry of 440 athletes with ICDs followed for a median of 44 months was performed. Programming characteristics were divided into groups for rate cutoff (very high, high, or low) and detection (long-detection interval [>nominal] or nominal). Endpoints included total, appropriate, and inappropriate shocks, transient loss-of-consciousness, and mortality.</AbstractText>In this cohort, 62% were programmed with high-rate cutoff and 30% with long detection. No athlete died of an arrhythmia (related or unrelated) to ICD shocks. Three patients had sustained ventricular tachycardia below programmed detection rate, presenting as palpations and/or dizziness. ICD shocks were received by 98 athletes (64 appropriate, 32 inappropriate); 2 patients received both. Programming a high-rate cutoff was associated with decreased risk of total (P = .01) and inappropriate (P = .04) shocks overall and during competition or practice. Programming long-detection intervals was associated with fewer total shocks. Single- vs dual-chamber devices and the number of zones were unrelated to risk of shock. Transient loss-of-consciousness, associated with 27 appropriate shocks, was not related to programming characteristics.</AbstractText>High-rate cutoff and long-detection duration programming of ICDs in athletes at risk for sudden death can reduce total and inappropriate ICD shocks without affecting survival or the incidence of transient loss-of-consciousness.</AbstractText>Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,714 | Current Device Therapies for Sudden Cardiac Death Prevention - the ICD, Subcutaneous ICD and Wearable ICD. | Defibrillator technology for sudden cardiac death (SCD) prevention now includes the transvenous implantable cardiac defibrillator (ICD), subcutaneous ICD (S-ICD) and wearable cardioverter defibrillator (WCD). ICD use improves survival in patients who survived previous sudden cardiac arrest (SCA) due to ventricular tachycardia (VT)/ventricular fibrillation (VF), as well as in patients who experienced haemodynamically significant VT. It is also currently indicated for primary prevention in ischaemic/non-ischaemic cardiomyopathies, certain congenital heart disease conditions and inherited channelopathies. In this review article, we hope to present an updated review on ICD use for SCD prevention, with a focus on contemporary issues affecting ICD selection. These include: the role of primary prevention ICD in patients with non-ischaemic cardiomyopathy (NICM) in light of the 2016 DANISH (Danish Study to Assess the Efficacy of ICDs in Patients with Non-Ischemic Systolic Heart Failure on Mortality) trial; the role of defibrillator component (CRT-D) in patients receiving cardiac resynchronisation therapy (CRT-P); and the emerging role of cardiac magnetic resonance imaging (cMRI) in particular, the presence of late gadolinium enhancement (LGE), as an important SCD risk predictor. The current use of S-ICD and WCD, including clinical indications, evidence for efficacy and limitations, will also be discussed. |
18,715 | Channelopathies That Lead to Sudden Cardiac Death: Clinical and Genetic Aspects. | Forty per cent (40%) of sudden unexpected natural deaths in people under 35 years of age are associated with a negative autopsy, and the cardiac ion channelopathies are the prime suspects in such cases. Long QT syndrome (LQTS), Brugada syndrome (BrS) and catecholaminergic polymorphic ventricular tachycardia (CPVT) are the most commonly identified with genetic testing. The cellular action potential driving the heart cycle is shaped by a specific series of depolarising and repolarising ion currents mediated by ion channels. Alterations in any of these currents, and in the availability of intracellular free calcium, leaves the myocardium vulnerable to polymorphic ventricular tachycardia or ventricular fibrillation. Each channelopathy has its own electrocardiogram (ECG) signature, typical mode of presentation, and most commonly related gene. Long QT type 1 (gene, KCNQ1) and CPVT (gene, RyR2) typically present with cardiac events (ie syncope or cardiac arrest) during or immediately after exercise in young males; long QT type 2 (gene, KCNH2) after startle or during the night in adult females-particularly early post-partum, and long QT type 3 and Brugada syndrome (gene, SCN5A) during the night in young adult males. They are commonly misdiagnosed as seizure disorders. Fever-triggered cardiac events should also raise the suspicion of BrS. This review summarises genetics, cellular mechanisms, risk stratification and treatments. Beta blockers are the mainstay of treatment for long QT syndrome and CPVT, and flecainide is remarkably effective in CPVT. Brugada syndrome is genetically a more complex disease than the others, and risk stratification and management is more difficult. |
18,716 | Epicardial fat thickness: A new predictor of successful electrical cardioversion and atrial fibrillation recurrence. | In recent years, epicardial fat tissue (EFT) has been found to be strongly associated with the development of atrial fibrillation (AF) and post-ablation long-term recurrence. The current study investigated the procedural success rate of electrical cardioversion (ECV) and potential predictors of treatment failure in patients with nonvalvular persistent AF.</AbstractText>A total of 262 nonvalvular persistent AF patients who were scheduled for elective ECV were included in this prospective study. Routine transthoracic echocardiography was performed before the procedure and EFT thickness was measured. The presence of left atrial appendage thrombus was evaluated by transesophageal echocardiography. The patients were followed up for 6 months to examine any recurrence after ECV.</AbstractText>The success rate of ECV was 85% and the recurrence rate was 35% during the 6-month follow-up period. The mean EFT thickness was 8.67 ± 1.2 mm in the persistent AF group with unsuccessful ECV and 6.81 ± 0.8 in the patients in whom sinus rhythm (SR) was maintained, the EFT was significantly thicker in the AF group (P = 0.001). EFT (P = 0.001) and left ventricular end-diastolic diameters (LVEDD) (P = 0.001) were significantly different between those who had maintained SR and those with recurrent AF during the 6-month follow-up period after ECV. In the multiple logistic regression analysis, LVEDD (odds ratio [OR]: 1.320 (1.023-1.703 95% confidence interval [CI]), P = 0.032)] and EFT [OR: 3.029 (1.013-9.055 95% CI), P = 0.047)] were identified as independent predictors of successful ECV.</AbstractText>Epicardial fat tissue thickness can be effectively used for the prediction of successful ECV and AF recurrence during follow-up in AF patients.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,717 | Left atrial strain - an early marker of left ventricular diastolic dysfunction in patients with hypertension and paroxysmal atrial fibrillation. | 2D strain imaging of the left atrium (LA) is a new echocardiographic method which allows us to determine contractile, conduit and reservoir functions separately. This method is particularly useful when changes are subtle and not easily determined by traditional parameters, as it is in arterial hypertension and atrial fibrillation (AF).</AbstractText>to determine LA contractile, conduit and reservoir function by 2D strain imaging in patients with mild arterial hypertension and paroxysmal AF; to assess LA contractile, conduit and reservoir functions' relation with LV diastolic dysfunction (DD) parameters.</AbstractText>LA contractile, conduit and reservoir functions together with echocardiographic signs of LV DD were assessed in 63 patients with arterial hypertension and paroxysmal AF. Patients were grouped according to number of signs showing LV DD (annular e' velocity: septal e' < 7 cm/s, lateral e' < 10 cm/s, average E/e' ratio > 14, LA volume index > 34 ml/m2</sup>, peak tricuspid regurgitation velocity > 2.8 m/s) present. Number of patients with 0 signs - 17, 1 sign - 26, 2 signs - 19. Contractile, conduit and reservoir functions were compared between the groups.</AbstractText>Mean contractile, conduit and reservoir strains in all the patients were - 14.14 (± 5.83) %, 15.98 (± 4.85) % and 31.03 (± 7.64) % respectively. Contractile strain did not differ between the groups. Conduit strain was higher in patients with 0 signs compared with other groups (p = 0.016 vs 1 sign of LV DD and p = 0.001 vs 2 signs of LV DD). Reservoir strain was higher in patients with 0 signs compared with other groups (p = 0.014 vs 1 sign of LV DD and p < 0.001 vs 2 signs of LV DD).</AbstractText>The patients with paroxysmal AF and primary arterial hypertension have decreased reservoir, conduit and pump LA functions even in the absence of echocardiographic signs of LV DD. With increasing number of parameters showing LV DD, LA conduit and reservoir functions decrease while contractile does not change. LA conduit and reservoir functions decrease earlier than the diagnosis of LV DD can be established according to the guidelines in patients with primary arterial hypertension and AF.</AbstractText> |
18,718 | Evaluation of Need for Implantable Cardioverter-Defibrillator by Thallium-201 Scintigraphy Among Japanese Patients With Prior Myocardial Infarction. | Identifying who among current Japanese patients with prior myocardial infarction (MI) would benefit from an implantable cardioverter-defibrillator (ICD) is imperative. Accordingly, this study seeks to determine whether single-photon emission computed tomography (SPECT) can help identify such patients. Methods and Results: This retrospective study enrolled 60 consecutive patients with prior MI who underwent stress thallium-201 SPECT and ICD implantation from February 2000 to October 2014. Occurrence of arrhythmic death and/or or appropriate ICD therapy, defined as shock or antitachycardia pacing for ventricular fibrillation or tachycardia, was identified until November 2016. During the median follow-up interval of 6.6 years, 18 (30%) patients experienced arrhythmic death and/or appropriate ICD therapy. Multivariate Cox proportional hazard regression analysis revealed that the summed stress score (SSS) [hazard ratio (HR)=1.14; P=0.005] and left ventricular ejection fraction (LVEF) at rest (HR=0.92; P=0.038) were significantly associated with the occurrence of arrhythmic events. Patients with SSS ≥21 and LVEF ≤30%, which were determined to be the best cutoff points, had significantly higher incidence of the arrhythmic events than the other patients (64% vs. 11%; HR=7.18; log-rank P=0.001).</AbstractText>SSS using stress thallium-201 SPECT in combination with LVEF can help determine the need for ICD therapy among current Japanese patients with prior MI.</AbstractText> |
18,719 | Improvement of Hemodynamic Parameters in Patients With Preserved Left Ventricular Systolic Function by Catheter Ablation of Atrial Fibrillation　- A Prospective Study Using Impedance Cardiography. | The effects of catheter ablation for atrial fibrillation (AF) on hemodynamic parameters in patients with preserved left ventricular (LV) systolic function are unclear. Methods and Results: We enrolled 178 patients with AF (paroxysmal, 108; persistent, 70) with preserved LV systolic function who underwent AF ablation. The stroke volume index (SVI) was repeatedly measured using impedance cardiography. Reduced SVI (SVI, <33 mL/m2</sup>) was observed in 55% of patients before ablation. In patients with paroxysmal AF, the SVI did not change immediately after ablation (from 35±6 mL/m2</sup>to 35±5 mL/m2</sup>; P=0.652); however, it increased 1 month after ablation and further increased 6 months after ablation (1 month, 37±6 mL/m2</sup>, P<0.001; 6 months, 38±6 mL/m2</sup>, P<0.001). In patients with persistent AF, the SVI increased immediately after ablation (from 30±5 mL/m2</sup>to 36±6 mL/m2</sup>; P<0.001) and further increased until 6 months after ablation (1 month, 37±6 mL, P<0.001; 6 months, 38±5 mL/m2</sup>, P<0.001). The baseline SVI was the strongest predictor of the cardiac function improvement with an area under the curve of 0.828.</AbstractText>The restoration and maintenance of sinus rhythm using catheter ablation increased the SVI in patients with preserved LV systolic function.</AbstractText> |
18,720 | [The clinical course of atrial fibrillation in patients with coronary heart disease]. | The modern medical literature practically does not contain clinical publications reporting studies of factors responsible for progression of atrial fibrillation (AF) in patients with coronary heart disease (CHD). It accounts for the importance of investigations into evolution of the clinical course of AF in such patients.</AbstractText>To elucidate evolution of the clinical course of AF in patients with CHD in a long-term prospective study.</AbstractText>The study included. 112 patient aged 57-74 (mean 67.44±3.3) years with CHD and paroxysmal form of AF carried outfrom 2011 to 2015. Evolution of the clinical course of AF was evaluated based on the number of arrhythmic attacks during the last 3 months. The appearance of prolonged persistent AF episodes or permanent AF was regarded as progression of arrhythmia.</AbstractText>During the 4 year study, 64 (57,2%) patients (group 1) did not experiencea rise in the frequency and duration of AF attacks. Progression of arrhythmia was documented in 48 (42,8%) of the 112 (100%) patients (group 2). These patients more frequently had the history of myocardial infarction and chronic heart failure than patients of group 1. The latter had the mean values of left ventricular (LV) ejection fraction 61,23±6,24%, i.e. significantly higher than 48,47±8,4% in group 2.47 and 28 % of the patients in group 2and 1 respectively suffered mitral regurgitation (p<0,05). Patients of group 2 had significantly more akineticzones. Intake of nitroglycerin in group 1 resulted in positive dynamics of local LV contractility that did not change in patients of group 2.</AbstractText>42,8% of the patients with CHD and paroxysmal form of AF experienced progression of arrhythmia into a persistent or permanent form. Predictors of AF progression in patients with CHD are the history of myocardial infarction, chronic heart failure, mitral regurgitation, and irreversible changes in local myocardial LV contraction.</AbstractText> |
18,721 | Thoracoscopic retrieval of an atrial appendage occlusion device after embolization into the left ventricular outflow tract and damaging the mitral valve requiring replacement. | Embolization of a percutaneous left atrial appendage occlusion device is a rare, but potentially life-threatening, complication. In this report, we present the case of an embolization of such a device into the left ventricular outflow tract causing extensive damage to the mitral subvalvular apparatus and requiring mitral valve replacement. We also describe the first thoracoscopic removal of such a device from the left ventricular outflow tract. |
18,722 | Comparison of complications and shocks in paediatric and young transvenous and subcutaneous implantable cardioverter-defibrillator patients. | Young implantable cardioverter-defibrillator (ICD) patients are prone to complications and inappropriate shocks (IAS). The subcutaneous ICD (S-ICD) may avoid lead-related complications. This study aims to describe the incidence and nature of device-related complications in young transvenous ICD (TV-ICD) and S‑ICD patients.</AbstractText>Single-chamber TV-ICD and S‑ICD patients up to and including the age of 25 years implanted between 2002 and 2015 were retrospectively analysed. Complications were defined as device-related complications requiring surgical intervention. IAS were defined as shocks for anything other than ventricular tachycardia or ventricular fibrillation. Follow-up data were collected 5 years post-implantation. Kaplan-Meier estimates for complications at 5‑year follow-up were calculated with a corresponding 95% confidence interval.</AbstractText>Eighty-one patients (46 TV-ICD, 35 S-ICD) were included (median age 19.0 (IQR 16.0-23.0) and 16.5 (IQR 13.0-20.2) years respectively). Median follow-up was 60 and 40 months respectively. All-cause complication rate was 34% in the TV-ICD group and 25% in the S‑ICD group (p = 0.64). TV-ICD patients had more lead complications: 23% (10-36%) versus 0% (p = 0.02). The rate of infections did not differ between TV-ICD and S‑ICD: 2% (0-6%) versus 10% (0-21%) (p = 0.15). No systemic infections occurred in the S‑ICD patients. The rates of IAS were similar, TV-ICD 22% (9-35%) versus S‑ICD 14% (0-30%) (p = 0.40), as were those for appropriate shocks: 25% (11-39%) versus 27% (6-48%) (p = 0.92).</AbstractText>The rates of all-cause complications in this cohort were equal, though the nature of the complications differed. S‑ICD patients did not suffer lead failures or systemic infections. An era effect is present between the two groups.</AbstractText> |
18,723 | The effect of asafoetida essential oil on myocardial ischemic-reperfusion injury in isolated rat hearts. | Previous studies reported that asafetida from Ferula assa-foetida</i> Linn. species and its essential oil (AEO) have antioxidant effects. In the present study, the effect of AEO was evaluated on ischemic-reperfusion injury in isolated rat hearts.</AbstractText>Forty-eight male Wistar rats were divided into 6 groups: 1) control group, 2) vehicle group, 3-5) AEO groups and, 6) carvedilol group. In the control group, hearts were only subjected to 30-min global ischemia followed by 120-min reperfusion. Hearts in other groups were perfused with vehicle (Tween 0.1%), AEO (0.125, 0.25 or 0.50 µL/g heart) or carvedilol (10 µM) for 5 min immediately before the induction of ischemia.</AbstractText>Compared to the control group, myocardial dysfunction was significantly more severe only in group 5 in which a significant increase in left ventricular end diastolic pressure and a significant decrease in left ventricular developed pressure and ± dp/dt. Also, the activities of lactate dehydrogenase and creatine kinase as the markers of myocardial injury were significantly higher only in group 5 compared to control group. The size of infarct and the incidence of irreversible fibrillation did not show any significant differences between the control group and groups 3-5.</AbstractText>These results showed that perfusion of isolated rat hearts with AEO 0.5 µL/g heart, but not at lower concentrations, might worsen myocardial ischemic-reperfusion injury.</AbstractText> |
18,724 | Cardiovascular Events after New-Onset Atrial Fibrillation in Adults with CKD: Results from the Chronic Renal Insufficiency Cohort (CRIC) Study. | Atrial fibrillation (AF), the most common sustained arrhythmia in CKD, is associated with poor clinical outcomes in both patients without CKD and patients with dialysis-treated ESRD. However, less is known about AF-associated outcomes in patients with CKD who do not require dialysis.</AbstractText>To prospectively examine the association of new-onset AF with subsequent risks of cardiovascular disease events and death among adults with CKD, we studied participants enrolled in the Chronic Renal Insufficiency Cohort Study who did not have AF at baseline. Outcomes included heart failure, myocardial infarction, stroke, and death occurring after diagnosis of AF. We used Cox regression models and marginal structural models to examine the association of incident AF with subsequent risk of cardiovascular disease events and death, adjusting for patient characteristics, laboratory values, and medication use.</AbstractText>Among 3080 participants, 323 (10.5%) developed incident AF during a mean 6.1 years of follow-up. Compared with participants who did not develop AF, those who did had higher adjusted rates of heart failure (hazard ratio [HR], 5.17; 95% confidence interval [95% CI], 3.89 to 6.87), myocardial infarction (HR, 3.64; 95% CI, 2.50 to 5.31), stroke (HR, 2.66; 95% CI, 1.50 to 4.74), and death (HR, 3.30; 95% CI, 2.65 to 4.12). These associations remained robust with additional adjustment for biomarkers of inflammation, cardiac stress, and mineral metabolism; left ventricular mass; ejection fraction; and left atrial diameter.</AbstractText>Incident AF is independently associated with two- to five-fold increased rates of developing subsequent heart failure, myocardial infarction, stroke, or death in adults with CKD. These findings have important implications for cardiovascular risk reduction.</AbstractText>Copyright © 2018 by the American Society of Nephrology.</CopyrightInformation> |
18,725 | Long-Term Results Following Repair for Degenerative Mitral Regurgitation - Analysis of Factors Influencing Durability. | The majority of patients with degenerative mitral regurgitation (DMR) are amenable to reconstructive procedures. There is debate regarding factors that influence long-term durability with respect to repair technique, valve remodelling and progressive myxomatous change.</AbstractText>A total of 685 patients with DMR underwent mitral valve repair by a single surgeon between 1991 and 2011 with follow-up completed at 31 December 2016. Repair rate for patients undergoing surgery for DMR was over 90%. Mean age was 64 years (18-89) with 66.2% male, 47% NYHA class III-IV, and 20% had permanent atrial fibrillation (PAF). Major associated procedures were performed in 28% of patients (189); including coronary artery bypass graft (CABG) (127), aortic valve replacement (15), aortic root surgery (3) and tricuspid valve annuloplasty (61).</AbstractText>Operative mortality (≤30 days) occurred in four patients (0.58%). At 20 years, survival was 58%, freedom from reoperation was 90% and freedom from reoperation and non-operated recurrent MR >2+ (relapse) was 78%. Factors influencing survival were advancing age, left ventricular (LV) dysfunction (ejection fraction <60% or end systolic dimension >40mm), New York Heart Association (NYHA) III-IV and PAF. Predictors of relapse were the degree of residual intraoperative mitral regurgitation (p<0.001), anterior leaflet prolapse (p<0.001) and the addition of a sliding annuloplasty in isolated posterior leaflet repair (p=0.023). The majority of reoperations were for technical issues related to the original repair. A competent valve at 6 months to 3 years postoperatively predicted an excellent long-term result.</AbstractText>The great majority of degenerative mitral valves are repairable regardless of age with excellent long-term results achievable following surgery. Survival is reduced by significant symptoms, LV dysfunction and preoperative PAF. Repair is best performed before these features develop. Durability is largely dependent on the technical performance of the repair and degree of residual MR on the post-pump transoesophageal echocardiogram. We recommend surgery should be performed by surgeons specialising and skilled in mitral valve repair.</AbstractText>Copyright © 2018 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> |
18,726 | Critical Volume of Human Myocardium Necessary to Maintain Ventricular Fibrillation. | Abnormal QT intervals, long QT or short QT, have been epidemiologically linked with sudden cardiac death because of ventricular fibrillation (VF). Consequently, Food and Drug Administration recommends testing all pharmacological agents for QT toxicity as a risk factor for cardiac toxicity. Such tests assess QT/QTc interval, which represents ventricular depolarization and repolarization. However, the current QT toxicity analysis does not account for the well-known anisotropy in cardiac tissue conductivity. Mines demonstrated in 1913 that cardiac wavelength (λ) determines inducibility of reentrant arrhythmia, where both repolarization time or action potential duration and conduction velocity determine λ=action potential duration×conduction velocity. We aimed to determine the role of anisotropic wavelength in inducibility of VF in explanted human left ventricular preparations. We tested the hypothesis that 3-dimensional cardiac wavelength, which takes into account anisotropic cardiac tissue conductivity, can accurately predict VF sustainability.</AbstractText>We conducted panoramic optical mapping of coronary perfused human left ventricular wedge preparations subjected to pharmacologically induced shortening and prolongation of action potential duration, by IK,ATP</sub> agonist pinacidil and antagonist glybenclamide, respectively. This measured action potential duration, conduction velocity, and thus determined pacing cycle length-dependent wavelengths in longitudinal (λL</sub>), transverse (λTV</sub>), and transmural (λTM</sub>) directions using S1S1 pacing protocol, from which wavelength volume (Vλ</sub>) was determined, as Vλ</sub>=λL</sub>×λTV</sub>×λTM</sub>, and compared with tissue volume.</sub> We tested a hypothesis that tissue volume/Vλ</sub> ratio can predict VF sustainability.</AbstractText>At baseline, at pacing rate of 240 beats per minute, the wavelengths were λL</sub>=9.6±0.6 cm, λTV</sub>=4.2±0.3 cm, and λTM</sub>=5.8±0.2 cm, respectively (n=7), and thus Vλ</sub>=246.4±42.1 cm3</sup>. Administration of pinacidil at escalating concentrations progressively decreased Vλ</sub>, and VF became sustained, when tissue volume/Vλ</sub> was above safety factor κ=4.4±0.6 (n=9) during rapid pacing. Treatment with glybenclamide decreased VT</sub>/Vλ</sub> below κ at any pacing rate and prevented VF sustainability.</AbstractText>Sustained VF was only sustained in ventricular volume exceeding critical Vλ</sub>=λL</sub>×λTV</sub>×λTM</sub>.</AbstractText> |
18,727 | Long-term outcome of video-assisted thoracoscopic thoracic duct ligation and pericardectomy in dogs with chylothorax: A multi-institutional study of 39 cases. | To evaluate the long-term outcome of video-assisted thoracoscopic (VATS) thoracic duct ligation (TDL) and pericardectomy for treatment of chylothorax in dogs.</AbstractText>Multi-institutional retrospective study.</AbstractText>Thirty-nine client-owned dogs.</AbstractText>Dogs were included if they had undergone a VATS TDL and pericardectomy and had at least 1-year follow-up or had died within 1 postoperative year. Medical records were evaluated, and recorded data included clinicopathological and diagnostic imaging results, surgical findings, complications, conversion rates, and long-term resolution and recurrence rates.</AbstractText>Thirty-nine dogs met the inclusion criteria. Two dogs died intraoperatively; 1 was euthanized after severe restrictive pleuritis was diagnosed intraoperatively, and 1 underwent ventricular fibrillation and cardiac arrest during pericardectomy and could not be resuscitated. Conversion to an open approach was required in 1 of 39 (3%) dogs for TDL and 4 of 36 (11%) dogs for pericardectomy. Overall follow-up time was median 38 months (range, 3-115). Resolution of pleural effusion occurred in 35 of 37 (95%) dogs that survived the perioperative period. Late recurrence of pleural effusion was seen at 12, 12, and 19 months postoperatively in 3 of 35 (9%) dogs that survived the perioperative period and in which chylothorax had initially resolved.</AbstractText>Successful long-term resolution of chylothorax was seen in a high proportion of dogs that underwent VATS TDL and pericardectomy, although late recurrence was sometimes seen.</AbstractText>Video-assisted thoracoscopic thoracic duct ligation and pericardectomy are highly successful in dogs with chylothorax. Future studies should evaluate whether pericardectomy is required in dogs without evidence of pericardial disease.</AbstractText>© 2018 The American College of Veterinary Surgeons.</CopyrightInformation> |
18,728 | Beat-to-beat detection of aortic valve opening in HeartWare left ventricular assist device patients. | Continuous flow left ventricular assist devices (cfLVADS) result in a significant reduction in aortic valve (AV) opening, which has been associated with several complications. Reliable monitoring of AV opening is needed to determine whether pump speed adjustment may be able to minimize adverse outcomes. We assessed AV status continuously by echocardiography for 4 minutes in 3 states in 18 HeartWare HVAD patients: 2 minutes at rest, and 1 minute each following Valsalva maneuver and supine leg-raising. Using a previously described algorithm, beat-to-beat AV status was compared with the area under the curve of the normalized power spectral density analysis (PSD-AUC) for the corresponding beats of the pump speed waveform. Five thousand five hundred twenty-seven beats were analyzed. AV opening varied between 0% and 100% for the cohort with the median AV opening frequency 21.5%, and median duration of opening of 124 msec (range 0-279). The receiver operating characteristic (ROC) curve area for AV opening by the PSD-AUC algorithm was 0.95 (P < 0.0001). A PSD-AUC cut-off of 0.82 distinguished between an open and closed AV with 86% sensitivity and 93% specificity. Accuracy was similar in regular cardiac rhythm, atrial fibrillation or with frequent ventricular ectopic beats. Valsalva maneuver and leg-raising had no impact on accuracy. The PSD-AUC was strongly predictive of AV opening duration (P < 0.0001). We found that AV status and opening duration can be determined with high accuracy on a beat-to-beat basis irrespective of cardiac rhythm and with low level exercise and changes in filling. |
18,729 | Predictors of low voltage areas in persistent atrial fibrillation: is it really a matter of time? | Time has been postulated as an important factor for electrical remodeling of the left atrium (LA) in persistent atrial fibrillation (AF) ('AF begets AF'). However, it is still a matter of debate if structural changes are the cause or consequence of AF. We sought to determine the clinical and invasive parameters, which correlate with LA scar as determined by voltage mapping, in patients with persistent AF.</AbstractText>Seventy consecutive patients undergoing ablation of persistent (49%) or long-standing persistent AF (51%), between January 2013 and February 2014, were enrolled in the study. Besides clinical parameters, 2D echocardiographic assessment of LA size and LA pressure (LAP) after transseptal puncture was also considered. Bipolar endocardial signals with a mean voltage amplitude < 0.1 mV during AF were defined as LA scar.</AbstractText>In the univariable analysis, LA scar was associated with age, gender, coronary artery disease (CAD), glomerular filtration rate (GFR), LA size and LAP. Arrhythmia duration, mild to moderate mitral regurgitation (MR), left ventricular dysfunction and left ventricular hypertrophy showed no significant correlation with atrial scar (all p > 0.05). In a multivariable regression model, LA scar area was independently associated with age, female gender and LA area. AF duration was not associated with LA scar.</AbstractText>In this study, older age, greater LA area and female gender predicted the degree of LA scar, while other variables tested did not. In particular, we found no significant association between AF duration and LA scar.</AbstractText> |
18,730 | Implantable Cardioverter-Defibrillator Placement for Primary Prevention in 2,346 Patients: Predictors of One-Year Survival. | Guidelines suggest that patients who receive implantable cardioverter-defibrillators (ICDs) for primary prevention should be expected to live more than one year after placement. However, tools for validating this prognosis are not sufficiently predictive. We sought to identify definitive predictors of one-year survival after ICD placement. By reviewing medical records and the Social Security Death Index, we analyzed baseline characteristics and survival outcomes of 3,164 patients who underwent ICD placement at our institution from January 2006 through March 2014. Survival outcome could be confirmed for 2,346 patients (74%). Of these, 184 (7.8%) died within one year of ICD placement. We noted significant differences in numerous variables between those who lived and died. However, multivariable analysis revealed only 5 independent predictors of earlier death: worse New York Heart Association functional class (hazard ratio [HR]=1.87 per class [95% CI, 1.22-2.87]; <i>P</i> <0.01); lower serum sodium level (HR=0.93 per 1 mEq/L increase [95% CI, 0.88-0.99]; <i>P</i>=0.04); atrial fibrillation (HR=1.81 [95% CI, 1.03-3.21]; <i>P</i>=0.04); chronic lung disease (HR=2.05 [95% CI, 1.20-3.51]; <i>P</i> <0.01), and amiodarone use (HR=10.1 [95% CI, 4.51-22.5]; <i>P</i> <0.01). Using receiver operating characteristic curves, we developed a model with an area under the curve of 0.718 that predicted death at one year after ICD implantation. Despite significant univariate differences between the ICD recipients who did and did not live beyond one year, we found only moderate predictors of survival. Better tools are needed to predict outcomes when considering ICD placement for primary prevention. |
18,731 | Prognostic Impact of Acute Myocardial Infarction in Patients Presenting With Ventricular Tachyarrhythmias and Aborted Cardiac Arrest. | Background The study sought to assess the prognostic impact of acute myocardial infarction ( AMI ) with and without ST -segment-elevation myocardial infarction ( STEMI and NSTEMI ) in patients with ventricular tachyarrhythmias and sudden cardiac arrest ( SCA ) on admission. Methods and Results A large retrospective registry was used including all consecutive patients presenting with ventricular tachycardia ( VT ), fibrillation ( VF ), and sudden cardiac arrest ( SCA ) on admission from 2002 to 2016. AMI versus non- AMI and STEMI versus NSTEMI were compared applying multivariable Cox regression models and propensity-score matching for evaluation of the primary prognostic end point defined as long-term all-cause mortality at 2.5 years. Secondary end points were 30 days all-cause mortality, cardiac death at 24 hours, in hospital death, and recurrent percutaneous coronary intervention (re- PCI ) at 2.5 years. In 2813 unmatched high-risk patients with ventricular tachyarrhythmias and SCA , AMI was present in 29% (10% STEMI , 19% NSTEMI ) with higher rates of VF (54% versus 31%) and SCA (35% versus 26%), whereas VT rates were higher in non- AMI (56% versus 30%) ( P < 0.05). AMI -related VT ≥48 hours was associated with higher mortality (log rank P = 0.001). Multivariable Cox regression models revealed non- AMI (hazard ratio = 1.458; P = 0.001) and NSTEMI (hazard ratio = 1.460; P = 0.036) associated with increasing long-term all-cause mortality at 2.5 years, which was also proven after propensity-score matching (non- AMI versus AMI : 55% versus 43%, log rank P = 0.001, hazard ratio = 1.349; NSTEMI versus STEMI : 45% versus 34%, log rank P = 0.047, hazard ratio = 1.372). Secondary end points including 30 days and in-hospital mortality, as well as re- PCI were higher in non- AMI patients. Conclusions In high-risk patients presenting with ventricular tachyarrhythmias and SCA , non- AMI revealed higher mortality than AMI , respectively NSTEMI than STEMI , alongside AMI -related VT ≥48 hours. |
18,732 | Ischemic Heart Disease Modifies the Association of Atrial Fibrillation With Mortality in Heart Failure With Reduced Ejection Fraction. | Background The CASTLE - AF (Catheter Ablation versus Standard Conventional Therapy in Patients With Left Ventricular Dysfunction and Atrial Fibrillation) trial recently reported that catheter ablation of atrial fibrillation ( AF ) improves survival in heart failure (HF) with reduced ejection fraction ( HF r EF ). However, established AF was not associated with mortality in trials of contemporary HF r EF pharmacotherapies. We investigated whether HF r EF pathogenesis may influence the conclusions of studies evaluating the prognostic impact of AF . Methods and Results Using a prospective cohort study of 791 patients with HFr EF , with AF determined using 24-hour ambulatory ECG monitoring, univariable and multivariable Cox regression analyses were used to define the association between AF and mode-specific mortality (mean follow-up of 5.4 years). One-year HF-related hospitalization was assessed with binary logistic regression analysis. One-year cardiac remodeling was assessed in a subgroup (n=378) using echocardiography. AF was present in 28.2% of patients, with 9.4% of these being paroxysmal. While AF was associated with increased risk of all-cause mortality (hazard ratio, 1.27; 95% confidence interval 1.03-1.57), with diverging survival curves after 1 year of follow-up, this association was lost in age-sex-adjusted analyses. However, AF was associated with increased risk of age-sex-adjusted all-cause mortality in people with ischemic pathogenesis, with a statistically significant interaction between pathogenesis and AF. This was predominantly attributed to progressive HF deaths. After 1 year, HF hospitalization and cardiac remodeling were not associated with AF , even in people with ischemic pathogenesis. Conclusions AF is associated with increased risk of death in HF r EF of ischemic pathogenesis, predominantly due to progressive HF deaths during long-term follow-up. HF r EF pathogenesis should be considered in trial design and interpretation. |
18,733 | Genotype-Positive Status Is Associated With Poor Prognoses in Patients With Left Ventricular Noncompaction Cardiomyopathy. | Background Left ventricular noncompaction cardiomyopathy ( LVNC ) is a genetically and phenotypically heterogeneous disease. This study aims to investigate the genetic basis and genotype-phenotype correlations in a cohort of Chinese patients with LVNC . Methods and Results A total of 72 cardiomyopathy-associated genes were comprehensively screened in 83 adults and 17 children with LVNC by targeted sequencing. Pathogenicity of the detected variants was determined according to their prevalence and American College of Medical Genetics and Genomics recommendations. Baseline and follow-up clinical data were collected. The primary end point was a composite of death and heart transplantation. Overall, 42 pathogenic variants were identified in 38 patients (38%), with TTN , MYH 7, MYBPC 3, and DSP being the most commonly involved genes. At baseline, genotype-positive adults had higher rates of atrial fibrillation and family history, and lower left ventricular ejection fraction, compared with genotype-negative adults. During a median follow-up of 4.2 years, more primary end points occurred in genotype-positive adults than in genotype-negative adults (50.0% versus 23.5%; P=0.013). Multivariable analysis demonstrated that genotype-positive status was associated with higher risks of death and heart transplantation, independent of age, sex, and cardiac function at baseline in patients with LVNC (adjusted hazards ratio, 2.49; 95% confidence interval, 1.15-5.37; P=0.020). Conclusions Our study revealed a distinct genetic spectrum in Chinese patients with LVNC , with variants in TTN , MYH 7, MYBPC 3, and DSP being the most common. The presence of pathogenic variants is an independent risk factor for adverse outcomes and may aid in risk stratification in adult patients. Larger studies are needed to confirm these findings. |
18,734 | Liver Disease as a Predictor of New-Onset Atrial Fibrillation. | Background Impact of liver disease on development of atrial fibrillation ( AF ) is unclear. The purpose of the study was to evaluate prevalence of AF in the setting of liver disease and whether increasing severity of liver disease, using Model for End-Stage Liver Disease ( MELD ), is independently associated with increased risk of AF . Methods and Results Retrospective data analysis of 1727 patients with liver disease evaluated for liver transplantation between 2006 and 2015 was performed, and patient characteristics were analyzed from billing codes and review of medical records. Multivariable time-dependent Cox proportional hazards model was performed to determine effect of increasing MELD score on risk of developing AF . Prevalence of AF was 11.2%. Incidence of AF at median follow-up time of 1.04 years was 8.5%. Both prevalence and incidence of AF increased with increasing MELD scores. Prevalence of AF was 3.7%, 6.4%, 16.7%, and 20.2% corresponding with MELD quartiles 1 to 10, 11 to 20, 21 to 30, and >30, respectively. Compared with patients with MELD quartile 1 to 10, patients with MELD quartile of 11 to 20 had hazard ratio of 2.73 (confidence interval, 1.47-5.07), those in the MELD quartile of 21 to 30 had a hazard ratio of 5.17 (confidence interval, 2.65-10.09), and those with MELD values >30 had hazard ratio of 9.33 (confidence interval, 3.93-22.14) for development of new-onset AF . Other significant variables associated with new-onset AF were age, sleep apnea, valvular heart disease, hemodynamic instability, and reduced left ventricular ejection fraction <50% (hazard ratio, of 1.06, 2.17, 3.21, 2.00, and 2.44, respectively). Conclusions Prevalence and incidence of AF in patients with liver disease is high. Severity of liver disease, as measured by MELD , is an important predictor of new-onset AF . This novel finding suggests an interaction between inflammatory and neurohormonal changes in liver disease and pathogenesis of AF . |
18,735 | Myocardial Perfusion Is Impaired and Relates to Cardiac Dysfunction in Patients With Atrial Fibrillation Both Before and After Successful Catheter Ablation. | Background Atrial fibrillation ( AF ) is associated with myocardial infarction, and patients with AF and no obstructive coronary artery disease can present with symptoms and evidence of cardiac ischemia. We hypothesized that microvascular coronary dysfunction underlies these observations. Methods and Results Myocardial blood flow ( MBF ) at baseline and during adenosine stress and left ventricular and left atrial function were evaluated by magnetic resonance in 49 patients with AF (25 paroxysmal, 24 persistent) with no history of epicardial coronary artery disease or diabetes mellitus, before and 6 to 9 months after ablation. Findings were compared with those obtained in matched controls in sinus rhythm (n=25). Before ablation, patients with AF had impaired left atrial function and left ventricular ejection fraction and strain indices (all P<0.05 versus controls). MBF was impaired in patients both under baseline conditions (1.21±0.24 mL/min per g·[mm Hg·bpm/10<sup>4</sup>]<sup>-1</sup> versus 1.34±0.28 mL/min per g·[mm Hg·bpm/10<sup>4</sup>]<sup>-1</sup> in controls, P=0.044) and during adenosine stress (2.29±0.48 mL/min per g versus 2.73±0.37 mL/min per g in controls, P<0.001). Under baseline conditions, MBF correlated with left ventricular strain and left atrial function (all P≤0.001), so that cardiac function was most impaired in patients with the lowest MBF . Baseline and stress MBF remained unchanged postablation (both P=ns), and baseline MBF showed similar correlations with functional indices to those present preablation (all P≤0.001). Conclusions Baseline and stress MBF are significantly impaired in patients with AF but no epicardial coronary artery disease. Reduction in MBF is proportional to severity of left ventricular and left atrial dysfunction, even after successful ablation. Coronary microvascular dysfunction may be a relevant pathophysiological mechanism in patients with a history of AF . |
18,736 | Elimination of Purkinje Fibers by Electroporation Reduces Ventricular Fibrillation Vulnerability. | Background The Purkinje network appears to play a pivotal role in the triggering as well as maintenance of ventricular fibrillation. Irreversible electroporation ( IRE ) using direct current has shown promise as a nonthermal ablation modality in the heart, but its ability to target and ablate the Purkinje tissue is undefined. Our aim was to investigate the potential for selective ablation of Purkinje/fascicular fibers using IRE . Methods and Results In an ex vivo Langendorff model of canine heart (n=8), direct current was delivered in a unipolar manner at various dosages from 750 to 2500 V, in 10 pulses with a 90-μs duration at a frequency of 1 Hz. The window of ventricular fibrillation vulnerability was assessed before and after delivery of electroporation energy using a shock on T-wave method. IRE consistently eradicated all Purkinje potentials at voltages between 750 and 2500 V (minimum field strength of 250-833 V/cm). The ventricular electrogram amplitude was only minimally reduced by ablation: 0.6±2.3 mV ( P=0.03). In 4 hearts after IRE delivery, ventricular fibrillation could not be reinduced. At baseline, the lower limit of vulnerability to ventricular fibrillation was 1.8±0.4 J, and the upper limit of vulnerability was 19.5±3.0 J. The window of vulnerability was 17.8±2.9 J. Delivery of electroporation energy significantly reduced the window of vulnerability to 5.7±2.9 J ( P=0.0003), with a postablation lower limit of vulnerability=7.3±2.63 J, and the upper limit of vulnerability=18.8±5.2 J. Conclusions Our study highlights that Purkinje tissue can be ablated with IRE without any evidence of underlying myocardial damage. |
18,737 | Primary Effect of SERCA 2a Gene Transfer on Conduction Reserve in Chronic Myocardial Infarction. | Background SERCA 2a gene transfer ( GT ) improves mechano-electrical function in animal models of nonischemic heart failure Whether SERCA 2a GT reverses pre-established remodeling at an advanced stage of ischemic heart failure is unclear. We sought to uncover the electrophysiological effects of adeno-associated virus serotype 1. SERCA 2a GT following myocardial infarction ( MI ). Methods and Results Pigs developed mechanical dysfunction 1 month after anterior MI , at which point they received intracoronary adeno-associated virus serotype 1. SERCA 2a ( MI + SERCA 2a) or saline ( MI ) and were maintained for 2 months. Age-matched naive pigs served as controls (Control). In vivo ECG -and-hemodynamic properties were assessed before and after dobutamine stress. The electrophysiological substrate was measured using optical action potential ( AP ) mapping in controls, MI , and MI + SERCA 2a preparations. In vivo ECG measurements revealed comparable QT durations between groups. In contrast, prolonged QRS duration and increased frequency of R' waves were present in MI but not MI + SERCA 2a pigs relative to controls. SERCA 2a GT reduced in in vivo arrhythmias in response to dobutamine. Ex vivo preparations from MI but not MI + SERCA 2a or control pigs were prone to pacing-induced ventricular tachycardia and fibrillation. Underlying these arrhythmias was pronounced conduction velocity slowing in MI versus MI + SERCA 2a at elevated rates leading to ventricular tachycardia and fibrillation. Reduced susceptibility to ventricular tachycardia and fibrillation in MI + SERCA 2a pigs was not related to hemodynamic function, contractile reserve, fibrosis, or the expression of Cx43 and Nav1.5. Rather, SERCA 2a GT decreased phosphoactive CAMKII -delta levels by >50%, leading to improved excitability at fast rates. Conclusions SERCA 2a GT increases conduction velocity reserve, likely by preventing CAMKII overactivation. Our findings suggest a primary effect of SERCA 2a GT on myocardial excitability, independent of altered mechanical function. |
18,738 | Sex-Dependent Phenotypic Variability of an SCN5A Mutation: Brugada Syndrome and Sick Sinus Syndrome. | Background Brugada syndrome ( BS ) is known to be 9 times more prevalent in males than females. However, little is known about the development of sick sinus syndrome in female members with familial BS . Methods and Results Familial BS patients and family members, both from our institutions and collaborating sites that specialize in clinical care of BS , participated in this study. We collected information on their clinical and genetic background, along with the inheritance patterns of BS . Detailed information on each case with familial BS is described. A total of 7 families, including 25 BS patients (12 females and 13 males), were included. Seven were probands and 18 were family members. Ten out of the 12 female patients and none of the 13 male patients developed sick sinus syndrome. Sudden death or spontaneous ventricular fibrillation occurred in 7 out of 13 male patients and 2 out of 12 female patients. Conclusions Familial BS existed in which female patients developed sick sinus syndrome but male patients did not. Some of those female patients with sick sinus syndrome had unrecognized BS . Information should be collected not only regarding a family history of sudden death or BS , but also whether a pacemaker was implanted in female members. |
18,739 | Discordant Alternans as a Mechanism for Initiation of Ventricular Fibrillation In Vitro. | Background Ventricular tachyarrhythmias are often preceded by short sequences of premature ventricular complexes. In a previous study, a restitution-based computational model predicted which sequences of stimulated premature complexes were most likely to induce ventricular fibrillation in canines in vivo. However, the underlying mechanism, based on discordant-alternans dynamics, could not be verified in that study. The current study seeks to elucidate the mechanism by determining whether the spatiotemporal evolution of action potentials and initiation of ventricular fibrillation in in vitro experiments are consistent with model predictions. Methods and Results Optical mapping voltage signals from canine right-ventricular tissue (n=9) were obtained simultaneously from the entire epicardium and endocardium during and after premature stimulus sequences. Model predictions of action potential propagation along a 1-dimensional cable were developed using action potential duration versus diastolic interval data. The model predicted sign-change patterns in action potential duration and diastolic interval spatial gradients with posterior probabilities of 91.1%, and 82.1%, respectively. The model predicted conduction block with 64% sensitivity and 100% specificity. A generalized estimating equation logistic-regression approach showed that model-prediction effects were significant for both conduction block ( P<1×10<sup>-15</sup>, coefficient 44.36) and sustained ventricular fibrillation ( P=0.0046, coefficient, 1.63) events. Conclusions The observed sign-change patterns favored discordant alternans, and the model successfully identified sequences of premature stimuli that induced conduction block. This suggests that the relatively simple discordant-alternans-based process that led to block in the model may often be responsible for ventricular fibrillation onset when preceded by premature beats. These observations may aid in developing improved methods for anticipating block and ventricular fibrillation. |
18,740 | Early Use of Echocardiography in Patients With Acute Pulmonary Embolism: Findings From the RIETE Registry. | Background Transthoracic echocardiography ( TTE ) is often considered for risk stratification of patients with acute pulmonary embolism ( PE ). We sought to determine the contemporary utilization of early TTE (within 72 hours of PE diagnosis) and explored the association between TTE findings and PE -related mortality. Methods and Results Data from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry, a multicenter registry of consecutive patients with acute PE , were used (2001-July 2017). We used a generalized linear mixed model to determine predictors of early TTE performance. Moreover, the association between 3 TTE variables (right atrial enlargement, right ventricular hypokinesis, and presence of right heart thrombi) and 30-day PE -related mortality was assessed in generalized linear mixed models adjusted for PE severity index, and other comorbidities. Among 35 935 enrollees with acute PE , 15 375 (42.8%) underwent early TTE . There was an increase in early TTE utilization rate over time ( P<0.001 for trend). Younger age, female sex, enrollment in countries other than Spain, history of coronary disease, heart failure, atrial fibrillation, tachycardia, and hypotension were the main predictors of early TTE ( P<0.01 for all). In multivariable analyses, right atrial enlargement (adjusted odds ratio: 3.74; 95% confidence interval, 2.10-6.66), right ventricular hypokinesis (adjusted odds ratio: 3.11, 95% confidence interval: 1.85-5.21) and right heart thrombi (adjusted odds ratio: 4.39, 95% confidence interval, 1.99-9.71) were associated with increased odds for PE -related mortality. Conclusions Early TTE is commonly performed for acute PE and utilization rates have increased over time. Right atrial enlargement, right ventricular hypokinesis, and right heart thrombi are predictive of worse outcomes. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02832245. |
18,741 | Intake of Vitamin K Antagonists and Worsening of Cardiac and Vascular Disease: Results From the Population-Based Gutenberg Health Study. | Background Preclinical data have indicated a link between use of vitamin K antagonists ( VKA ) and detrimental effects on vascular structure and function. The objective of the present study was to determine the relationship between VKA intake and different phenotypes of subclinical cardiovascular disease in the population. Methods and Results Clinical and laboratory data, as well as medical-technical examinations were assessed from 15 010 individuals aged 35 to 74 years during a highly standardized 5-hour visit at the study center of the population-based Gutenberg Health Study. In total, the study sample comprised 287 VKA users and 14 564 VKA nonusers. Multivariable analysis revealed an independent association between VKA intake and stiffness index (β=+2.54 m/s; [0.41/4.66]; P=0.019), ankle-brachial index (β=-0.03; [-0.04/-0.01]; P<0.0001), intima-media thickness (β=+0.03 mm [0.01/0.05]; P=0.0098), left ventricular ejection fraction (β=-4.02% [-4.70/-3.33]; P<0.0001), E/E' (β=+0.04 [0.01/0.08]; P=0.014) left ventricular mass (β=+5.34 g/m<sup>2.7</sup> [4.26/6.44]; P<0.0001), and humoral markers of cardiac function and inflammation (midregional pro-atrial natriuretic peptide: β=+0.58 pmol/L [0.50/0.65]; P<0.0001; midregional pro-adrenomedullin: β=+0.18 nmol/L [0.14/0.22]; P<0.0001; N-terminal pro B-type natriuretic peptide: β=+1.90 pg/mL [1.63/2.17]; P<0.0001; fibrinogen: β=+143 mg/dL [132/153]; P<0.0001; C-reactive protein: β=+0.31 mg/L [0.20/0.43]; P<0.0001). Sensitivity analysis in the subsample of participants with atrial fibrillation stratified by intake of VKA demonstrated consistent and robust results. Genetic variants in CYP 2C9, CYP 4F2, and VKORC 1 were modulating effects of VKA on subclinical markers of cardiovascular disease. Conclusions These data demonstrate negative effects of VKA on vascular and cardiac phenotypes of subclinical cardiovascular disease, indicating a possible influence on long-term disease development. These findings may be clinically relevant for the provision of individually tailored antithrombotic therapy. |
18,742 | Atrial fibrillation in the cardiometabolic patient. | Prevalence of obesity, metabolic syndrome (MetS) and type 2 diabetes (T2D) is growing alarmingly, and the number of affected people continues to escalate. Such cardiometabolic states exert many deleterious effects on the heart as they are associated with adverse left ventricular (LV) remodeling and, most notably, with a marked increase in the risk of developing atrial fibrillation (AF) and subsequent stroke. Epidemiological studies clearly show a strong association between obesity and AF, with a 4-5% increase in AF risk for every unit increase in BMI. The increased risk of developing AF in cardiometabolic patients is explained by changes in volume status, energy substrate utilization, tissue metabolism and systemic inflammation, all factors promoting elevation in left atrial and systolic blood pressure, LV systo-diastolic dysfunction, with subsequent atrial stretch and "triggers" for AF. In the present review, we critically discuss available evidence on AF risk in the cardiometabolic patient. Specific aspects will be discussed: 1) epidemiology and prognosis of AF in patients with obesity, MetS and T2D; 2) molecular mechanisms involved in the pathophysiology of metabolic cardiomyopathy and left atrial remodeling; 3) advances in medical therapy including weight loss strategies and lifestyle changes; 4) new oral anticoagulants and stroke risk in obese and diabetic patients; 5) effectiveness and safety of AF catheter ablation. Taken together, these novel insights point to the development of new therapeutic strategies to combat the burden of AF in patients with cardiometabolic disturbances. |
18,743 | Activin Receptor-Like Kinase 4 Haplodeficiency Mitigates Arrhythmogenic Atrial Remodeling and Vulnerability to Atrial Fibrillation in Cardiac Pathological Hypertrophy. | Background Activin receptor-like kinase 4 ( ALK 4) is highly expressed in mammal heart. Atrial fibrillation ( AF ) is closely related to ventricular pressure overload. Because pressure overload increases atrial pressure and leads to atrial remodeling, it would be informative to know whether ALK 4 exerts potential effects on atrial remodeling and AF vulnerability in a pressure-overload model. Methods and Results Wild-type littermates and ALK 4<sup>+/-</sup> mice were subjected to abdominal aortic constriction or a sham operation. After 4 or 8 weeks, echocardiographic and hemodynamic measurements were performed, and inducibility of AF was tested. The hearts were divided into atria and ventricles and then were fixed in formalin for staining, or they were weighted and snap-frozen for quantitative real-time polymerase chain reaction and Western blot analysis. Compared with wild-type littermates, ALK 4<sup>+/-</sup> mice demonstrated a similar extent of atrial hypertrophy but significantly suppressed atrial fibrosis at 8 weeks post-abdominal aortic constriction. ALK 4 haplodeficiency partially blocked abdominal aortic constriction-induced upregulation of monocyte chemotactic protein 1 and interleukin-6, and the increased chemotaxin of macrophages. ALK 4 haplodeficiency also blunted a reduction of connexin 40 and redistribution of connexin 43 from the intercalated disk to the lateral membranes, thereby improving localized conduction abnormalities. Meanwhile, ALK 4 haplodeficiency inhibited abdominal aortic constriction-induced decreased I<sub>N</sub><sub>a</sub>, I<sub>C</sub><sub>a-L</sub> and I<sub>K</sub><sub>1</sub> densities as well as the accompanying action potential duration shortening. Mechanistically, ALK 4 haploinsufficiency resulted in the suppression of Smad2/3 activity in this model. Conclusions Our results demonstrate that ALK 4 haplodeficiency ameliorates atrial remodeling and vulnerability to AF in a pressure-overload model through inactivation of the Smad2/3 pathway, suggesting that ALK 4 might be a potential therapeutic target in combating pressure overload-induced AF . |
18,744 | Prevalence, Echocardiographic Correlations, and Clinical Outcome of Tricuspid Regurgitation in Patients with Significant Left Ventricular Dysfunction. | We initiated this study to evaluate the prevalence and clinical significance of tricuspid regurgitation in patients with left ventricular dysfunction.</AbstractText>A single-center analysis of all echocardiographic studies between 2000 and 2013 was performed. Patients with ejection fraction <35% were included, and those with mechanical valves, mitral stenosis, or significant aortic valve pathology were excluded. Patients were grouped based on tricuspid regurgitation severity (nonsignificant, moderate, and severe). Demographic and echocardiographic findings and survival were compared.</AbstractText>The study included 3943 patients (74% male, age 69 ± 14 years); 70% had nonsignificant, 24% had moderate, and 6% had severe tricuspid regurgitation. In a multivariate model, tricuspid regurgitation was independently associated with older age (odds ratio [OR] 1.009; 95% confidence interval [CI], 1.001-1.017; P = .022), female sex (OR 1.644; 95% CI, 1.329-2.035; P < .001), atrial fibrillation (OR 1.764; 95% CI, 1.429-2.134; P < .001), tricuspid regurgitation gradient (OR 1.051; 95% CI, 1.045-1.058; P < .001 per mm Hg), right ventricular dysfunction (OR 3.492; 95% CI, 2.870-4.248; P < .001), left atrial area (cm2</sup>, OR 1.031; 95% CI, 1.013-1.049; P < .001), mitral regurgitation severity (P < .001), and lack of hypertension (OR 0.760; 95% CI, 0.616-0.936; P = .010) or obesity (OR 0.583; 95% CI, 0.427-0.796; P < .001). Patients were followed for a median of 8.15 years (interquartile range 4.75-11.42). Median survival was 4.88 years for nonsignificant, 2.3 years for moderate, and 1.6 years for patients with severe tricuspid regurgitation, significantly associated with tricuspid regurgitation severity (hazard ratio 1.513; 95% CI, 1.383-1.656 for moderate, hazard ratio 1.857; 95% CI, 1.606-2.148 for severe tricuspid regurgitation; P < .001), the association persisted after multiple adjustments.</AbstractText>Significant tricuspid regurgitation is common in patients with left ventricular dysfunction. It is linked to various cardiac pathologies and independently associated with increased mortality.</AbstractText>Copyright © 2019. Published by Elsevier Inc.</CopyrightInformation> |
18,745 | A novel approach to devise the therapy for ventricular fibrillation by epicardial delivery of lidocaine using active hydraulic ventricular attaching support system: An experimental study in rats. | Active hydraulic ventricular attaching support system (ASD) placed around the heart is not only a novel, nontransplant surgical device used for epicardial administration of drugs like lidocaine, but also a promising treatment option for ventricular fibrillation (VF) and arrhythmias. We hypothesize that lidocaine in 5 mg/kg dose released by ASD significantly improves the VF in the rat model. Sprague-Dawley (SD) rats were selected and were divided into four groups, intravenous injection (IV), epicardial infusion (EI), ASD, and control. ASD group was further divided into four subgroups for different lidocaine doses (i) ASD+A group (10 mg/kg), (ii) ASD+B group (5 mg/kg), (iii) ASD+C group (1 mg/kg), and (iv) ASD+D group (0.1 mg/kg). VF was induced with calcium chloride injection and was confirmed by electrocardiogram (ECG) in all the groups. VF was treated with different doses of lidocaine using different modes of administration. Data were analyzed using the SPSS 19.0 Chi-square tests and one-way analysis of variance (ANOVA). The Kaplan-Meier curve for OS was compared to the Logrank test based on the survival time. P < 0.05 was considered as statistically significant. ASD + B group (5 mg/kg) showed significantly reduced sgroup. The time of first sinus rhythm recovered (15.96 ± 21.77 min) and ▵T-SOD in plasma (-42.02 ± 26.99 U/mL) was significantly different than that of control, IV, and EI groups. ▵T-SOD in plasma for all ASD-treated groups was smaller than the control and IV groups. This study proves that ASD with 5 mg/kg lidocaine dose appears as a promising therapeutic platform for treating VF in rats. Furthermore, ASD may also have potential for treating VF or other cardiovascular disease with different therapeutic agents. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1722-1731, 2019. |
18,746 | Effectiveness of the 2014 European Society of Cardiology guideline on sudden cardiac death in hypertrophic cardiomyopathy: a systematic review and meta-analysis. | In 2014, the European Society of Cardiology (ESC) recommended the use of a novel risk prediction model (HCM Risk-SCD) to guide use of implantable cardioverter defibrillators (ICD) for the primary prevention of sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM). We sought to determine the performance of HCM Risk-SCD by conducting a systematic review and meta-analysis of articles reporting on the prevalence of SCD within 5 years of evaluation in low, intermediate and high-risk patients as defined by the 2014 guidelines (predicted risk <4%, 4%-<6% and ≥6%, respectively).</AbstractText>The protocol was registered with PROSPERO (registration number: CRD42017064203). MEDLINE and manual searches for papers published from October 2014 to December 2017 were performed. Longitudinal, observational cohorts of unselected adult patients, without history of cardiac arrest were considered. The original HCM Risk-SCD development study was included a priori. Data were pooled using a random effects model.</AbstractText>Six (0.9%) out of 653 independent publications identified by the initial search were included. The calculated 5-year risk of SCD was reported in 7291 individuals (70% low, 15% intermediate; 15% high risk) with 184 (2.5%) SCD endpoints within 5 years of baseline evaluation. Most SCD endpoints (68%) occurred in patients with an estimated 5-year risk of ≥4% who formed 30% of the total study cohort. Using the random effects method, the pooled prevalence of SCD endpoints was 1.01% (95% CI 0.52 to 1.61) in low-risk patients, 2.43% (95% CI 1.23 to 3.92) in intermediate and 8.4% (95% CI 6.68 to 10.25) in high-risk patients.</AbstractText>This meta-analysis demonstrates that HCM Risk-SCD provides accurate risk estimations that can be used to guide ICD therapy in accordance with the 2014 ESC guidelines.</AbstractText>PROSPERO CRD42017064203;Pre-results.</AbstractText>© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
18,747 | Left Atrial Appendage Occlusion With Left Ventricular Assist Device Decreases Thromboembolic Events. | Thromboembolic events (TEs) are common adverse events with continuous-flow left ventricular assist devices (LVADs). Left atrial appendage occlusion (LAAO) is commonly performed at the time of a cardiac operation. The effect of LAAO on TEs in LVAD patients remains unknown.</AbstractText>All patients receiving a first LVAD implantation between January 2013 and January 2014 were reviewed. TEs included device thrombosis and ischemic cerebrovascular accidents. The incidence of TEs with respect to LAAO was evaluated using Kaplan-Meier and Cox proportional hazards analyses.</AbstractText>The analysis included 102 patients, 36 of whom received LAAO and 66 did not. LAAO patients were an average age of 60 years, and 69.4% were men. Non-LAAO patients were an average age of 59.3 years, and 71.2% were men. There were no significant differences in characteristics other than history of coronary artery bypass grafting (8.3% of LAAO vs 44% of non-LAAO, p = 0.0005). Preoperative atrial fibrillation was present in 19 LAAO patients (52.7%) and in 36 non-LAAO patients (54.5%; p = 1.0). Patients were monitored for a median of 306 days. TEs occurred in 3 LAAO patients (1 device thrombosis and 2 cerebrovascular accidents) compared with 15 non-LAAO patients (5 device thromboses and 11 cerebrovascular accidents, p = 0.049). In a Cox hazards analysis including age, sex, hypertension, and atrial fibrillation, LAAO demonstrated a decreased risk of TE (hazard ratio, 0.27; 95% confidence interval, 0.08 to 0.95; p = 0.04).</AbstractText>In patients undergoing LVAD implantation, LAAO is associated with reduced TEs, and this effect may be independent of atrial fibrillation. A prospective randomized study to examine the efficacy LAAO in prevention of TE is needed to confirm these findings.</AbstractText>Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,748 | Mode of presentation and mortality amongst patients hospitalized with heart failure? A report from the First Euro Heart Failure Survey. | Heart failure is heterogeneous in aetiology, pathophysiology, and presentation. Despite this diversity, clinical trials of patients hospitalized for HF deal with this problem as a single entity, which may be one reason for repeated failures.</AbstractText>The first EuroHeart Failure Survey screened consecutive deaths and discharges of patients with suspected heart failure during 2000-2001. Patients were sorted into seven mutually exclusive hierarchical presentations: (1) with cardiac arrest/ventricular arrhythmia; (2) with acute coronary syndrome; (3) with rapid atrial fibrillation; (4) with acute breathlessness; (5) with other symptoms/signs such as peripheral oedema; (6) with stable symptoms; and (7) others in whom the contribution of HF to admission was not clear.</AbstractText>The 10,701 patients enrolled were classified into the above seven presentations as follows: 260 (2%), 560 (5%), 799 (8%), 2479 (24%), 1040 (10%), 703 (7%), and 4691 (45%) for which index-admission mortality was 26%, 20%, 10%, 8%, 6%, 6%, and 4%, respectively. Compared to those in group 7, the hazard ratios for death during the index admission were 4.9 (p ≤ 0.001), 4.0 (p < 0.001), 2.2 (p < 0.001), 2.1 (p < 0.001), 1.4 (p < 0.04) and 1.4 (p = 0.04), respectively. These differences were no longer statistically significant by 12 weeks.</AbstractText>There is great diversity in the presentation of heart failure that is associated with very different short-term outcomes. Only a minority of hospitalizations associated with suspected heart failure are associated with acute breathlessness. This should be taken into account in the design of future clinical trials.</AbstractText> |
18,749 | Rare recurrence of apical ballooning (takotsubo) syndrome in an elderly man. | Apical ballooning syndrome (ABS) is an under recognised clinical entity characterised by acute reversible left ventricular systolic dysfunction that mimics acute myocardial infarction in the absence of obstructive coronary artery disease; typically occurring in the setting of profound stress.<sup>1</sup> ABS disproportionately affects older women and recurrences are infrequent. We, hereby, describe a rare phenomenon of recurrent ABS in an elderly male patient, 10 years apart, presenting with the same left ventricular morphological appearance following non-cardiac surgeries. The case illustrates the importance of considering ABS in the differential diagnosis of perioperative acute myocardial infarction in older men undergoing major surgery. |
18,750 | Predictors of outcome in heart failure patients with severe functional mitral regurgitation undergoing MitraClip treatment. | The prognostic predictors of outcome in patients with functional mitral regurgitation (FMR) undergoing MitraClip implantation (MCi) are still poorly known. The aim of our study is to identify the baseline predictors of outcome in FMR patients candidate to MCi.</AbstractText>All patients with symptomatic moderate-to-severe or severe FMR undergoing MCi at our institution were consecutively and prospectively enrolled. Baseline clinical and instrumental data were collected. Primary endpoint was the occurrence of cardiac death; secondary endpoints were all-cause death and the composite of cardiac death or rehospitalization for heart failure.</AbstractText>74 patients (mean 71.6 ± 8.3 years) were enrolled. During follow-up (median 416.0 days), the primary endpoint occurred in 15 (20.3%), all-cause death in 26 (35.1%) and the composite endpoint in 25 (33.8%). At multivariate analysis, the left atrial volume index (LAVi; HR:1.02; P = 0.048) and the low peak oxygen uptake (peak VO2</sub>; HR:0.73; P = 0.018) increased the risk of cardiac death at follow-up; atrial fibrillation (AF; HR:2.69; P = 0.027) was independently associated to all-cause death and the low level of peak VO2</sub> was an independent predictor of overall mortality (HR:0.70; P < 0.001) as well as of the composite endpoint (HR:0.73; P < 0.001). The ROC analysis identified a peak VO2</sub> cut-off of 10.0 mL/kg/min as the best predictor for the three study endpoints; the best LAVi cut-off for cardiac death was 67 mL/m2</sup>. Kaplan-Meier analysis for the individual and combined outcome predictors confirmed their significant stratification ability during follow-up.</AbstractText>Peak VO2</sub>, along with LAVi and AF, identify FMR patients with the worst prognosis after MCi.</AbstractText>Copyright © 2018. Published by Elsevier B.V.</CopyrightInformation> |
18,751 | Sex Differences in Heart Failure With Preserved Ejection Fraction Reflected by B-type Natriuretic Peptide Level. | Prevalence of heart failure with preserved ejection fraction (HFpEF) increases with advancing age, particularly among women. Plasma levels of B-type natriuretic peptide (BNP), a surrogate marker of heart failure, have consistently been shown to be higher in women in the general populations. Whether BNP levels differ as per the sex of HFpEF patients remains largely unknown.</AbstractText>The study subjects were 733 HFpEF patients (204 men and 529 women, aged 80.9 ± 9.6 years) who underwent echocardiography and routine clinical examination, including plasma BNP level evaluation. These parameters were compared between women and men.</AbstractText>Plasma levels of BNP were significantly lower in women than in men (104 [61, 192] versus 133 [78, 255] pg/mL, P < 0.001), just as hemoglobin, atrial fibrillation, diabetes mellitus, beta-blockers, left ventricular diastolic dimension, left ventricular mass index, left ventricular eccentric hypertrophy and left atrial dimension were. Age, systolic blood pressure, pulse pressure, heart rate, left ventricular relative wall thickness, left ventricular ejection fraction and left ventricular concentric hypertrophy were higher in women than in men. Multiple regression analyses revealed that left ventricular mass index, body mass index, the ratio of early diastolic mitral flow velocity to tissue annular motion velocity divided by left ventricular diastolic dimension, estimated glomerular filtration rate, beta-blockers, left atrial dimensions, female sex and atrial fibrillation were significant predictors for BNP levels (t = 5.41, P < 0.001; t = -4.06, P < 0.001; t = 3.76, P < 0.001; t = -3.68, P < 0.001; t = 3.32, P = 0.001; t = 3.11, P = 0.002; t = -3.07, P = 0.002; and t = 2.65, P = 0.008, respectively).</AbstractText>Plasma BNP levels were lower in women and were related to left ventricular concentric remodeling and hypertrophy among HFpEF patients, contrary to those in the general population.</AbstractText>Copyright © 2018 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,752 | Heart Failure Etiologies and Challenges to Care in the Developing World: An Observational Study in the Democratic Republic of Congo. | Limited data are available regarding causes and outcomes of heart failure as well as organization of care in the developing world.</AbstractText>We included consecutive patients diagnosed with heart failure from November 2014 to September 2016 in a university and private hospital of Lubumbashi, Democratic Republic Congo. Baseline data, including echocardiography, were analyzed to determine factors associated with mortality. Cost of hospitalization as well as challenges for care regarding follow-up were determined. A total of 231 patients (56 ± 17 years, 47% men, left ventricular ejection fraction 29 ± 15%, 20% atrial fibrillation) were diagnosed, more during heart failure hospitalizations (69%) than as outpatients (31%). Main risk factors for heart failure included hypertension (59%), chronic kidney disease (51%), alcohol abuse (38%), and obesity (32%). Dilated cardiomyopathy was the most prevalent etiology (48%), with ischemic cardiomyopathy being present in only 4%. In-hospital mortality rate was 19% and associated with an estimated glomerular filtration rate of <60 mL·min-1</sup>·1.73 m-2</sup> (P < .01) and atrial fibrillation (P = .02). One hundred six patients (46%) were lost to follow-up, which was mainly related to lack of organization of care, poverty, and poor health literacy. Of the remaining 95 subjects, another 33 (35%) died within 1 year after presentation. The average cost of care for a 10-day hospitalization was higher in a private than in a university hospital (885 vs 409 USD).</AbstractText>Patients admitted for heart failure in DRC have a high incidence of nonischemic cardiomyopathy and present late during their disease, with limited resources being available accounting for a high mortality rate and very high loss to follow-up.</AbstractText>Copyright © 2018. Published by Elsevier Inc.</CopyrightInformation> |
18,753 | Management of atrial fibrillation-flutter: uptodate guideline paper on the current evidence. | The term 'flutter' and 'fibrillation' were first coined to differentiate the differences between fast, regular contractions in Atrial Flutter (AFLUT) with irregular, vermiform contractions of Atrial Fibrillation (AFIB). Management of these two diseases has been a challenge for physicians. Rate control (along with rhythm control) is the first line of management for symptomatic AFIB/AFLUT with Rapid Ventricular Rate (RVR). In some situations, atrial rhythms may not be well controlled by these anti-arrhythmic drugs, making cardioversion to sinus rhythm necessary. Anti-coagulation therapy in both the disease population is essential. Catheter ablation is an effective treatment option in certain patients that have AFIB/AFLUT refractory to medical management. Newer techniques like left atrial appendage (LAA) has been developed and is a highly attractive concept for the future in the management of AFIB/AFLUT. Newer novel drugs targeting specific ion channels are approaching the stages of clinical investigation. However, while advances in technologies have helped elucidate many aspects of these diseases, many mysteries still remain. This literature review serves as one of the guideline papers for current up-to-date management on both AFIB and AFLUT. |
18,754 | Profibrotic, Electrical, and Calcium-Handling Remodeling of the Atria in Heart Failure Patients With and Without Atrial Fibrillation. | Atrial fibrillation (AF) and heart failure (HF) are common cardiovascular diseases that often co-exist. Animal models have suggested complex AF-promoting atrial structural, electrical, and Ca<sup>2+</sup>-handling remodeling in the setting of HF, but data in human samples are scarce, particularly regarding Ca<sup>2+</sup>-handling remodeling. Here, we evaluated atrial remodeling in patients with severe left ventricular (LV) dysfunction (HFrEF), long-standing persistent ('chronic') AF (cAF) or both (HFrEF-cAF), and sinus rhythm controls with normal LV function (Ctl) using western blot in right-atrial tissue, sharp-electrode action potential (AP) measurements in atrial trabeculae and voltage-clamp experiments in isolated right-atrial cardiomyocytes. Compared to Ctl, expression of profibrotic markers (collagen-1a, fibronectin, periostin) was higher in HFrEF and HFrEF-cAF patients, indicative of structural remodeling. Connexin-43 expression was reduced in HFrEF patients, but not HFrEF-cAF patients. AP characteristics were unchanged in HFrEF, but showed classical indices of electrical remodeling in cAF and HFrEF-cAF (prolonged AP duration at 20% and shorter AP duration at 50% and 90% repolarization). L-type Ca<sup>2+</sup> current (I<sub>Ca,L</sub>) was significantly reduced in HFrEF, cAF and HFrEF-cAF, without changes in voltage-dependence. Potentially proarrhythmic spontaneous transient-inward currents were significantly more frequent in HFrEF and HFrEF-cAF compared to Ctl, likely resulting from increased sarcoplasmic reticulum (SR) Ca<sup>2+</sup> load (integrated caffeine-induced current) in HFrEF and increased ryanodine-receptor (RyR2) single-channel open probability in HFrEF and HFrEF-cAF. Although expression and phosphorylation of the SR Ca<sup>2+</sup>-ATPase type-2a (SERCA2a) regulator phospholamban were unchanged in HFrEF and HFrEF-cAF patients, protein levels of SERCA2a were increased in HFrEF-cAF and sarcolipin expression was decreased in both HFrEF and HFrEF-cAF, likely increasing SR Ca<sup>2+</sup> uptake and load. RyR2 protein levels were decreased in HFrEF and HFrEF-cAF patients, but junctin levels were higher in HFrEF and relative Ser2814-RyR2 phosphorylation levels were increased in HFrEF-cAF, both potentially contributing to the greater RyR2 open probability. These novel insights into the molecular substrate for atrial arrhythmias in HF-patients position Ca<sup>2+</sup>-handling abnormalities as a likely trigger of AF in HF patients, which subsequently produces electrical remodeling that promotes the maintenance of the arrhythmia. Our new findings may have important implications for the development of novel treatment options for AF in the context of HF. |
18,755 | Atrial Dysfunction in Arrhythmogenic Right Ventricular Cardiomyopathy. | Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy that is predominantly known to affect the ventricles. Evidence for atrial involvement remains limited. Therefore, we aimed to characterize atrial involvement in ARVC using functional cardiac magnetic resonance, define the extent of atrial size and function variation attributable to ventricular variables, and identify cardiac magnetic resonance-based predictors of atrial arrhythmias (AA) in ARVC.</AbstractText>We analyzed cine cardiac magnetic resonance images of 66 definite ARVC patients without a history of AA or severe heart failure and 24 healthy controls. Using tissue tracking, we evaluated phasic biatrial volumes, ejection fractions (EFs), peak longitudinal strain, and strain rates (SRs). The primary outcome was the occurrence of AA during 6.8 years [3.0-10.8 years] of follow-up. Compared with controls, ARVC patients had higher biatrial volumes, reduced right atrial (RA) conduit function (passive EF [RAEFpassive</sub>] and peak early-diastolic SR), reduced RA and left atrial (LA) reservoir function (peak systolic SR), and reduced RA and LA pump function (peak late-diastolic SR; P<0.05). Using multivariable analysis, predictors of increased risk of AA during follow-up were higher atrial volumes (RAVmin</sub> and LAVmin</sub>), decreased LA reservoir function (total LAEF and LA peak longitudinal strain), and decreased RA conduit function (passive RAEF and RA early-diastolic SR).</AbstractText>Compared with controls, patients with ARVC were found to have enlarged atria with decreased function on functional cardiac magnetic resonance examination. RA and LA parameters predict incident AA after adjusting for clinical and ventricular characteristics which suggests atrial involvement in ARVC.</AbstractText> |
18,756 | Transcatheter Mitral Valve Replacement in Patients With Previous Aortic Valve Replacement. | Transcatheter mitral valve replacement (TMVR) may mature to become a therapeutic option for high-risk patients with severe mitral regurgitation (MR), particularly in patients at high or prohibitive surgical risk. MR patients with preexisting aortic valve prosthesis have been excluded from most TMVR trials because of the potential risks of left ventricular outflow tract obstruction or interaction between the TMVR anchoring mechanism and the aortic prosthesis. We describe the procedural and short-term outcomes of transapical TMVR with the Tiara valve in patients experiencing severe symptomatic MR with previous aortic valve replacement (AVR).</AbstractText>Twelve consecutive high surgical risk patients (11 men; mean age, 75±6 years) with aortic valve prosthesis and severe MR underwent TMVR with Tiara valve. Aortic valves were mechanical in 5 and biological in 7 patients, while 1 patient had previously undergone implantation of a transcatheter valve within a failed bioprosthetic surgical valve. Six patients (50%) had undergone redo surgical aortic valve replacement. Clinical characteristics of the group include prior mitral valve repair in 2, prior coronary bypass grafting surgery in 5, chronic atrial fibrillation in 7, renal failure in 9, and pacemaker/cardiac resynchronization device in 9 patients. Mean Society of Thoracic Surgery score and EuroSCORE II were 10.5±4.4 and 12.4±3.7, respectively. Mean baseline left ventricular ejection fraction was 35.5±5.3% (range, 30%-45%). The Tiara valve was implanted uneventfully in all patients. Device migration or left ventricular outflow tract obstruction was not observed. No patient required conversion to open heart surgery or periprocedural hemodynamic support. Procedural success was 100% with no death, MI, stroke, major bleeding, or access site complications at 30 days. MR was eliminated in all 12 patients immediately after implantation.</AbstractText>Transapical mitral valve replacement with the Tiara valve in high-risk patients with severe MR and aortic valve prostheses is technically feasible and can be performed safely.</AbstractText> |
18,757 | Prognostic Importance of Left Ventricular Mechanical Dyssynchrony in Predicting Cardiovascular Death in the General Population. | Cardiovascular death (CVD) is a leading cause of death and constitutes a major burden on society. Left ventricular mechanical dyssynchrony (LVMD), evaluated as SD of time to peak regional longitudinal strain, is a capable predictor of many cardiovascular outcomes related to CVD, including ventricular arrhythmias, but the prognostic utility of LVMD in the general population is unknown. Hence, this study sought to determine the prognostic value of LVMD in the general population in predicting CVD.</AbstractText>A total of 1138 participants underwent a general health examination and an echocardiographic examination including speckle tracking analysis with subsequent calculation of LVMD from time-to-peak regional strain. Primary end point was CVD, and secondary end point was noncardiovascular death. Follow-up was 100%. During a median follow-up of 11.1 years (interquartile range: 10.2-11.3 years), 62 participants suffered CVD (5.5%) while 131 participants experienced noncardiovascular death (11.5%). LVMD was an independent predictor of CVD (subdistribution hazard ratio, 1.04; 95% CI, 1.01-1.06; P=0.004, per 10-ms increase) in competing risk regression treating noncardiovascular death as a competing risk and retained prognostic capability after extensive multivariable adjustment. LVMD was not a significant predictor of noncardiovascular death. LVMD added incremental prognostic information in predicting CVD beyond the Systematic Coronary Risk Evaluation risk chart and a modified version of the American College of Cardiology/American Heart Association Pooled Cohort Equation.</AbstractText>Left ventricular mechanical dyssynchrony adds incremental prognostic information in addition to established risk factors in prediction of CVD in individuals from the general population without atrial fibrillation and significant valvular disease.</AbstractText> |
18,758 | Efficacy of Endocardial Ablation of Drug-Resistant Ventricular Fibrillation in Brugada Syndrome: Long-Term Outcome. | Background Both endocardial trigger elimination and epicardial substrate modification are effective in treating ventricular fibrillation (VF) in Brugada syndrome. However, the primary approach and the characteristics of patients who respond to endocardial ablation remain unknown. Methods Among 123 symptomatic Brugada syndrome patients (VF, 63%; syncope, 37%), ablation was performed in 21 VF/electrical storm patients, the majority of whom were resistant to antiarrhythmic drugs. Results Careful endocardial mapping revealed that 81% of the patients had no specific findings, whereas 19% of the patients, who experienced the most frequent VF episodes with notching of the QRS in lead V<sub>1</sub>, had delayed low-voltage fractionated endocardial electrograms. Ablation of VF triggers followed by endocardial substrate modification was performed in the right ventricular outflow tract in 85% of the cases and in the right ventricle in 15%. VF triggers could not be completely eliminated in 1 patient and VF became noninducible in 14 (88%) patients among 16 patients who underwent VF induction with normalization of Brugada-type ECG in 3. During follow-up (56.14±36.95 months), VF recurrence was observed in 7 patients. Importantly, all patients who had nothing of QRS in lead V<sub>1</sub> did not respond to endocardial ablation despite presence of VF-triggering ectopic beats during ablation. Conclusions With careful documentation of VF-triggering ectopic beats and detailed endocardial mapping, endocardial VF trigger elimination followed by endocardial substrate modification has an excellent long-term outcome, whereas presence of QRS notching in lead V<sub>1</sub> was associated with high VF recurrence suggesting epicardial substrate ablation as effective initial approach. |
18,759 | Effect of Ascertainment Bias on Estimates of Patient Mortality in Inherited Cardiac Diseases. | Accurate estimates of survival are indispensable for cardiologists, clinical geneticists, and genetic counselors dealing with families with an inherited cardiac disease. However, a bias towards a more severe disease with a worse outcome in the first publications may not accurately represent the actual survival forecast. We, therefore, evaluated the effect of ascertainment bias on survival in 3 different inherited cardiac diseases (idiopathic ventricular fibrillation, SCN5A overlap syndrome, and arrhythmogenic cardiomyopathy) caused by a founder mutation.</AbstractText>We collected mortality data from mutation-positive subjects with either DPP6-associated idiopathic ventricular fibrillation, SCN5A overlap syndrome, and PLN-R14del-mediated arrhythmogenic cardiomyopathy >2 to 10 years of ongoing clinical/cascade genetic screening.</AbstractText>The median age of survival in DPP6 mutation-positive subjects increased from 44.6 years in the original cohort from 2008 (n=60; 95% CI, 36.8-52.4 years) to 68.2 years in the extended cohort from 2012 (n=235; 95% CI, 64.6-71.7 years; P<0.001). In the SCN5A overlap syndrome, survival increased from 56.1 years in 1999 (n=86; 95% CI, 48.0-64.2 years) to 69.7 years in 2009 (n=197; 95% CI, 61.3-78.2 years; P=0.049). In PLN-R14del positive patients, the median age of survival increased from 63.5 years in 2010 (n=89; 95% CI, 59.1-68.0 years) to 65.2 years in 2012 (n=370; 95% CI, 62.0-68.3 years; P=0.046).</AbstractText>The median age of survival in 3 different inherited cardiac diseases with an established pathogenic substrate significantly increased once genetic testing and cascade screening extended, after the first publication that elucidated the discovery of the disease-susceptibility gene/mutation. This underscores the direct and negative influence of ascertainment bias on survival forecasts and the importance of ongoing clinical/genetic follow-up to establish the most accurate disease prognosis for genetically mediated heart diseases.</AbstractText> |
18,760 | Epicardial Substrate as a Target for Radiofrequency Ablation in an Experimental Model of Early Repolarization Syndrome. | Early repolarization syndrome (ERS) is an inherited cardiac arrhythmia syndrome associated with sudden cardiac death. Approaches to therapy are currently very limited. This study probes the mechanisms underlying the electrocardiographic and arrhythmic manifestation of experimental models of ERS and of the ameliorative effect of radiofrequency ablation.</AbstractText>Action potentials, bipolar electrograms, and transmural pseudo-ECGs were simultaneously recorded from coronary-perfused canine left ventricular wedge preparations (n=11). The Ito</sub> agonist NS5806 (7-10 μmol/L), calcium channel blocker verapamil (3 μmol/L), and acetylcholine (1-3 μmol/L) were used to pharmacologically mimic the effects of genetic defects associated with ERS.</AbstractText>The provocative agents induced prominent J waves in the ECG secondary to accentuation of the action potential notch in epicardium but not endocardium. Bipolar recordings displayed low-voltage fractionated potentials in epicardium because of temporal and spatial variability in appearance of the action potential dome. Concealed phase 2 reentry developed when action potential dome was lost at some epicardial sites but not others, appearing in the bipolar electrogram as discrete high-frequency spikes. Successful propagation of the phase 2 reentrant beat precipitated ventricular tachycardia/ventricular fibrillation. Radiofrequency ablation of the epicardium destroyed the cells displaying abnormal repolarization and thus suppressed the J waves and the development of ventricular tachycardia/ventricular fibrillation in 6/6 preparations.</AbstractText>Our findings suggest that low-voltage fractionated electrical activity and high-frequency late potentials recorded from the epicardial surface of the left ventricle can identify regions of abnormal repolarization responsible for ventricular tachycardia/ventricular fibrillation in ERS and that radiofrequency ablation of these regions in left ventricular epicardium can suppress ventricular tachycardia/ventricular fibrillation by destroying regions of ER.</AbstractText> |
18,761 | Permanent His Bundle Pacing for Cardiac Resynchronization Therapy in Patients With Heart Failure and Right Bundle Branch Block. | Background Cardiac resynchronization therapy utilizing biventricular pacing is an effective therapy for patients with left ventricular (LV) systolic dysfunction, left bundle branch block, and heart failure. Benefits of biventricular pacing may be limited in patients with right bundle branch block (RBBB). Permanent His bundle pacing (HBP) has recently been reported as an option for cardiac resynchronization therapy. The aim of the study was to assess the feasibility and outcomes of HBP in patients with RBBB and heart failure. Methods HBP was attempted as a primary or rescue (failed LV lead implant) strategy in patients with reduced LV ejection fraction, RBBB, QRS duration ≥120 ms, and New York Heart Association class II to IV heart failure. Implant characteristics, New York Heart Association functional class, and echocardiographic data were assessed in follow-up. Results Mean age was 72±10 years, female 15%, with an average LV ejection fraction of 31±10%. HBP was successful in 37 of 39 patients (95%) with narrowing of RBBB in 78% cases. His capture and bundle branch block correction thresholds were 1.1±0.6 V and 1.4±0.7 V at 1 ms, respectively. During a mean follow-up of 15±23 months, there was a significant narrowing of QRS from 158±24 to 127±17 ms ( P=0.0001), increase in LV ejection fraction from 31±10% to 39±13% ( P=0.004), and improvement in New York Heart Association functional class from 2.8±0.6 to 2±0.7 ( P=0.0001) with HBP. Increase in capture threshold occurred in 3 patients. Conclusions Permanent HBP was associated with significant narrowing of QRS duration and improvement in LV function in patients with RBBB and reduced LV ejection fraction. Permanent HBP is a promising option for cardiac resynchronization therapy in patients with RBBB and reduced LV ejection fraction. |
18,762 | Potentially modifiable factors of dofetilide-associated risk of torsades de pointes among hospitalized patients with atrial fibrillation. | There is a significant variation in the clinical approach of initiation and dose adjustment of dofetilide in atrial fibrillation (AF). Excessive QT prolongation could predispose patients to torsades de pointes (TdP), which can be fatal.</AbstractText>We performed a retrospective case-control study at Mayo Clinic Rochester (January 1, 2003 to December 31, 2016). "TdP risk" cases were defined as patients on dofetilide therapy for AF with subsequent TdP or excessive QTc prolongation requiring dose reduction or discontinuation (N = 31). A control group was matched 1:1 with cases by age, gender, year of admission, and dofetilide dose (N = 31).</AbstractText>Using multivariate regression analysis, independent predictors of TdP risk included baseline QTc exceeding recommendations (adjusted odd ratio [AOR] 4.57; P = 0.023); underlying AF with rapid ventricular rate (AOR 16.95; P = 0.004); and diuretic therapy for acute heart failure (AOR 8.42; P = 0.007). Poor inter-observer agreement was identified among QT interval measurement in patients with AF and rapid ventricular rate compared to those in rate controlled AF or sinus rhythm. TdP risk cases receiving diuretics for acute heart failure had a significant decline in creatinine clearance than controls, although serum electrolytes and replacement did not differ among the two groups.</AbstractText>Excessive QTc prolongation and AF with rapid ventricular rate at time of dofetilide initiation (likely due to difficulty in measuring QT intervals), and diuretic therapy for acute heart failure were independent factors for dofetilide-related TdP risk. Based on these data, possible preventive strategies could be adapted for safety protocols among hospitalized patients.</AbstractText> |
18,763 | Ionic and cellular mechanisms underlying TBX5/PITX2 insufficiency-induced atrial fibrillation: Insights from mathematical models of human atrial cells. | Transcription factors TBX5 and PITX2 involve in the regulation of gene expression of ion channels and are closely associated with atrial fibrillation (AF), the most common cardiac arrhythmia in developed countries. The exact cellular and molecular mechanisms underlying the increased susceptibility to AF in patients with TBX5/PITX2 insufficiency remain unclear. In this study, we have developed and validated a novel human left atrial cellular model (TPA) based on the ten Tusscher-Panfilov ventricular cell model to systematically investigate how electrical remodeling induced by TBX5/PITX2 insufficiency leads to AF. Using our TPA model, we have demonstrated that spontaneous diastolic depolarization observed in atrial myocytes with TBX5-deletion can be explained by altered intracellular calcium handling and suppression of inward-rectifier potassium current (I<sub>K1</sub>). Additionally, our computer simulation results shed new light on the novel cellular mechanism underlying AF by indicating that the imbalance between suppressed outward current I<sub>K1</sub> and increased inward sodium-calcium exchanger current (I<sub>NCX</sub>) resulted from SR calcium leak leads to spontaneous depolarizations. Furthermore, our simulation results suggest that these arrhythmogenic triggers can be potentially suppressed by inhibiting sarcoplasmic reticulum (SR) calcium leak and reversing remodeled I<sub>K1</sub>. More importantly, this study has clinically significant implications on the drugs used for maintaining SR calcium homeostasis, whereby drugs such as dantrolene may confer significant improvement for the treatment of AF patients with TBX5/PITX2 insufficiency. |
18,764 | Smoking aggravates ventricular arrhythmic events in non-ischemic dilated cardiomyopathy associated with a late gadolinium enhancement in cardiac MRI. | Smoking is known to increase cardiovascular events, but the association and mechanisms between smoking and ventricular arrhythmic events in dilated cardiomyopathy (DCMP) are unknown. The purpose of this study is to investigate the hypothesis that smoking is associated with sudden cardiac death (SCD) and ventricular arrhythmia in DCMP patients. We enrolled 378 patients who underwent cardiovascular magnetic resonance imaging (cMRI) and were diagnosed with DCMP at two general hospitals in Korea. The clinical data and left ventricular late-gadolinium enhancement (LV-LGE) of all patients were analyzed according to being never-smokers or smokers. Smokers were more likely to be male than never-smokers, but there was no other clinical difference between them. Smokers had a greater LV-LGE ratio, and multi-segment involvement of LV-LGEs. Smoking and a low left ventricular (LV) ejection fraction were significant predictors of the presence of LV-LGEs even after adjusting for optimal medical therapy. In addition, smokers had a higher fatal ventricular arrhythmic (FVA; sustained ventricular tachycardia, and ventricular fibrillation) and FVA + SCD, and ex-smokers had a similar FVA to never-smokers during 44.3 ± 36.4 months of follow-up. Finally, smoking independently increased the FVA + SCD even after adjusting for the clinical variables and LV-LGE. Smoking is associated with a multi-segmental involvement of LV-LGE and increased FVA + SCD in DCMP patients when compared to never-smokers. |
18,765 | Catheter Ablation of Atrial Fibrillation in Patients With Heart Failure. | Atrial fibrillation (AF) and heart failure (HF) both have become major cardiovascular epidemics, adversely affecting quality of life, decreasing longevity, and imparting a large economic burden on the healthcare system. Both share similar risk factors and frequently coexist, leading to increased morbidity and mortality relative to patients with either condition alone. Although evidence-based treatment guidelines for both diseases exist, consensus treatment strategies are less clear when AF and HF co-occur. Given the risks of antiarrhythmic drugs and their incomplete success in maintaining sinus rhythm, catheter ablation has become an increasingly popular alternative to pharmacologic rhythm control in symptomatic patients with AF with normal cardiac function. Although multiple studies have demonstrated the efficacy of catheter ablation in AF, studies examining the use of catheter ablation specifically in patients with HF have recently begun to emerge and provide some guidance in this group of patients. In this review, we examine the effects of catheter ablation of AF in patients with HF on maintenance of sinus rhythm, left ventricular ejection fraction, exercise capacity, quality of life, hospitalization, and mortality rates. Data regarding both HF with reduced ejection fraction and preserved ejection fraction are discussed. |
18,766 | Mechanisms of sex differences in atrial fibrillation: role of hormones and differences in electrophysiology, structure, function, and remodelling. | Atrial fibrillation (AF) is the clinically most prevalent rhythm disorder with large impact on quality of life and increased risk for hospitalizations and mortality in both men and women. In recent years, knowledge regarding epidemiology, risk factors, and patho-physiological mechanisms of AF has greatly increased. Sex differences have been identified in the prevalence, clinical presentation, associated comorbidities, and therapy outcomes of AF. Although it is known that age-related prevalence of AF is lower in women than in men, women have worse and often atypical symptoms and worse quality of life as well as a higher risk for adverse events such as stroke and death associated with AF. In this review, we evaluate what is known about sex differences in AF mechanisms-covering structural, electrophysiological, and hormonal factors-and underscore areas of knowledge gaps for future studies. Increasing our understanding of mechanisms accounting for these sex differences in AF is important both for prognostic purposes and the optimization of (targeted, mechanism-based, and sex-specific) therapeutic approaches. |
18,767 | PR deviation as a risk marker for cardiac events in patients with Takotsubo syndrome. | PR segment deviation (PRD: defined as PR elevation in aVR and PR depression in lead II/III) on electrocardiography is frequently observed in patients with acute pericarditis; however, there have been few studies that explore the occurrence of PRD in patients with Takotsubo syndrome (TTS). The clinical significance of PRD in TTS is not clearly elucidated.</AbstractText><AbstractText Label="METHODS & RESULTS">A total of 52 consecutive patients with TTS in sinus rhythm (73.9 ± 13.8 years, nine males) were enrolled in the study. The major cardiac events were defined as sustained ventricular tachycardia or ventricular fibrillation, Killip class 4 heart failure, and cardiac death within 30 days. PRD in the hyperacute phase (within 48 h from the onset of TTS) was observed in 15 patients (29%), and all PRDs disappeared or diminished at 1 week later. The PRD (+) group had a higher value of C-reactive protein level (median: 1.80 mg/dL [0.31-3.26] vs 0.20 mg/dL [0.06-0.81], P  =  0.013) and creatine kinase-muscle/brain isoenzyme (median: 60 IU/L [28-75] vs 17 IU/L [13-26], P < 0.001) and a lower level of left ventricular ejection fraction (42.7 ± 7.2% vs 48.8 ± 9.4%, P  =  0.041) than the PRD (-) group. Multivariate analysis showed that PRD was a significant and independent predictor for major cardiac events (odds ratio  =  21.0, 95% confidence interval  =  1.18-273).</AbstractText>TTS patients with PRD in the hyperacute phase showed a high incidence of major cardiac events. Therefore, PRD may help to identify TTS patients at high risk for cardiac event.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,768 | Mathematical approach to unpinning of spiral waves anchored to an obstacle with high-frequency pacing. | Spiral waves are observed in wide variety of reaction-diffusion systems. Those observed in cardiac tissues are important since they are related to serious disease that threatens human lives, such as atrial or ventricular fibrillation. We consider the unpinning of spiral waves anchored to a circular obstacle on excitable media using high-frequency pacing. Here, we consider two types of the obstacle; <i>i.e.</i>, that without any diffusive interaction with the environment, and that with diffusive interaction. We found that the threshold frequency for success in unpinning is lower for the obstacle with diffusive interaction than for the one without it. We discuss the threshold frequency based on the angular velocity of a chemical wave anchoring the obstacle. |
18,769 | Penetrance and expressivity of the R858H CACNA1C variant in a five-generation pedigree segregating an arrhythmogenic channelopathy. | Isolated cardiac arrhythmia due to a variant in CACNA1C is of recent knowledge. Most reports have been of singleton cases or of quite small families, and estimates of penetrance and expressivity have been difficult to obtain. We here describe a large pedigree, from which such estimates have been calculated.</AbstractText>We studied a five-generation family, in which a CACNA1C variant c.2573G>A p.Arg858His co-segregates with syncope and cardiac arrest, documenting electrocardiographic data and cardiac symptomatology. The reported patients/families from the literature with CACNA1C gene variants were reviewed, and genotype-phenotype correlations are drawn.</AbstractText>The range of phenotype in the studied family is wide, from no apparent effect, through an asymptomatic QT interval prolongation on electrocardiography, to episodes of presyncope and syncope, ventricular fibrillation, and sudden death. QT prolongation showed inconsistent correlation with functional cardiology. Based upon analysis of 28 heterozygous family members, estimates of penetrance and expressivity are derived.</AbstractText>These estimates of penetrance and expressivity, for this specific variant, may be useful in clinical practice. Review of the literature indicates that individual CACNA1C variants have their own particular genotype-phenotype correlations. We suggest that, at least in respect of the particular variant reported here, "arrhythmogenic channelopathy" may be a more fitting nomenclature than long QT syndrome.</AbstractText>© 2018 The Authors. Molecular Genetics & Genomic Medicine published by Wiley Periodicals, Inc.</CopyrightInformation> |
18,770 | Possibility of a New Therapeutic Strategy for Left Ventricular Dysfunction in Type 2 Diabetes. | Type 2 diabetes mellitus (T2DM) substantially increases the risk of cardiovascular events, including heart failure (HF), due to complications such as hypertension, obesity and dyslipidemia based on metabolic syndrome, which plays the central pathological role in HF. A reason is that T2DM causes left ventricular (LV) diastolic dysfunction beginning in the early phase of the disease, which in turn increases the risk of development of HF independently of the control of blood glucose levels, blood pressure or the presence of coronary artery diseases. Intracellular metabolic disorders and increased oxidative stress due to hyperglycemia, increased insulin resistance and chronic inflammation are pathogenic mechanisms involved in the LV diastolic dysfunction caused by T2DM. These mechanisms lead to structural changes in the heart such as LV hypertrophy and interstitial fibrosis, resulting in HF. The prevalence of HF with preserved ejection fraction (HFpEF), the major pathology of LV diastolic dysfunction, has been increasing recently, and a high incidence of HFpEF in patients with T2DM was reported. An effective therapy has not been established for HFpEF because multiple comorbidities such as advanced age, hypertension, obesity, dyslipidemia, chronic kidney disease and atrial fibrillation as well as diabetes are involved in its pathology. In the present review, we review the involvement of associated conditions such as hypertension, obesity and advanced age from the aspect of the T2DM and LV diastolic dysfunction and discuss the possibility of the development of a new therapeutic strategy for LV diastolic dysfunction and HFpEF. |
18,771 | Risk Factors, Co-Morbidities and Treatment of In-Hospital Patients with Atrial Fibrillation in Bulgaria. | Atrial fibrillation (AF) is the most common arrhythmia worldwide and a major risk factor for cardiovascular complications. Our study aimed to investigate the prevalence, risk factors, demographics, co-morbidities and treatment of AF among in-hospital Bulgarian patients.</AbstractText>A cross-sectional study including 1027 consecutive patients (n</i> = 516, 50.2% males) with a mean age of 67.6 ± 11.3 years, hospitalized for any reason from 1 May until 31 December 2016 in one of the largest internal clinics in Bulgaria, was carried out.</AbstractText>Atrial fibrillation was diagnosed in 634 (61.7%) patients. The prevalence of modifiable AF risk factors was as follows: heart failure, 98.9%; arterial hypertension (HTN), 93.5%; valvular heart disease, 40.9%; chronic lung disease, 26.7%; type 2 diabetes mellitus, 24.9%; thyroid disease, 16.9%; and ischemic heart disease, 11.2%. Univariate logistic regression analysis identified the following risk factors with strongest impact on AF: left ventricular ejection fraction <40% (odds ratio (OR) = 1.951, 95% confidence interval (CI) 1.208⁻3.151), valvular heart disease (OR = 1.926, 95% CI 1.134⁻3.862), left ventricular ejection fraction 40⁻49% (OR = 1.743, 95% CI 1.248⁻3.017), HTN (OR = 1.653, 95% CI 1.092⁻3.458). History of ischemic stroke was present in 14.4% of the patients with AF. Oral antithrombotic drugs were prescribed to 85.7%: direct oral anticoagulants to 37.9%, vitamin K antagonists to 43.2%, and antiplatelets to 4.6%. Heart rate control medications and antiarrhythmics were prescribed to 75.4% and 40.2%, respectively.</AbstractText>Atrial fibrillation was highly prevalent among our study population. Reduced and mid-range left ventricular ejection fraction, valvular heart disease, and HTN were the risk factors with the strongest association with AF. Although a large number of our AF patients were administered antithrombotic treatment, the prescription rate of oral anticoagulants should be further improved.</AbstractText> |
18,772 | Current Trends in Implantable Cardioverter-Defibrillator Therapy in Children　- Results From the JCDTR Database. | Implantable cardioverter defibrillators (ICDs) are being used with increasing frequency in children. Our aim was to examine the current trend of pediatric ICD implantation in Japan. Methods and Results: Data was extracted from the Japanese Cardiac Device Treatment Registry (JCDTR), a nation-wide registry started in 2006. All patients aged less than 18 years who had an ICD implantation registered between 2006 and 2016 were included in the analysis. A total of 201 patients were included, with a median age of 16 years (range 1-18). The underlying cardiac diagnosis was primary electrical disease (67%), cardiomyopathy (26%) and congenital heart disease (4%), with idiopathic ventricular fibrillation (29%) and long QT syndrome (21%) being the 2 most common diagnoses. Implantation indication was primary prevention in only 30 patients (15%). There were 27 patients (13%) aged ≤12 years, with a larger proportion of patients with cardiomyopathy (33%). The indication in younger children was secondary prevention in all cases. Younger children may be under-represented in our study given the nature of the database as it is a predominantly adult cardiology database.</AbstractText>In the past decade, ICD implantation has been performed in approximately 20 children per year in Japan, mostly for secondary prevention. There was no increase in the trend nor a change in age distribution.</AbstractText> |
18,773 | Prognostic impact of peak mitral inflow velocity in asymptomatic degenerative mitral regurgitation. | Appropriate timing of mitral valve surgery in asymptomatic mitral regurgitation (MR) remains controversial. Peak mitral inflow velocity (peak E wave velocity) has been reported as a simple and easy predictor of quantitative MR severity; however, its prognostic significance in asymptomatic MR remains unclear. Therefore, we sought to investigate the prognostic impact of peak E wave velocity in asymptomatic MR.</AbstractText>Among 529 consecutive patients with degenerative MR of grade 3+ (moderate to severe) or 4+ (severe), 188 asymptomatic patients in sinus rhythm without left ventricular (LV) dysfunction (end-systolic dimension ≥40 mm or ejection fraction <60%) or pulmonary hypertension were studied. Cardiovascular events were defined as a composite endpoint of cardiovascular death or events that indicated mitral surgery including congestive heart failure, atrial fibrillation, LV dysfunction or pulmonary hypertension.</AbstractText>Average peak E wave velocity was 1.05±0.26 m/s, and was significantly higher in grade 4+ than grade 3+ (1.20±0.28 vs 0.98±0.21 m/s, p<0.001). Peak E wave velocity was associated with quantitative MR severity, as well as clinical characteristics of advanced MR (higher brain natriuretic peptide, larger LV and left atrium, higher tricuspid regurgitation pressure gradient and dilated inferior vena cava). During a median follow-up of 4.3 years, 66 (35%) patients developed cardiovascular events. Multivariate Cox proportional hazards analysis showed that peak E wave velocity was an independent predictor of cardiovascular events (adjusted HR 1.245 (95% CI 1.126 to 1.378) per 0.1 m/s, p<0.001).</AbstractText>Peak E wave velocity was an independent predictor of cardiovascular events in asymptomatic degenerative MR with preserved LV function.</AbstractText>© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
18,774 | Safety and efficacy of in-hospital cardiac rehabilitation following antiarrhythmic therapy for patients with electrical storm. | Exercise-based in-hospital rehabilitation for patients with electrical storm (ventricular tachycardia/ventricular fibrillation, VT/VF) following antiarrhythmic therapy may prevent the deleterious outcomes of prolonged immobility, but the safety and efficacy of this strategy are still uncertain. We retrospectively investigated the rate of electrical storm recurrence in patients receiving rehabilitation.</AbstractText>Sixty-seven patients receiving therapy for electrical storm were included in this study. After treatment, patients were divided into rehabilitation (n=39) and non-rehabilitation (n=28) groups.</AbstractText>Incidences of electrical storm recurrence and VT/VF requiring anti-tachycardia pacing or electrical defibrillation did not differ significantly between the rehabilitation and non-rehabilitation groups (13% vs. 21% and 28% vs. 25%, respectively). However, early mobilization initiated ≤2 days after primary therapy was disadvantageous for electrical storm and VT/VF recurrence compared to later mobilization (21% vs. 6% and 34% vs. 19%, respectively). Although the activities of daily living (ADL) at admission were significantly lower in the rehabilitation group, the scores were restored to the level of the non-rehabilitation group at the time of discharge. Univariate analysis revealed that high B-type natriuretic peptide (hazard ratio [HR]: 3.2; 95% confidence interval [CI]: 1.1-11), decreased left ventricular ejection fraction, and elevated E/E' (HR: 3.4; 95% CI: 1.1-11) were associated with VT/VF recurrence.</AbstractText>The incidence of electrical storm relapse is substantial following antiarrhythmic therapy, but it is not increased by in-hospital rehabilitation. Although caution is urged for early mobilization, sustaining mobility to resume activity is recommended because ADL levels tend to deteriorate as a result of prolonged bed rest.</AbstractText>Copyright © 2018. Published by Elsevier Ltd.</CopyrightInformation> |
18,775 | Usefulness of the CHA<sub>2</sub>DS<sub>2</sub>-VASc Score to Predict the Risk of Sudden Cardiac Death and Ventricular Arrhythmias in Patients With Atrial Fibrillation. | Sudden cardiac death (SCD), the most devastating manifestation of ventricular arrhythmias (VAs), is the leading cause of mortality in patients with atrial fibrillation (AF). We hypothesized that the CHA<sub>2</sub>DS<sub>2</sub>-VASc score, consisting of age and several clinical risk factors, could be used to estimate the individual risk of SCD/VAs for AF patients. From year 2000 to 2011, 288,181 newly-diagnosed AF patients without antecedent SCD/VAs were identified from "Taiwan National Health Insurance Research Database." During the follow-up of 1,065,751 person-years, 11,166 patients experienced SCD/VAs with an annual risk of 1.05% which increased from 0.34% for patients with a CHA<sub>2</sub>DS<sub>2</sub>-VASc score of 0% to 2.63% for those with a score of 9. The CHA<sub>2</sub>DS<sub>2</sub>-VASc score was a significant predictor of SCD/VAs with an adjusted hazard ratio of 1.21 (95% confidence interval 1.20 to 1.22) per 1 point increment of the score. As the CHA<sub>2</sub>DS<sub>2</sub>-VASc score increased from 1 to 9, the hazard ratio of SCD/VAs continuously increased from 1.28 to 4.17 compared with patients with a CHA<sub>2</sub>DS<sub>2</sub>-VASc score of 0. In conclusion, CHA<sub>2</sub>DS<sub>2</sub>-VASc score was a convenient scoring system which could be used to predict the risk of SCD/VAs in AF patients in addition to its ability for stroke risk stratification. |
18,776 | Case report: life-threatening coronary artery spasm under transversus abdominis plane block in combination with general anesthesia. | Many cases of coronary artery spasm (CAS) during general plus epidural anesthesia have been reported. But transversus abdominis plane(TAP) block in combination with general anesthesia has not been reported to be a cause of CAS, let alone a life-threatening CAS.</AbstractText>In this case report, we present a case of a patient with CAS accompanied by ventricular fibrillation under general anesthesia with TAP block.</AbstractText>Coronary artery spasm, even life-threatening CAS, may occur during TAP block in combination with general anesthesia.</AbstractText> |
18,777 | Study of Rhythm Disturbances in Acute Myocardial Infarction. | Cardiac rhythm disturbances are common presentation in acute coronary syndromes and are cause of frequent serious complications in acute myocardial infarction (AMI). However due to availability of early reperfusion therapy and primary angioplasty, arrhythmias have cause a reduction in mortality. Arrhythmias are key events before, during or after the occurrence of acute MI. There are few clinical studies describing the types of arryhthmias, their correlation with the clinical profile of acute MI and effect on outcomes. In rural tertiary care centre, patients of acute MI, receive reperfusion therapy. The Indian population from central India is mostly a farming community from rural areas with limited medical aid resources. A tertiary care centre can only provide early reperfusion therapy in acute MI. There is very little data on rhythm disturbances in acute myocardial infarction from this geographic region.</AbstractText>To study rhythm disturbances in acute myocardial infarction(AMI) and its effect on outcome.</AbstractText>All cases of acute ST elevation and non ST elevation MI having rhythm disturbances during reperfusion or ICU stay admitted between April 2012 to 2014.</AbstractText>Rhythm disturbances were seen in 40-69 years of age. Chest pain (97%) and palpitation (63%) were commonest complaints. Hypertension was commonest risk factor. Sinus tachycardia (86%),ventricular ectopics (17%) and ventricular tachycardia (16%) were commonest tachyarrhythmias and sinus bradycardia (68%), right (23%) and left (18%)bundle branch blocks commonest bradyarrhythmias. Mortality was higher in tachyarrhythmias.</AbstractText>Compared to studies elsewhere it was observed that sinus tachycardia and bradycardia were commonest arrhythmias in AMI. That atrial fibrillation as observed in most studies elsewhere was not a common arrhythmia in this study. Mortality was statistically significant in tachyarrhythmias in both AWMI(55.71%) and IWMI(17.14%) as compared to bradyarrhythmias with p < 0.0001.</AbstractText>© Journal of the Association of Physicians of India 2011.</CopyrightInformation> |
18,778 | Left atrial longitudinal strain in dilated cardiomyopathy patients: is there a discrimination threshold for atrial fibrillation? | To determine the left atrial longitudinal strain discrimination threshold of atrial fibrillation (AF) in patients with dilated cardiomyopathy (DCM). A total of 100 DCM patients and LVEF < 25% were included. Of them, 50 had sinus rhythm (SR), and 50 had AF. Patients with significant valvular disease, cardiac pacemakers and prosthetic valves were excluded. Speckle tracking echocardiography was performed to visualize the inferior and lateral walls of the left atrium as well as the interatrial septum. The Q-Analysis software was used to assess left atrial contractile strain (ε<sub>CT</sub>) during the atrial systole and left atrial conduit strain (ε<sub>CD</sub>) during the atrial filling. In SR patients analysis was P-wave timed. In AF patients the reference point was at 200 ms before the QRS complex on the surface ECG. The ε<sub>CD</sub> was significantly higher in SR patients than in those with AF (9.68% vs. 4.7%; p = 0.0003). ROC analysis demonstrated that ε<sub>CD</sub> less than 5.43% (AUC 0.95; 95% CI 0.905-0.995; p < 0.0001) together with ε<sub>CT</sub> below - 1.97% (AUC = 0.97; 95% CI 0.46-1.00; p < 0.0001) identified patients with AF. In patients with LVEF < 25% and AF left atrial contractile strain analysis is feasible. In these patients both contractile and conduit strain values are significantly lower than in patients with preserved SR, and ε<sub>CD</sub> below 5.43% and ε<sub>CT</sub> less than - 1.97% distinguish SR from AF patients with LVEF < 25%. |
18,779 | Neurokinin-3 receptor activation selectively prolongs atrial refractoriness by inhibition of a background K<sup>+</sup> channel. | The cardiac autonomic nervous system (ANS) controls normal atrial electrical function. The cardiac ANS produces various neuropeptides, among which the neurokinins, whose actions on atrial electrophysiology are largely unknown. We here demonstrate that the neurokinin substance-P (Sub-P) activates a neurokinin-3 receptor (NK-3R) in rabbit, prolonging action potential (AP) duration through inhibition of a background potassium current. In contrast, ventricular AP duration was unaffected by NK-3R activation. NK-3R stimulation lengthened atrial repolarization in intact rabbit hearts and consequently suppressed arrhythmia duration and occurrence in a rabbit isolated heart model of atrial fibrillation (AF). In human atrial appendages, the phenomenon of NK-3R mediated lengthening of atrial repolarization was also observed. Our findings thus uncover a pathway to selectively modulate atrial AP duration by activation of a hitherto unidentified neurokinin-3 receptor in the membrane of atrial myocytes. NK-3R stimulation may therefore represent an anti-arrhythmic concept to suppress re-entry-based atrial tachyarrhythmias, including AF. |
18,780 | Information theory to tachycardia therapy: electrogram entropy predicts diastolic microstructure of reentrant ventricular tachycardia. | There is no known strategy to differentiate which multicomponent electrograms in sinus rhythm maintain reentrant ventricular tachycardia (VT). Low entropy in the voltage breakdown of a multicomponent electrogram can localize conditions suitable for reentry but has not been validated against the classic VT activation mapping. We examined whether low entropy in a late and diversely activated ventricular scar region characterizes and differentiates the diastolic path of VT and represents protected tissue channels devoid of side branches. Intraoperative bipolar electrogram (Bi<sub>EGM</sub>) activation and entropy maps were obtained during sinus rhythm in 17 patients with ischemic cardiomyopathy and compared with diastolic activation paths of VT (total of 39 VTs). Mathematical modeling of a zigzag main channel with side branches was also used to further validate structural representation of low entropy in the ventricular scar. A median of one region per patient (range: 1-2 regions) was identified in sinus rhythm, in which Bi<sub>EGM</sub> with the latest mean activation time and adjacent minimum entropy were assembled together in a high-activation dispersion region. These regions accurately recognized diastolic paths of 34 VTs, often to multiple inducible VTs within a single individual arrhythmogenic region. In mathematical modeling, side branching from the main channel had a strong influence on the Bi<sub>EGM</sub> composition along the main channel. The Bi<sub>EGM</sub> obtained from a long unbranched channel had the lowest entropy compared with those with multiple side branches. In conclusion, among a population of multicomponent sinus electrograms, those that demonstrate low entropy and are delayed colocalize to critical long-protected channels of VT. This information is pertinent for planning VT ablation in sinus rhythm. NEW & NOTEWORTHY Entropy is a measure to quantify breakdown in information. Electrograms from a protected tissue channel can only possess a few states in their voltage and thus less information. In contrast, current-load interactions from side branches in unprotected channels introduce a number of dissimilar voltage deflections and thus high information. We compare here a mapping approach based on entropy against a rigorous reference standard of activation mapping during VT and entropy was assessed in sinus rhythm. |
18,781 | Out-of-hospital cardiac arrests in the toilet in Japan: a population-based descriptive study. | This study aimed to reveal the characteristics and outcomes of patients with out-of-hospital cardiac arrests (OHCAs) occurring in the toilet. These traits provide useful clues for the prevention of OHCAs and the improvement of prehospital care for these patients.</AbstractText>Out-of-hospital cardiac arrest data were obtained from the population-based, Utstein-style registry in Osaka City, Japan, between 2009 and 2015. This study identified patients with OHCAs that occurred inside the toilet. The primary end-point was 1-month survival with favorable neurological outcome after OHCA.</AbstractText>During the 7-year study period, a total of 18,458 OHCAs were identified. Of these cases, 849 (4.6%) occurred inside the toilet. Among them, the analysis included 733 patients. The distribution depicting monthly OHCA occurrences showed that OHCAs tended to occur in cold months (28.1% [206/733] from October to December and 30.0% [220/733] from January to March). Most OHCAs occurring inside the toilet were of cardiac origin (91.5% [671/733]), and 36.2% (265/733) were witnessed by bystanders. The proportion of patients with ventricular fibrillation was 5.2% (38/733) and those receiving shocks by public-access automated external defibrillators was 0.4% (3/733). The proportion of patients with 1-month survival with favorable neurological outcome was 1.9% (14/733).</AbstractText>Out-of-hospital cardiac arrests occurring inside the toilet accounted for 4.6% of all OHCAs and were frequently observed during cold months, and their outcome was poor. Establishment of preventive measures against OHCAs occurring in the toilet as well as earlier recognition of OHCAs are needed.</AbstractText> |
18,782 | The hemodynamic and atrial electrophysiologic consequences of chronic left atrial volume overload in a controllable canine model. | The purpose of this study was to determine the effects of chronic left atrial volume overload on atrial anatomy, hemodynamics, and electrophysiology using a titratable left ventriculoatrial shunt in a canine model.</AbstractText>Canines (n = 16) underwent implantation of a shunt between the left ventricle and the left atrium. Sham animals (n = 8) underwent a median sternotomy without a shunt. Atrial activation times and effective refractory periods were determined using 250-bipolar epicardial electrodes. Biatrial pressures, systemic pressures, left atrial and left ventricle diameters and volumes, atrial fibrillation inducibility, and durations were recorded at the initial and at 6-month terminal study.</AbstractText>Baseline shunt fraction was 46% ± 8%. The left atrial pressure increased from 9.7 ± 3.5 mm Hg to 13.8 ± 4 mm Hg (P < .001). At the terminal study, the left atrial diameter increased from a baseline of 2.9 ± 0.05 cm to 4.1 ± 0.6 cm (P < .001) and left ventricular ejection fraction decreased from 64% ± 1.5% to 54% ± 2.7% (P < .001). Induced atrial fibrillation duration (median, range) was 95 seconds (0-7200) compared with 0 seconds (0-40) in the sham group (P = .02). The total activation time was longer in the shunt group compared with the sham group (72 ± 11 ms vs 62 ± 3 ms, P = .003). The right atrial and not left atrial effective refractory periods were shorter in the shunt compared with the sham group (right atrial effective refractory period: 156 ± 11 ms vs 141 ± 11 ms, P = .005; left atrial effective refractory period: 142 ± 23 ms vs 133 ± 11 ms, P = .35).</AbstractText>This canine model of mitral regurgitation reproduced the mechanical and electrical remodeling seen in clinical mitral regurgitation. Left atrial size increased, with a corresponding decrease in left ventricle systolic function, and an increased atrial activation times, lower effective refractory periods, and increased atrial fibrillation inducibility. This model provides a means to understand the remodeling by which mitral regurgitation causes atrial fibrillation.</AbstractText>Copyright © 2018. Published by Elsevier Inc.</CopyrightInformation> |
18,783 | Targeted Ganglionated Plexi Denervation Using Magnetic Nanoparticles Carrying Calcium Chloride Payload. | This study sought to develop a novel targeted delivery therapy to ablate the major atrial ganglionated plexi (GP) using magnetic nanoparticles carrying a CaCl2</sub> payload.</AbstractText>Prior studies indicated the role of hyperactivity of the cardiac autonomic nervous system in the genesis of atrial fibrillation.</AbstractText>Twenty-eight male mongrel dogs underwent a bilateral thoracotomy. CaCl2</sub>-encapsulated magnetic nanoparticles (Ca-MNP) included magnetite in a sphere of biocompatible, biodegradable poly(lactic-co-glycolic acid). A custom external electromagnet focusing the magnetic field gradient (2,600 G) on the epicardial surface of the targeted GP was used to pull Ca-MNP into and release CaCl2</sub> within the GP. The ventricular rate slowing response to high frequency stimulation (20 Hz, 0.1 ms) of the GP was used to assess the GP function.</AbstractText>The minimal effective concentration of CaCl2</sub> to inhibit the GP function was 0.5 mmol/l. Three weeks after CaCl2</sub> (0.5 mmol/l, n = 18 GP) or saline (n = 18 GP) microinjection into GP, the increased GP function, neural activity, and atrial fibrillation inducibility, as well as shortened effective refractory period in response to 6 h of rapid atrial pacing (1,200 beats/min) were suppressed by CaCl2</sub> microinjection. After intracoronary infusion of Ca-MNP, the external electromagnet pulled Ca-MNP to the targeted GP and suppressed the GP function (n = 6 GP) within 15 min.</AbstractText>Ca-MNP can be magnetically targeted to suppress GP function by calcium-mediated neurotoxicity. This novel approach may be used to treat arrhythmias related to hyperactivity of the cardiac autonomic nervous system, such as early stage of atrial fibrillation, with minimal myocardial injury.</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,784 | Catheter Ablation of Ventricular Arrhythmia for Ebstein's Anomaly in Unoperated and Post-Surgical Patients. | The purpose of this study was to determine the ventricular arrhythmia (VA) substrates in patients with unoperated and post-surgical Ebstein's Anomaly (EA).</AbstractText>EA is associated with variable atrialization of the right ventricle and a propensity for VA and sudden death. There are scant data on catheter ablation for VA in this population.</AbstractText>This was a retrospective study involving 11 congenital heart disease centers.</AbstractText>A total of 24 patients (median age 17 [interquartile range (IQR): 11 to 37] years; age range 1 to 68 years; 42% men) with EA undergoing catheter ablation were identified. Prior tricuspid valve (TV) surgery had been performed in 12 (50%). Presenting symptoms were palpitations in 15, syncope in 4, aborted cardiac arrest in 4, and none in 1. At procedure, 28 VA substrates were encountered and 25 were completely characterized (median 1 per patient; cycle length 305 [IQR: 268 to 400] ms). In 3 cases, premature ventricular contraction (PVC) foci were targeted (1 with a history of PVC-induced ventricular fibrillation). VA mechanisms were focal in 15 and macro-re-entrant in 10, and did not differ significantly between those with and those without prior TV surgery (p = 0.7). Focal VAs predominantly localized to the atrialized right ventricle ARV in unoperated patients and to diseased myocardium or Purkinje tissue after TV surgery. Macro-re-entry was related to isolated scar or split potentials in the ARV in unoperated patients, and larger, more diffuse scar after TV surgery. Complete success was achieved in 22 (92%). There were 2 of 13 complications in patients <18 years of age and none in patients >18 years of age. There was a single recurrence over a median follow-up of 3.4 years.</AbstractText>VA in EA may be either focal or macro-re-entrant. In the absence of surgery, substrates chiefly involve the ARV. After surgery, focal VA involves injured myocardium or Purkinje tissue and re-entrant ventricular tachycardia is related to post-surgical scar. Catheter ablation is a reasonable therapeutic approach for these patients.</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,785 | Early Initiation of Continuous Renal Replacement Therapy Induces Fast Hypothermia and Improves Post-Cardiac Arrest Syndrome in a Porcine Model. | Rapid induction of hypothermia early after resuscitation can be an effective strategy against post-cardiac arrest syndrome (PCAS). Preliminary data suggested that continuous renal replacement therapy (CRRT) might be an efficient method to rapidly induce hypothermia. In this study, we investigated the efficacy of cooling induced by CRRT and its effects on the outcomes of PCAS in a porcine model.Thirty-two male domestic pigs weighing 36 ± 2 kg were randomized into 4 groups: sham control (n = 5), normothermia (n = 9), surface cooling (SC, n = 9), and CRRT (n = 9). Sham animals underwent the surgical preparation only. The animal model was established by 8 min of untreated ventricular fibrillation and then 5 min of cardiopulmonary resuscitation. At 5 min after resuscitation, the animals were cooled by either the combination of an earlier 8-h CRRT and later 16-h SC or the whole 24-h SC in the 2 hypothermic groups. For the other 2 groups, a normal temperature of 38.0 ± 0.5°C was maintained throughout the experiment.Blood temperature was decreased to 33°C within 28 min in animals treated with CRRT, which was significantly faster than that in the SC group requiring 185 min to achieve target temperature. Post-resuscitation myocardial dysfunction, brain injury, and systemic inflammation were significantly improved in the 2 hypothermic groups compared to the normothermia group. However, the improvement was significantly greater in the CRRT group than in the SC group.In conclusion, fast hypothermia was successfully induced by CRRT and significantly alleviated the severity of PCAS in a porcine model. |
18,786 | Safety and efficacy of AAIR pacing in selected patients with sick sinus syndrome. | The DANPACE study suggested implanting dual-pacing dual-sensing dual-response rate-adaptive (DDDR) pacemakers in patients with sick sinus syndrome, even though 90.7% of their atrial-pacing atrial-sensing inhibited-response rate-adaptive (AAIR) group did not require upgrade. Most centers implant DDDR pacemakers due to risk of future atrioventricular (AV) block. Given that AAIR pacemakers are less expensive, have one less lead with potentially one less point of complication, we question whether DDDR pacemakers are superior to AAIR pacemakers. We aim to describe long-term outcomes of AAIR implants.</AbstractText>Patients presenting to the Grey Nuns Hospital in Edmonton, Canada from 1990 to 2012 with sick sinus syndrome without AV block had AAIR pacemakers implanted. Outcomes that were measured over the follow-up time included need for ventricular lead reoperation, incidence of AV block and incidence of sudden cardiac death from AV block.</AbstractText>During this period, 330 patients presented with sick sinus syndrome. Eighty-seven (26.4%) patients met criteria for and received AAIR pacemakers. Seventy-eight (91.8%) did not require upgrade over mean follow-up of 10.6 ± 0.6 years. Amongst this group, 31 patients (39.7%) were alive, whereas 47 (60.3%) were deceased at end of follow-up due to other comorbidities. No sudden deaths were attributable to AV block. Only 7 patients (8.2%) required ventricular lead reoperation: 2 (2.4%) presented urgently with symptomatic AV block; 3 (3.5%) had atrial fibrillation requiring beta-blockade; 1 (1.2%) had atrial lead dislodgment; and 1 (1.2%) was electively upgraded at battery end-of-life.</AbstractText>This study looks at safety of AAIR pacemakers with only 2.4% of patients developing AV block requiring urgent upgrade. Approximately 91.8% of patients remained with their original AAIR pacemakers (mean follow-up 10.6 vs 5.4 years in DANPACE). Our findings are similar to the DANPACE study but our conclusions are different as we believe AAIR pacing should be considered for selected patients with sick sinus syndrome without AV block.</AbstractText> |
18,787 | A case report of unexpected sudden cardiac death due to aortic rupture following laparoscopic appendectomy. | Aortic dissection is a very rare but life-threatening condition associated with a high mortality. Unexpected sudden cardiac death due to aortic rupture following laparoscopic appendectomy is very rare and may be difficult to diagnose. However, early diagnosis of aortic dissection is essential for the timely treatment and outcome of aortic dissection.</AbstractText>A 50-year-old man underwent a laparoscopic appendectomy. Postoperatively, the patient complained of dyspnea and chest pain. In 25 minutes after arrival in the postanesthesia care unit (PACU), the patient was in asystole. Then, he underwent cardiopulmonary resuscitation (CPR) according to advanced cardiac life support (ACLS) protocol using 1 mg of epinephrine, one 200J DC shock for ventricular fibrillation (V-fib). After that, his noninvasive blood pressure (NIBP) was 80/40 mm Hg, pulse rate (PR) was 140 beats/min, and peripheral oxygen saturation (SpO2) was 84%. His electrocardiogram (ECG) finding was atrial fibrillation (A-fib). After 20 minutes, the patient developed asystole rhythm again and CPR was restarted. He remained severely hypotensive despite vasopressors and died after 5 hours CPR. A forensic autopsy was performed postmoterm and thoracic and abdominal aortic dissection along the root of ascending aorta was present and massive hematoma within right and left thorax was present.</AbstractText>Acute aortic disease can be difficult to recognize; therefore, diagnosis is sometimes delayed or missed. It is important to recognize the atypical symptoms of aortic dissection and maintain a broad differential diagnosis if patients complained of abdominal pain.</AbstractText> |
18,788 | Bisoprolol Successfully Improved the Intraventricular Pressure Gradient in a Patient with Midventricular Obstructive Hypertrophic Cardiomyopathy with an Apex Aneurysm due to Apical Myocardial Damage. | Midventricular obstructive hypertrophic cardiomyopathy (MVOHCM) is a rare form of hypertrophic cardiomyopathy (HCM). An 80-year-old man was administered bisoprolol and warfarin therapies as treatment for MVOHCM with an apex aneurysm due to myocardial damage and intra-aneurysmal thrombus not complicated by atrial fibrillation. The pressure gradient in the midventricle successfully improved from 53.9 to 21.8 mmHg, and the intra-aneurysmal thrombus disappeared. |
18,789 | Baseline fragmented QRS is associated with increased all-cause mortality in heart failure with reduced ejection fraction: A systematic review and meta-analysis. | Recent studies suggested that fragmented (fQRS) is associated with poor clinical outcomes in heart failure with reduced ejection fraction (HFrEF) patients. However, no systematic review or meta-analysis has been done. We conducted a systematic review and meta-analysis to assess the association between baseline fQRS and all-cause mortality in HFrEF.</AbstractText>We comprehensively reviewed the databases of MEDLINE and EMBASE from inception to February 2018. Published studies of HFrEF that reported fQRS and outcome of all-cause mortality and major arrhythmic event (sudden cardiac death, sudden cardiac arrest, ventricular fibrillation, or sustained ventricular tachycardia) were included. Data were integrated using the random-effects, generic inverse-variance method of DerSimonian and Laird.</AbstractText>Ten studies from 2010 to 2017 were included. Baseline fQRS was associated with increased all-cause mortality (risk ratio [RR] 1.63, 95% confidence interval [CI] 1.22-2.19, p < 0.0001, I2</sup>  = 73%) as well as major arrhythmic events (RR = 1.74, 95% CI 1.09-2.80, I2</sup>  = 89%). Baseline fQRS increased all-cause mortality in both Asian and Caucasian cohorts (RR = 2.17 with 95% CI 1.33-3.55 and RR = 1.45 with 95% CI 1.05-1.99, respectively) as well as increased major arrhythmic events in Asian cohort (RR = 1.50, 95% CI 1.05-2.13). Baseline fQRS also increased all-cause mortality in patients who had not received implantable cardioverter-defibrillator, significantly more than in patients who had received implantable cardioverter-defibrillator (RR = 2.46 with 95% CI 1.56-3.89 and 1.36 with 95% CI 1.08-1.71, respectively).</AbstractText>Baseline fQRS is associated with increased all-cause mortality up to 1.63-fold in HFrEF patients. Fragmented QRS could be a predictor of clinical outcome in patients with HFrEF.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,790 | Improvement in ejection fraction after cryoballoon pulmonary vein isolation for atrial fibrillation in individuals with systolic dysfunction. | Cryoballoon pulmonary vein isolation (PVI) is commonly used for rhythm control of atrial fibrillation (AF). Data are limited examining the outcomes of cryoballoon PVI in patients with systolic dysfunction. We evaluate the impact of cryoballoon PVI in patients with systolic dysfunction.</AbstractText>We evaluated a single-center prospective registry of patients undergoing cryoballoon PVI between 8/2011 and 6/2016. Patients with systolic dysfunction (EF < 55%) between the time of AF diagnosis and their cryoballoon PVI procedure were assessed for AF recurrence at 6 months and 1 year post-procedure, with a 3-month blanking period.</AbstractText>Final analysis included 66 patients with systolic dysfunction undergoing cryoballoon PVI. An AF diagnosis for ≥ 1 year prior to PVI was present in 62.1% (n = 41), and 53.0% (n = 35) had systolic dysfunction for ≥ 1 year pre-procedure. The proportion of AF-free patients at 1 year was 51.5%. Of patients with echocardiograms performed at 1 year (n = 43), a greater proportion of individuals without AF recurrence had an improvement in EF of ≥ 10% than in those with AF recurrence (54.2% vs. 25.0%, p = 0.039). Of the patients who had systolic dysfunction at the time of the ablation (EF < 55%), there was a significant increase in EF post-procedure (36.5% pre-procedure vs. 48.3% post-procedure, mean change 11.8%, p < 0.001).</AbstractText>In patients with systolic dysfunction, cryoballoon PVI provides an acceptable AF recurrence-free rate at 1 year. AF recurrence-free individuals were more likely to have improvement in EF. Further evaluation is needed to determine the potential role of early cryoballoon PVI in patients with a new diagnosis of systolic dysfunction and AF.</AbstractText> |
18,791 | Haemodynamic mechanisms and long-term prognostic impact of pulmonary hypertension in patients with severe aortic stenosis undergoing valve replacement. | We aimed to investigate the prevalence, detailed invasive haemodynamics, and prognostic impact of pulmonary hypertension (PH) in severe aortic stenosis (AS).</AbstractText>We studied 503 patients (mean age 74 ± 10 years) with severe AS (indexed aortic valve area 0.4 ± 0.1 cm2</sup> /m2</sup> , left ventricular ejection fraction 57 ± 12%) undergoing left and right heart catheterization prior to aortic valve replacement. Median follow-up was 3.7 (interquartile range 2.6-5.4) years. Baseline PH (mean pulmonary artery pressure ≥ 25 mmHg) was found in 239 (48%) patients: 31 patients had pre-capillary PH [mean pulmonary artery wedge pressure (mPAWP) ≤ 15 mmHg], 144 had isolated post-capillary PH [IpcPH; mPAWP > 15 mmHg, pulmonary vascular resistance (PVR) ≤ 3 Wood units (WU)], and 64 had combined pre- and post-capillary PH (CpcPH; mPAWP > 15 mmHg, PVR > 3 WU). Patients with CpcPH had higher mortality than those with IpcPH, pre-capillary PH, and without PH. In the multivariate analysis, CpcPH remained an independent predictor of death (hazard ratio 4.39, 95% confidence interval 2.40-8.03; P < 0.001). Patients with CpcPH had higher mPAWP (26 ± 7 vs. 22 ± 5 mmHg) and lower pulmonary arterial capacitance (1.5 ± 0.6 vs. 2.9 ± 1.2 mL/mmHg) than IpcPH patients but similar left ventricular end-diastolic pressure (LVEDP; 25 ± 7 vs. 25 ± 7 mmHg). A smaller LVEDP-mPAWP difference was related to larger left atrial size, atrial fibrillation, and more severe mitral regurgitation.</AbstractText>In patients with severe AS, PH is common but underlying mechanisms differ. Patients with CpcPH have higher mPAWP, lower pulmonary arterial capacitance, and worse survival than all other groups. Left atrial dysfunction and mitral regurgitation seem to be drivers of high mPAWP in CpcPH.</AbstractText>© 2018 The Authors. European Journal of Heart Failure © 2018 European Society of Cardiology.</CopyrightInformation> |
18,792 | A Lucky Accident: Brugada Syndrome Associated with Out-of-Hospital Cardiac Arrest. | About 350,000 cases of out-of-hospital cardiac arrest (OHCA) occur yearly in the United States. Unfortunately, even with treatment from emergency medical service (EMS) staff and hospitalization, only 12% survive past discharge for multiple reasons. Classically, Brugada syndrome (BrS) initially presents as a new syncopal episode in young males without obstructive coronary artery disease (CAD). However, in this case report, a patient who emergently presented with a ST-elevation myocardial infarction (STEMI) challenges the stereotypical presentation. Despite successful stent placement for relatively minor obstructive CAD, new ST-segment elevations appeared on electrocardiogram (ECG) and persistent ventricular fibrillation arrests may signify an additional underlying pathology of BrS. |
18,793 | The limitations and potential adverse effects of the premature ventricular contraction response. | A 69-year-old man, who had undergone surgery for mitral and tricuspid regurgitation with the Maze procedure for paroxysmal atrial fibrillation, was admitted with an episode of syncope due to sick sinus syndrome. Three days after implantation of a dual-chamber pacemaker (Accent MRI™, St. Jude Medical Inc.,), ventricular pacing on T-wave was recorded multiple times. St. Jude Medical Inc. pacemakers have a unique additional algorithm, called premature ventricular contraction response, related to preventing pacemaker-mediated tachycardia. This algorithm was determined to be a cause of ventricular pacing on T-wave. We report the limitations and potential adverse effects of such automated algorithms. |
18,794 | SCN5A gene mutations and the risk of ventricular fibrillation and syncope in Brugada syndrome patients: A meta-analysis. | Mutations in the gene encoding the main cardiac sodium channel (SCN5A) are the commonest genetic cause of Brugada syndrome (BrS). However, the effect of SCN5A mutations on the outcomes of ventricular fibrillation (VF) and syncope remains uncertain. To clarify this relationship, a meta-analysis was performed. A comprehensive search was conducted to identify all eligible studies from PubMed, MEDLINE, EBSCO, ProQuest, Science Direct, Clinical Key, and Cochrane database for cohort studies of BrS populations that had been systematically tested for SCN5A mutations. We did meta-analysis to see the relationship between SCN5A mutations and the occurrence of VF and/or syncope using RevMan 5.3. Five clinical studies met our criteria and included a total of 665 BrS patients. These studies included 45 patients with VF and 178 patients with syncope. We found that in BrS patients with SCN5A mutations the rate of VF event was 30.7% while in patients without mutations was 28.5% (Risk Ratio [RR] = 1.11, [95% CI: 0.61, 2.00], <i>P</i> = 0.73, <i>I</i> <sup>2</sup> = 0%). The occurrence of syncope events was 35.9% in patients with SCN5A mutations and 34.5% in patients without mutations (RR = 1.12, [95% CI: 0.87, 1.45], <i>P</i> = 0.37, <i>I</i> <sup>2</sup> = 39%). Furthermore, the occurrence of combined VF and syncope events were similar between the 2 groups (RR = 1.12, [95% CI: 0.89, 1.42], <i>P</i> = 0.34, <i>I</i> <sup>2</sup> = 11%). BrS patients with SCN5A mutations exhibit a similar risk of future occurence of VF and/or syncope as compared to those without SCN5A mutations. |
18,795 | Cardiac dysfunction in exacerbations of chronic obstructive pulmonary disease is often not detected by electrocardiogram and chest radiographs. | Cardiac dysfunction is common in exacerbations of chronic obstructive pulmonary disease (COPD), even in patients without clinically suspected cardiac disorders.</AbstractText>To investigate associations between electrocardiogram (ECG) and chest radiograph abnormalities and biochemical evidence of cardiac dysfunction (N-terminal pro-B-type natriuretic peptide and troponin T) in patients hospitalised with exacerbations of COPD at Waikato Hospital.</AbstractText>Independent examiners, blinded to NT-proBNP and troponin T levels, assessed ECG for tachycardia, atrial fibrillation, ventricular hypertrophy and ischaemic changes in 389 patients and chest radiographs for signs of heart failure in 350 patients. Associations between electrocardiographic and radiographic abnormalities with at least moderate interrater agreement and cardiac biomarkers were analysed.</AbstractText>High NT-proBNP values (>220 pmol/L) were associated with atrial fibrillation (22 vs 6%), right ventricular hypertrophy (24 vs 15%), left ventricular hypertrophy (15 vs 4%), ischaemia (59 vs 33%) and cardiomegaly (42 vs 20%). High troponin T values (>0.03ug/L or high-sensitivity >50 ng/L) were associated with tachycardia (65 vs 41%), right ventricular hypertrophy (26 vs 15%) and ischaemia (60 vs 36%). None of the electrocardiographic or radiographic abnormalities was sensitive or specific for cardiac biomarker abnormalities. Ischaemia on ECG was the best indicator for raised NT-proBNP (sensitivity 59%, specificity 67%). Tachycardia and ischaemia were the best indicators of raised troponin T (sensitivity 65 and 60%, specificity 59 and 64% respectively).</AbstractText>ECG and chest radiograph abnormalities have poor sensitivity and specificity for diagnosing acute cardiac dysfunction in exacerbations of COPD. Cardiac biomarkers provide additional diagnostic information about acute cardiac dysfunction in exacerbations of COPD.</AbstractText>© 2018 Royal Australasian College of Physicians.</CopyrightInformation> |
18,796 | Clinical Features of Post Cardiac Injury Syndrome Following Catheter Ablation of Arrhythmias: Systematic Review and Additional Cases. | Post cardiac injury syndrome (PCIS) is a troublesome but not uncommon complication following catheter ablation of arrhythmias. We aimed to study the clinical features of ablation-associated PCIS.</AbstractText>For this purpose, we conducted a computerised literature search that identified 19 published cases, and we additionally included another two new cases from our centres. Twenty-one (21) cases of PCIS following ablation were analysed.</AbstractText>Among the 21 cases, PCIS most commonly occurred after atrial flutter/fibrillation (AFL/AF) ablation (71.4%), followed by atrioventricular re-entrant tachycardia (AVRT) ablation (9.5%), atrioventricular node (AVN) ablation (9.5%), atrioventricular nodal re-entrant tachycardia (AVNRT) ablation (4.8%) and ventricular tachycardia (VT) ablation (4.8%). Thirty-eight (38) per cent of PCIS was suggested to be secondary to cardiac perforation. Specific symptoms or features include pleuritic chest pain (76.2%), fever (76.2%), elevated markers of inflammation (76.2%), pericardial effusion (90.5%), pleural effusion (71.4%) and pulmonary infiltrates (28.6%). Interestingly, all the six cases with pulmonary infiltrates were following AFL/AF ablation (6/15, 40%). Serious clinical manifestations include cardiac tamponade, massive pleural effusion with hypoalbuminaemia and hyponatraemia, and massive pulmonary infiltrates with hypoxaemia. Notably, empiric antibiotic therapy was used in seven cases including five with pulmonary infiltrates but failed to work. No mortality occurred during a mean follow-up of 4.1±5.3 (1 to 19) months.</AbstractText>Catheter ablation of AFL/AF was most commonly involved in ablation-associated PCIS. Pulmonary infiltrate is an important feature of PCIS following AFL/AF ablation and may be misdiagnosed as pneumonia. Although PCIS is troublesome and even dangerous, it does carry a benign prognosis.</AbstractText>Copyright © 2018 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> |
18,797 | MicroRNA-206 Downregulates Connexin43 in Cardiomyocytes to Induce Cardiac Arrhythmias in a Transgenic Mouse Model. | MicroRNAs (miRNAs) are critical modulators of various physiological and pathological processes, but their role in cardiac arrhythmias remains yet to be completely understood. Connexin43 (Cx43) is an important cardiac gap junction protein and a potential target of miR-206, and downregulation of Cx43 induces ventricular tachyarrhythmias.</AbstractText>We investigated the effects of miR-206 overexpression on the adult mouse heart and in cardiac arrhythmias. Luciferase activity assay was employed to validate Cx43 as a direct target of miR-206. Expression of Cx43 was measured in cardiac muscle cell line HL-1 securely expressing miR-206. An inducible miR-206 overexpression mouse model was established to evaluate the in vivo effect of miR-206 on Cx43 expression and cardiac rhythm.</AbstractText>MiR-206 directly recognised 3'-untranslated region of Cx43 mRNA to inhibit its expression in HL-1 cells. Induction of miR-206 in the adult mouse heart suppressed Cx43 expression, particularly in the atria and ventricle. Importantly, miR-206 overexpression also induced abnormal heart-rate and PR interval, and shortened life-span in the experimental mice.</AbstractText>In cardiomyocytes, miR-206 is a upstream regulator of Cx43, and its overexpression downregulates Cx43 to induce abnormal heart-rate and PR interval.</AbstractText>Copyright © 2018 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> |
18,798 | Selective beta-blocker esmolol improves cerebral cortex microcirculation in a swine ventricular fibrillation model. | This study aimed to identify whether esmolol attenuates cerebral cortex microcirculation blood flow due to epinephrine in prolonged ventricular fibrillation (VF) and cardiopulmonary resuscitation (CPR), and may improve neurological prognosis.</AbstractText>Male pigs were randomized into the esmolol+epinephrine group (group EE), the epinephrine group (group EP), and the normal saline group (group NS) (n = 8 each group). Untreated VF for 8 minutes was induced in pigs. After CPR for 2 minutes, group EE received esmolol (500 µg/kg)+epinephrine (20 µg/kg), group EP received epinephrine 20 µg/kg, and group NS received 5 mL normal saline. Then, a 120 J electric shock was delivered. If the return of spontaneous circulation (ROSC) failed, epinephrine (20 µg/kg) was repeated in group EP and EE, followed by another 2 minutes of CPR, a 150 J electric shock was delivered every 2 minutes until ROSC. Cerebral microcirculation images were obtained at 0.5, 6, 12, and 24 hours by cranial windows after ROSC. Cerebral performance category scores and neurological deficit scores (NDS) were calculated. The frontal cortices were harvested after the animals were euthanized.</AbstractText>The NDS, the perfused vessel density, and the microcirculatory flow index of group EE were better than other two groups. The morphology of endothelial cells in the group EE remained intact; however, it was destroyed in the group EP.</AbstractText>Administration of esmolol with epinephrine may alleviate the impairment of cerebral microcirculation blood flow caused by the administration of epinephrine in prolonged VF and thereby improves neurological outcomes in a swine model.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,799 | Ventricular Arrhythmias in the Patient with a Structurally Normal Heart. | Ventricular arrhythmias (VAs) are among the most common cardiac rhythm disturbances encountered in clinical practice. Patients presenting with frequent ventricular ectopy or sustained ventricular tachycardia represent a challenging and worrisome clinical scenario for many practitioners because of concerning symptoms, frequent associated acute hemodynamic compromise, and the adverse prognostic implications inherent to these cases. While an underlying structural or functional cardiac abnormality, metabolic derangement, or medication toxicity is often readily apparent, many patients have no obvious underlying condition, despite a comprehensive diagnostic evaluation. Such patients are diagnosed as having an idiopathic VA, which is a label with specific implications regarding arrhythmia origin, prognosis, and potential for pharmacologic and invasive management. Further, a subset of patients with otherwise benign idiopathic ventricular ectopy can present with polymorphic ventricular tachycardia and ventricular fibrillation, adding a layer of complexity to a clinical syndrome previously felt to have a benign clinical course. Thus, this review seeks to highlight the most common types of idiopathic VAs with a focus on their prognostic implications, underlying electrophysiologic mechanisms, unique electrocardiographic signatures, and considerations for invasive electrophysiologic study and catheter ablation. We further address some of the data regarding idiopathic ventricular fibrillation with respect to the heterogeneous nature of this diagnosis. |
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