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18,800 | Left Atrial Function Predicts Cardiovascular Events in Patients With Chronic Heart Failure With Reduced Ejection Fraction. | Heart failure (HF) is known to be the most widespread epidemic of cardiovascular disease. Among several factors with prognostic value for the clinical course of HF, left atrial (LA) function has not yet been fully examined. The aim of this prospective study was to evaluate LA function for the prediction of major cardiovascular outcomes in stable patients with chronic HF with reduced ejection fraction. Additionally, as secondary end points, cardiovascular mortality and atrial fibrillation were analyzed separately.</AbstractText>The predictive value of LA function evaluated by speckle-tracking echocardiography was assessed in a population of 286 outpatients referred to the authors' institution for routine evaluation of chronic HF. Global peak atrial longitudinal strain was measured at the end of the reservoir phase and calculated by averaging in all LA segments.</AbstractText>During a median follow-up period of 48 ± 11 months, major adverse cardiac events occurred in 98 patients (34%). In a multivariate model, global peak atrial longitudinal strain (hazard ratio, 0.95; 95% CI, 0.94-0.96; P = .02), left ventricular ejection fraction (hazard ratio, 0.95; 95% CI, 0.93-0.97; P = .01), and renal failure (hazard ratio, 0.98; 95% CI, 0.97-0.99; P = .01) were independent predictors of an adverse outcome. Sixty-six patients (23%) died of cardiac causes. Fifty-four patients (19%) developed atrial fibrillation. Patients with lower global peak atrial longitudinal strain showed worse event-free survival and developed atrial fibrillation more frequently than those with higher levels.</AbstractText>LA function assessed by speckle-tracking echocardiography is an independent prognostic marker in patients with HF with reduced ejection fraction.</AbstractText>Copyright © 2018 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,801 | Average e' velocity on transthoracic echocardiogram is a novel predictor of left atrial appendage sludge or thrombus in patients with atrial fibrillation. | Studies have demonstrated the value of transthoracic echocardiogram (TTE) diastolic parameters in predicting left atrial appendage (LAA) thrombus; however, these studies have been small. We aim to clarify the relationship between TTE diastolic parameters, in particular average e', and LAA thrombus or sludge.</AbstractText>A case-control review was conducted of subjects with non-valvular atrial fibrillation (n = 2263) who had undergone TEE (transesophageal echocardiogram) and had a TTE within 1 year of TEE. Cases of LAA sludge or thrombus were matched to controls by age, sex, left ventricular ejection fraction (LVEF), and anticoagulation status.</AbstractText>Forty-three subjects (mean age 73 ± 12, 65% male, LVEF 47%, 44% on anticoagulation) with LAA sludge or thrombus were identified. Compared to matched controls, average TTE e' (7.3 ± 2.1 cm/s vs 8.7 ± 2.1 cm/s, P < 0.001) and the E:e' ratio (15 ± 7 cm/s vs 12 ± 5 cm/s; P = 0.005) were significant predictors of LAA sludge or thrombus. Average TTE e' value of >11 cm/s had 100% sensitivity for ruling out LAA sludge or thrombus.</AbstractText>In individuals with atrial fibrillation, average e' >11 cm/s on TTE is a promising independent predictor of the absence of LAA sludge or thrombus on TEE.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,802 | Whole-heart spiral simultaneous multi-slice first-pass myocardial perfusion imaging. | To develop and evaluate a simultaneous multislice (SMS) spiral perfusion pulse sequence with whole-heart coverage.</AbstractText>An orthogonal set of phase cycling angles following a Hadamard pattern was incorporated into a golden-angle (GA) variable density spiral perfusion sequence to perform SMS imaging at different multiband (MB) factors. Images were reconstructed using an SMS extension of L1-SPIRiT that we have termed SMS-L1-SPIRiT. The proposed sequence was evaluated in 40 subjects (10 each for MB factors of 1, 2, 3, and 4). Images were blindly graded by 2 cardiologists on a 5-point scale (5, excellent). To quantitatively evaluate the reconstruction performance against images acquired without SMS, the MB =1 data were used to retrospectively simulate data acquired at MB factors of 2 to 4.</AbstractText>Analysis of the SMS point-spread function for the desired slice showed that the proposed sampling strategy significantly canceled the main-lobe energy of the other slices and has low side-lobe energy resulting in an incoherent temporal aliasing pattern when rotated by the GA. Retrospective experiments demonstrated the SMS-L1-SPIRiT method removed aliasing from the interfering slices and showed excellent agreement with the ground-truth MB =1 images. Clinical evaluation demonstrated high-quality perfusion images with average image-quality scores of 4.3 ± 0.5 (MB =2), 4.2 ± 0.5 (MB =3), and 4.4 ± 0.4 (MB =4) with no significant quality difference in image quality between MB factors (P = 0.38).</AbstractText>SMS spiral perfusion at MB factors 2, 3, and 4 produces high-quality perfusion images with whole-heart coverage in a clinical setting with high sampling efficiency.</AbstractText>© 2018 International Society for Magnetic Resonance in Medicine.</CopyrightInformation> |
18,803 | Role of Echocardiography in Assessment of Cardioembolic Sources: a Strong Diagnostic Resource in Patients with Ischemic Stroke. | This review will discuss the most frequent sources of cardiac embolism and the role of echocardiography in these different clinical settings, and, in addition, provide suggestions about the choice between transthoracic (TTE) and transesophageal echocardiography (TEE).</AbstractText>Stroke is the third leading cause of death in industrial countries, and 15-40% of all ischemic strokes are due to cardioembolism. TTE and TEE are cornerstones in the detection of cardioembolic sources and provide fundamental information about the embolic risk and most suitable treatment of these patients, improving long-term outcomes. Echocardiography is a widely available, inexpensive, and safe diagnostic tool that is almost free from contraindication, and these elements allow the common use of this technique in almost all the patients with ischemic stroke. The most common cardioembolic sources include left atrial appendage thrombosis during atrial fibrillation; vegetations in infective endocarditis; cardiac masses including left ventricular thrombosis, cardiac tumors, etc.; atherosclerotic plaques; and passageways within the heart serving as conduits for paradoxical embolization, e.g., patent foramen ovale.</AbstractText> |
18,804 | Cardiac Structural or Functional Changes Associated with CHA<sub>2</sub>DS<sub>2</sub>-VASc Scores in Nonvalvular Atrial Fibrillation: A Cross-Sectional Study Using Echocardiography. | CHA2</sub>DS2</sub>-VASc is the most widely accepted scoring system for atrial fibrillation (AF) to assess stroke risk, although little has been revealed regarding the accompanying cardiac functional/structural changes. This echocardiography study was undertaken to understand the changes related to CHA2</sub>DS2</sub>-VASc scores.</AbstractText>A total of 4,795 nonvalvular AF patients were enrolled for the cohort, from which 591 were excluded as they did not meet the inclusion criteria. Based on the CHA2</sub>DS2</sub>-VASc scores, the remaining 4,204 patients included in the study were divided into 4 groups: 0 to 1 (n = 991); 2 to 3 (n = 1,642); 4 to 6 (n = 1,407); 7 to 9 (n = 164).</AbstractText>Increase in the left ventricular mass index and prevalence of left ventricular hypertrophy (LVH) were observed with elevating CHA2</sub>DS2</sub>-VASc scores (p < 0.05 for all). Diastolic parameters such as left atrial volume index (LAVI) and the ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus (E/E') also increased significantly in the higher CHA2</sub>DS2</sub>-VASc score groups (p < 0.001 for all), although two-way ANOVA analysis showed that such incremental diastolic impairment was independent of hypertension. LVH (hazard ratio [HR], 3.609; confidence interval [CI], 2.426-5.369; p < 0.001) and E/E' (HR, 1.087; CI, 1.054-1.121; p < 0.001) were independent risk factors for CHA2</sub>DS2</sub>-VASc scores 2 or higher.</AbstractText>Our findings suggest that increasing CHA2</sub>DS2</sub>-VASc scores are associated with impaired diastolic function that may represent high left atrial pressure favoring thrombogenic propensity.</AbstractText> |
18,805 | Amiodarone and thyroid physiology, pathophysiology, diagnosis and management. | Although amiodarone is considered the most effective antiarrhythmic agent, its use is limited by a wide variety of potential toxicities. The purpose of this review is to provide a comprehensive "bench to bedside" overview of the ways amiodarone influences thyroid function. We performed a systematic search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2017. Amiodarone was searched using the terms adverse effects, hypothyroidism, myxedema, hyperthyroidism, thyroid storm, atrial fibrillation, ventricular arrhythmia, and electrical storm. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. We included 163 germane references in this review. Because amiodarone is one of the most frequently prescribed antiarrhythmic drugs in the United States, the mechanistic, diagnostic and therapeutic information provided is relevant for practicing clinicians in a wide range of medical specialties. |
18,806 | Nonspecific electrocardiographic abnormalities are associated with increased length of stay and adverse cardiac outcomes in prehospital chest pain. | Nonspecific ST-T repolarization (NST) abnormalities alter the ST-segment for reasons often unrelated to acute myocardial ischemia, which could contribute to misdiagnosis or inappropriate treatment. We sought to define the prevalence of NST patterns in patients with chest pain and evaluate how such patterns correlate with the eventual etiology of chest pain and course of hospitalization.</AbstractText>This was a prospective observational study that included consecutive prehospital chest pain patients from three tertiary care hospitals in the U.S. Two independent reviewers blinded from clinical data audited the prehospital 12-lead ECG for the presence or absence of NST patterns (i.e., right or left bundle branch block, left ventricular hypertrophy with strain pattern, ventricular pacing, ventricular rhythm, or coarse atrial fibrillation). The primary outcome was 30-day major adverse cardiac events (MACE) defined as cardiac arrest, acute heart failure, post-discharge infarction, or all-cause death.</AbstractText>The final sample included 750 patients (age 59 ± 17, 58% males). A total of 40 patients (5.3%) experienced 30-MACE and 131 (17.5%) had NST patterns. The presence of NST patterns was an independent multivariate predictor of 30-day MACE (9.9% vs. 4.4%, OR = 2.2 [95% CI = 1.1-4.5]. Patients with NST patterns had increased median length of stay (1.0 [IQR 0.5-3] vs. 2.0 [IQR 1-4] days, p < 0.05) independent of the etiology of chest pain.</AbstractText>One in six prehospital ECGs of patients with chest pain has NST patterns. This pattern is associated with increased length of stay and adverse cardiac outcomes, suggesting the need of preventive measures and close follow up in such patients.</AbstractText>Copyright © 2018 Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,807 | [Protective effects of endovascular cooling treatment on post-resuscitation syndrome and its mechanism]. | To investigate the protective function of endovascular cooling method on post-resuscitation syndrome (PRS) in porcine cardiac arrest (CA) model and its mechanism.</AbstractText>Ventricular fibrillation (VF) was electrically induced and untreated for 8 minutes in 15 healthy male porcines, cardiopulmonary resuscitation (CPR) was then initiated. All successful recovery animals were randomly divided into two groups by random number table. In normal temperature group, the core temperature was maintained at (38.0±0.5) centigrade for 12 hours. In mild hypothermia group, the mild hypothermia treatment was initiated at 5 minutes after successful resuscitation, the treatment of rapid endovascular cooling was performed to reach the target cooling temperature of (33.0±1.0) centigrade, and then maintained until 6 hours after resuscitation. Rewarming was implemented at the rate of 0.7 centigrade/h until the body temperature reached (38.0±0.5) centigrade. Hemodynamic parameters including heart rate (HR), mean arterial blood pressure (MAP), cardiac output (CO) were continually monitored. Right femoral vein blood was collected before VF and 1, 2, 4, 6, 12 and 24 hours after resuscitation, respectively, and the serum concentrations of E-selectin, soluble thrombomodulin (sTM), and interleukin-1β (IL-1β) were determined with enzyme linked immunosorbent assay (ELISA). The survival of porcines at 24 hours after resuscitation was observed, and the neurological deficit score (NDS) was calculated for the surviving porcines. All animals were sacrificed, and brain, heart and lung tissues were collected, after hematoxylin and eosin (HE) staining, the histopathology changes were evaluated under a light microscopy.</AbstractText>After 8-minute VF, 14 porcines were resuscitated successfully, 7 porcines in normal temperature group and 7 in mild hypothermia group respectively, with the resuscitation success rate of 93.3%. There was no significant difference in body weigh, core temperature, hemodynamics, or blood lactate as well as duration of CPR and the number of defibrillations between the two groups. The core temperature of normal temperature group was maintained at (38.0±0.5) centigrade, while in mild hypothermia group, the hypothermia was reduced to the hypothermia range (33.0±1.0) centigrade until 6 hours, then rewarmed to normothermia gradually [(38.0±0.5) centigrade]. Compared with those before VF, HR was significantly increased after resuscitation in both groups, and MAP and CO were decreased, then they tended to normal. There was no significant difference in hemodynamic parameter at all time points between the two groups. Compared with those before VF, the levels of E-selectin and sTM in serum of the two groups were increased significantly at 1 hour after resuscitation, and they were decreased gradually after reaching the peak at 6 hours, and IL-1β was increased continuously with time. There was no significant difference in E-selectin (μg/L: 1.34±0.52 vs. 1.60±0.61), sTM (μg/L: 19.13±0.34 vs. 19.24±0.73), or IL-1β (ng/L: 25.73±0.87 vs. 25.32±0.25) before VF between normal temperature group and mild hypothermia group (all P > 0.05). The levels of E-selection, sTM and IL-1β in mild hypothermia group were significantly lower than those in normal temperature group from 2 hours after resuscitation [E-selection (μg/L): 11.15±2.73 vs. 16.04±3.23, sTM (μg/L): 49.67±3.32 vs. 62.22±1.85, IL-1β (ng/L): 140.51±6.66 vs. 176.29±18.51, all P < 0.05], and E-selection decreased to the baseline level at 12 hours (μg/L: 1.17±0.65 vs. 1.60±0.61, P > 0.05). The 24-hour survival rates of two groups were both 100%. The NDS score of mild hypothermia group was obviously lower than that of normal temperature group (150.0±6.6 vs. 326.4±12.3, P < 0.05). In normal temperature group, neuronal cell necrosis was observed in the cerebral cortex at 24 hours after resuscitation, and nucleus was deeply stained. The myocardial necrosis and alveolar collapse was found. Meanwhile the infiltration of inflammatory cell could be found in the myocardium and alveolar. The brain, lung and myocardium injury were significantly milder in mild hypothermia group as compared with those in normal temperature group.</AbstractText>The intravascular cooling therapy was a safe and effective method for inducing mild hypothermia after resuscitation. This cooling effect was fast and reliable, and the rewarming speed was controllable and stable. The protective mechanism of mild hypothermia on PRS may be related to inhibiting systemic inflammatory response and reducing vascular endothelial cell injury.</AbstractText> |
18,808 | German Cardiac Society Working Group on Cellular Electrophysiology state-of-the-art paper: impact of molecular mechanisms on clinical arrhythmia management. | Cardiac arrhythmias remain a common challenge and are associated with significant morbidity and mortality. Effective and safe rhythm control strategies are a primary, yet unmet need in everyday clinical practice. Despite significant pharmacological and technological advances, including catheter ablation and device-based therapies, the development of more effective alternatives is of significant interest to increase quality of life and to reduce symptom burden, hospitalizations and mortality. The mechanistic understanding of pathophysiological pathways underlying cardiac arrhythmias has advanced profoundly, opening up novel avenues for mechanism-based therapeutic approaches. Current management of arrhythmias, however, is primarily guided by clinical and demographic characteristics of patient groups as opposed to individual, patient-specific mechanisms and pheno-/genotyping. With this state-of-the-art paper, the Working Group on Cellular Electrophysiology of the German Cardiac Society aims to close the gap between advanced molecular understanding and clinical decision-making in cardiac electrophysiology. The significance of cellular electrophysiological findings for clinical arrhythmia management constitutes the main focus of this document. Clinically relevant knowledge of pathophysiological pathways of arrhythmias and cellular mechanisms of antiarrhythmic interventions are summarized. Furthermore, the specific molecular background for the initiation and perpetuation of atrial and ventricular arrhythmias and mechanism-based strategies for therapeutic interventions are highlighted. Current "hot topics" in atrial fibrillation are critically appraised. Finally, the establishment and support of cellular and translational electrophysiology programs in clinical rhythmology departments is called for to improve basic-science-guided patient management. |
18,809 | The burden of cardiac arrhythmias in sarcoidosis: a population-based inpatient analysis. | Cardiac involvement in the sarcoidosis is known to ensue with diverse clinical forms and its investigation is challenging at times. This article features the under-perceived burden, patterns, and outcomes of different arrhythmias, which may have a prognostic significance in patients with sarcoidosis.</AbstractText>We queried the National Inpatient Sample (NIS) for 2010-2014 to recognize sarcoidosis, arrhythmia, and comorbidities affecting hospitalizations. The nationwide estimates were attained using discharge records. We assessed incidence and trends in sarcoidosis-related arrhythmia and consequential inpatient mortality, hospital length of stay (LOS), hospitalization charges and predictors of mortality with multivariate analysis.</AbstractText>We identified 369,285 sarcoidosis-related hospitalizations. Of these, nearly one-fifth suffered from arrhythmias (n=73,424). The sarcoidosis patients developing arrhythmias were older (61.9 vs.</i> 56.0 years) compared to those without. Males had the higher incidence of arrhythmias compared to females. Atrial fibrillation (Afib) (10.97%) was the most common subtype, followed by ventricular tachycardia (1.97%). There was a rising trend in arrhythmia-related hospital admissions and mortality among sarcoidosis, with Afib incidence displaying the highest increase. Traditional cardiac comorbidities were higher in the sarcoid-arrhythmia group. The arrhythmia group had significantly higher mortality (3.7% vs.</i> 1.5%), mean hospital LOS (6.4 vs.</i> 5.2 days) and hospital charges ($64,118 vs.</i> $41,565) compared to non-arrhythmia group (P<0.001). Incident arrhythmia significantly increased the mortality odds in sarcoidosis (adjusted odds ratio, 2.06).</AbstractText>The growing trend, deteriorating outcomes and higher mortality associated with sarcoid-related arrhythmias highlight the importance of timely diagnosis and aggressive management in this population.</AbstractText> |
18,810 | Clinical Predictors of Recurrent Ventricular Arrhythmias in Secondary Prevention Implantable Cardioverter Defibrillator Recipients With Coronary Artery Disease　- Lower Left Ventricular Ejection Fraction and Incomplete Revascularization. | The implantable cardioverter defibrillator (ICD) is a standard prevention therapy for patients at high risk for sudden cardiac death (SCD) due to life-threatening ventricular arrhythmia (VA), that is, ventricular fibrillation and ventricular tachycardia. However, clinical predictors of recurrent VA in secondary prevention ICD recipients with coronary artery disease (CAD) remain unknown. Methods and Results: We followed up 96 consecutive patients with CAD undergoing ICD implantation for secondary prevention of SCD. Long-term rates and clinical predictors of appropriate ICD therapy (ICD-Tx) for VA were analyzed. Appropriate ICD-Tx occurred in 41 (42.7%) patients during a median follow-up of 2.4 years (interquartile range, 0.9-6.1). These patients had significantly greater left ventricular end-diastolic diameter (62.3±1.3 vs. 54.6±1.1 mm, P<0.001), lower left ventricular ejection fraction (LVEF; 36.3±2.0% vs. 45.7±1.8%, P<0.001), and more incomplete revascularization (ICR; 70.7% vs. 45.5%, P=0.014) than those without appropriate ICD-Tx. Multivariable analysis showed that LVEF (hazards ratio [HR], 0.950; 95% CI: 0.925-0.975; P<0.001) and ICR (HR, 2.293; 95% CI: 1.133-4.637; P=0.021) were significant predictors of appropriate ICD-Tx for VA.</AbstractText>Lower LVEF and ICR were independent predictors of recurrent VA in secondary prevention ICD recipients with CAD.</AbstractText> |
18,811 | The use of Apixaban for the treatment of an LV thrombus. | A 42-year-old male was admitted with shortness of breath secondary to suspected heart failure and chest infection. An echocardiogram revealed a dilated and impaired left ventricle; ejection fraction 29%, with a large, mobile thrombus within the left ventricular apex. Due to the presence of liver dysfunction, vitamin K antagonists were deemed inappropriate; thus, the decision was taken to use the novel anticoagulation agent Apixaban. After 6 days of receiving Apixaban, a cardiac magnetic resonance scan was preformed, which showed complete resolution of the LV apical thrombus.</AbstractText>Patients with a dilated and impaired LV are at an increased risk of developing LV thrombus. A large and mobile LV thrombus is associated with an increased risk of embolic events. Vitamin K antagonists (VKAs) are often the first-line therapy for LV thrombus; however, these may be inappropriate in some patients. NOACs are advantageous in comparison to VKAs and are used to treat: non-valvular atrial fibrillation, pulmonary embolisms and used in the prevention of recurrent deep vein thrombosis in adults. To date, NOACs are not licensed for the treatment of an LV thrombus; however, there are growing evidence whereby there use has shown promise in reducing the risk of embolic events and demonstrate rapid reduction in size/full resolution of an LV thrombus. Large, randomised research trials comparing NOACs and VKAs in the treatment of LV thrombus are needed, which may lead to a change in standard clinical practice that could benefit patients.</AbstractText>© 2018 The authors</CopyrightInformation> |
18,812 | Prognostic value of noninvasive programmed stimulation in patients with implantable cardioverter defibrillator. | Implantable cardioverter defibrillator (ICD) offers an opportunity to examine vulnerability to ventricular tachycardia (VT) or ventricular fibrillation (VF) by performing noninvasive programmed ventricular stimulation (NIPS). Whether NIPS can predict VT/VF recurrences has not yet been established.</AbstractText>To examine the predictive value of NIPS for identification of patients with VT/VF recurrences.</AbstractText>The study group consisted of consecutive 105 ICD recipients included in the prospective NIPS-ICD study (ClinicalTrials ID: NCT02373306) (88 males, age 65 ± 11 years). The patients underwent NIPS using the protocol up to three premature extrastimuli at 600-500- and 400-ms drive cycle lengths. The endpoint of NIPS was induction of sustained VT or VF or completion of the protocol.</AbstractText>VT/VF was induced in 29 (27.6%) patients. During a 12-month follow-up NIPS-inducible patients had significantly more frequently appropriate ICD therapy than noninducible patients (17% vs 4%, P = 0.023). NIPS-induced VT/VF had a sensitivity of 63%, specificity of 75%, positive predictive value of 17%, and negative predictive value of 96% for identification of patients with future VT/VF. Apart from NIPS, age ≥ 65 years, QRS duration, treatment with angiotensin-converting enzyme, history of coronary artery bypass grafting, history of VT/VF prior to NIPS, and prior appropriate ICD therapy were also associated with VT/VF recurrences. Multivariate analysis showed that, together with QRS duration, NIPS result was an independent predictor of future VT/VF. Predictive value of NIPS was significantly higher in ischemic than nonischemic patients.</AbstractText>NIPS result is associated with future VT/VF. Noninducibility at NIPS identifies those patients with high accuracy who will have uneventful follow-up.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,813 | Silent ischemic brain lesions detected by multi-slice computed tomography are associated with subclinical atrial fibrillation in patients with cardiac resynchronization therapy. | There is insufficient research on the relationship between subclinical atrial fibrillation (SCAF) and silent ischemic brain lesions (IBLs).</AbstractText>To investigate the relationship between SCAF and silent IBLs in patients with cardiac resynchronization therapy (CRT).</AbstractText>Of 720 CRT implanted patients in our department between 2012 and 2018, 121 patients who underwent elective cranial multi-slice computed tomography (MSCT) during their follow-up were included in our study. Atrial high-rate episodes (AHRE) were detected by the CRT device. Subclinical atrial fibrillation was defined as asymptomatic AHRE longer than 6 min and shorter than 24 h. A cranial MSCT scan was performed using a 128-section scanner with contiguous 2-5 mm axial images. Patients were divided into two groups - with and without silent IBL.</AbstractText>Silent IBLs were detected in 21 (17.4%) of 121 patients with CRT. Ischemic brain lesion presence was found to be associated with age, CHA2DS2-VASc score, left ventricular (LV) ejection fraction (EF), hypertension and SCAF in univariate analysis (p</i> < 0.05). In multivariate regression analysis, presence of SCAF and LVEF were found to be independent parameters predicting the risk of silent IBLs. According to this analysis, the presence of SCAF and every 1% decrease in LVEF were found to increase the risk of silent IBL by 3.5 times and 14.8%, respectively.</AbstractText>Subclinical atrial fibrillation is independently associated with silent IBL presence. Patients with CRT should be closely monitored for SCAF. Patients diagnosed with SCAF should be evaluated for IBL development and treated with the appropriate oral anticoagulant.</AbstractText> |
18,814 | Increased risk profile in the treatment of patients with symptomatic degenerative aortic valve stenosis over the last 10 years. | Currently, Cardiology Centres are overfilled with patients with degenerative aortic valve stenosis (DAS), usually eldery, with severe concommittant comorbidities, who are referred for further decisions and possible intervention.</AbstractText>To evaluate changes in the risk profile of patients with severe DAS admitted to the cardiology department a decade ago compared with patients currently being admitted.</AbstractText>We retrospectively evaluated all patients admitted with confirmed severe DAS, hospitalized during 2005-2006 (group I: 140 patients) and in 2016 (group II: 152 patients), admitted for aortic valve intervention. A standard transthoracic echocardiogram, cardiovascular symptom and risk factor distribution, perioperative risk with the logistic EuroSCORE II and STS mortality scores were obtained.</AbstractText>Patients in group II were significantly older (p</i> < 0.001), had more cardiovascular risk factors, and more often presented with atrial fibrillation (27% vs. 11.4%, p</i> = 0.001), renal impairment (34.9% vs. 22.8%; p</i> = 0.024), severe lung disease (17.1% vs. 2.1%, p</i> < 0.001), and extracardiac arteriopathy (40.1% vs. 17.8%, p</i> < 0.001). The aortic valve area (AVA) (p</i> = 0.356), mean-transvalvular pressure gradient (p</i> = 0.215), and left ventricular ejection fraction (p</i> = 0.768) were similar in both groups. However, the prevalence of pulmonary hypertension, severe mitral regurgitation, and low-flow, low-gradient DAS were 3.1-, 8.4- and 1.84-fold more frequent in group II than group I. The percentages of subjects with EuroSCORE II and STS scores ≥ 4% in 2005-2006 were 7.1% and 6.4%, as compared to 27% and 26.3% in 2016 (both p</i> < 0.001). 22% of patients in 2016, as compared to 31% in 2005/2006, were considered ineligible for DAS intervention.</AbstractText>In just a decade, the risk profile of patients admitted with DAS has increased hugely, mainly due to older age, accumulation of comorbidities and more advanced disease at presentation. Although transcatheter aortic valve intervention has expanded the indications for intervention in high-risk patients, the number of patients disqualified from interventional treatment remains high.</AbstractText> |
18,815 | Catheter Ablation of Ventricular Fibrillation. | Ventricular fibrillation (VF) is a common and life-threatening arrhythmia resulting in sudden cardiac death (SCD). Due to the inherent challenges of mapping VF in humans, the underlying mechanisms that initiate and sustain this common arrhythmia are still poorly understood. In high-risk patients and survivors of SCD, implantable cardioverter defibrillators (ICD) play a central role in treating VF episodes, however, ICDs do not prevent VF recurrences and patients remain at risk of electrical storm and multiple shocks that are often refractory to escalation of medical therapy. More recently, the utility of catheter ablation (CA) has extended to the treatment of VF storms. This review will focus on updates in elucidating the mechanism of VF leading into the role and indication of CA as a treatment strategy. |
18,816 | [Unusual cause of Takotsubo cardiomyopathy after pacemaker implantation]. | Since its first description in Japan in 1990, Takotsubo (stress) cardiomyopathy has gained worldwide recognition. The disease is characterized by transient systolic and diastolic left ventricular dysfunction with a variety of wall-motion abnormalities. She predominantly affects elderly women and she is often preceded by an emotional or physical trigger. In the acute phase, the clinical presentation, electrocardiographic findings and biomarker profiles are often similar to those of an acute coronary syndrome. Although, the cause of Takotsubo cardiomyopathy remains unknown, the role of the brain-heart axis in the pathogenesis of the disease has been described. The potential role of catecholamine excess in the pathogenesis of Takotsubo cardiomyopathy has been long debated, and as such beta-blockers have been proposed as a therapeutic strategy. Currently, the treatment is not codified and it adapts according to clinical symptomatology. It seems difficult to summarize all the factors to provoque the cardiomyopathy, we describe a case of Takotsubo after a pacemaker (PM) implantation and to give a recent progress on this heart disease. |
18,817 | Genotype and Lifetime Burden of Disease in Hypertrophic Cardiomyopathy: Insights from the Sarcomeric Human Cardiomyopathy Registry (SHaRe). | A better understanding of the factors that contribute to heterogeneous outcomes and lifetime disease burden in hypertrophic cardiomyopathy (HCM) is critically needed to improve patient management and outcomes. The Sarcomeric Human Cardiomyopathy Registry (SHaRe) was established to provide the scale of data required to address these issues, aggregating longitudinal datasets curated by eight international HCM specialty centers.</AbstractText>Data on 4591 HCM patients (2763 genotyped), followed for a mean of 5.4±6.9 years (24,791 patient-years; median [interquartile range] 2.9 [0.3-7.9] years) were analyzed regarding cardiac arrest, cardiac transplantation, appropriate implantable cardioverter-defibrillator (ICD) therapy, all-cause death, atrial fibrillation, stroke, New York Heart Association Functional Class III/IV symptoms (all comprising the overall composite endpoint), and left ventricular ejection fraction (LVEF)<35%. Outcomes were analyzed individually and as composite endpoints.</AbstractText>Median age of diagnosis was 45.8 [30.9-58.1] years and 37% of patients were female. Age of diagnosis and sarcomere mutation status were predictive of outcomes. Patients <40 years old at diagnosis had a 77% [95% confidence interval: 72%, 80%] cumulative incidence of the overall composite outcome by age 60, compared to 32% [29%, 36%] by age 70 for patients diagnosed >60 years. Young HCM patients (20-29 years) had 4-fold higher mortality than the general United States population at a similar age. Patients with pathogenic/likely pathogenic sarcomere mutations had two-fold greater risk for adverse outcomes compared to patients without mutations; sarcomere variants of uncertain significance were associated with intermediate risk. Heart failure and atrial fibrillation were the most prevalent adverse events, although typically not emerging for several years after diagnosis. Ventricular arrhythmias occurred in 32% [23%, 40%] of patients <40 years at diagnosis, but in 1% [1%, 2%] >60 years.</AbstractText>The cumulative burden of HCM is substantial and dominated by heart failure and atrial fibrillation occurring many years following diagnosis. Young age of diagnosis and the presence of a sarcomere mutation are powerful predictors of adverse outcomes. These findings highlight the need for close surveillance throughout life, and the need to develop disease-modifying therapies.</AbstractText> |
18,818 | Tips for management of arrhythmias in endocrine disorders from an European Heart Rhythm Association position paper. | In endocrine diseases, hormonal changes, electrolyte abnormalities, and the deterioration of heart structure can lead to various arrhythmias. In diabetic patients, hypoglycemia, hyperglycemia, and hypokalemia can trigger arrhythmias, and diabetic cardiomyopathy can also cause electrical and structural remodeling to form substrates for arrhythmias. The risk of atrial fibrillation (AF) increases in hyperthyroidism; however, the prevalence of ventricular arrhythmias in hypothyroidism is higher. Besides AF and ventricular tachycardias, bradycardias and atrioventricular blocks can also be seen in pheochromocytoma due to the desensitization of adrenergic cardiovascular receptors. The correction of metabolic and electrolyte disturbances in patients with adrenal cortex disease should be the main approach in the prevention and treatment of arrhythmias. Early initiation of treatment in patients with acromegaly seems to decrease the development of cardiac remodeling and ventricular arrhythmia. Early and late after depolarizations due to hypercalcemia in hyperparathyroidism can lead to life-threatening ventricular arrhythmias. This elegant position paper provides important recommendations regarding prevention and treatment of arrhythmias for specific endocrine disorders. |
18,819 | Description of a novel RyR2 mutation in a juvenile patient with symptomatic catecholaminergic polymorphic ventricular tachycardia in sleep and during exercise: a case report. | Catecholaminergic polymorphic ventricular tachycardia is an inherited disease presenting with arrhythmic events during physical exercise or emotional stress. If untreated, catecholaminergic polymorphic ventricular tachycardia is a highly lethal condition: About 80% of affected individuals experience recurrent syncope, and 30% experience cardiac arrest. Catecholaminergic polymorphic ventricular tachycardia is caused by mutations in genes encoding ryanodine receptor type 2 (RyR2) and cardiac calsequestrin (CASQ2). In cases of sympathoadrenergic activation, both mutations result in a spontaneous Ca2+</sup> release in cardiac cells, facilitating ventricular arrhythmias.</AbstractText>We present a case of a 17-year-old Caucasian boy who survived sudden cardiac death caused by ventricular fibrillation while performing running exercise in a fitness center. The diagnostic workup included blood tests, coronary angiography, electrophysiological testing, and cardiac magnetic resonance imaging, but all results were normal. Because the patient's medical history included recurrent syncope during physical and emotional stress, we strongly suspected catecholaminergic polymorphic ventricular tachycardia as the underlying disease. Genetic screening was performed and confirmed the diagnosis, revealing a new heterozygous point mutation in the gene for RyR2, c.12520T>A (p.F4174 l, exon 90, RyR2 gene). The patient was discharged from our hospital after undergoing implantation of an implantable cardioverter defibrillator for secondary prevention. Shortly after implantation, the implantable cardioverter defibrillator terminated a sustaining ventricular tachycardia episode by antitachycardic pacing. This episode occurred early in the morning while the patient was asleep.</AbstractText>We present a case of catecholaminergic polymorphic ventricular tachycardia associated with a novel single point mutation in the RyR2 gene, which, to the best of our knowledge, has not been described in the literature so far. Our patient experienced arrhythmic events under both resting conditions and physical activity, an uncommon finding in patients with catecholaminergic polymorphic ventricular tachycardia. This novel mutation may cause arrhythmias independent of sympathoadrenergic stimulation, but further evidence is needed to prove causality.</AbstractText> |
18,820 | First Hospitalization for Heart Failure in Outpatients With Stable Coronary Artery Disease: Determinants, Role of Incident Myocardial Infarction, and Prognosis. | We lack recent data on the incidence, correlates, and prognosis associated with heart failure (HF) development in patients with stable coronary artery disease (CAD). Here, we analyzed HF development in a contemporary population of outpatients with stable CAD.</AbstractText>Of 4184 unselected outpatients with stable CAD (ie, myocardial infarction [MI] and/or coronary revascularization >1 year earlier) included in the multicenter CORONOR registry, we identified 3871 patients with no history of hospitalization for HF at inclusion and followed 3785 (98%) of them for 5 years. During follow-up, 211 patients were hospitalized for HF (5-year cumulative incidence 5.7%) and 163 patients had incident MIs. Independent predictors of hospitalization for HF were older age, lower left ventricular ejection fraction (LVEF), atrial fibrillation, higher body mass index, diabetes mellitus, history of hypertension, angina at inclusion, and multivessel CAD. Most hospitalizations for HF (62.6%) occurred in patients with LVEF ≥50% at inclusion, and most (92.4%) were not preceded by an incident MI. Hospitalization for HF was a powerful predictor of mortality (adjusted hazard ratio 5.97, 95% confidence interval 4.55-7.83; P < .0001). After hospitalization for HF, mortality rates were similar in patients with LVEFs ≥50% and <50% at hospitalization.</AbstractText>Outpatients with stable CAD were frequently hospitalized for HF, and HF was associated with high mortality. Most HF hospitalizations were associated with preserved LVEF at inclusion and were not preceded by an incident MI.</AbstractText>Copyright © 2018. Published by Elsevier Inc.</CopyrightInformation> |
18,821 | Is obstructive sleep apnea associated with ventricular tachycardia? A retrospective study from the National Inpatient Sample and a literature review on the pathogenesis of Obstructive Sleep Apnea. | Obstructive sleep apnea (OSA) is a known independent risk factor for a multiple cardiovascular morbidities and mortality. The association of OSA and ventricular arrhythmias is less well understood. The aim of this analysis is to study the relationship between OSA and ventricular tachyarrhythmias.</AbstractText>OSA is associated with increased ventricular arrhythmias.</AbstractText>Data from the national inpatient sample (NIS) 2012 to 2014, were reviewed. Discharges associated with OSA were identified as the target population using the relevant ICD-9-CM codes. The primary outcome was a diagnosis of ventricular tachycardia (VT) in the OSA population. Secondary outcomes include the rate of ventricular fibrillation (VF) and cardiac arrest. Multivariable analyses were performed to examine the association of VT with multiple potential confounding clinical variables.</AbstractText>Of 18 013 878 health encounters, 943 978 subjects (5.24%) had a diagnosis of OSA. VT and VF were more prevalent among patients with OSA compared to those without a diagnosis of OSA (2.24% vs 1.16%; P < 0.001 and 0.3% vs 0.2%; P < 0.001, respectively). Odds ratio for cardiac arrest in OSA group was not statistically significant (1, 95% confidence interval 0.97-1.02, P < 0.76). In unadjusted analyses, all examined comorbidities were significantly more common in those with OSA, including diabetes mellitus, hypertension, chronic kidney disease, acute coronary syndrome, and heart failure.</AbstractText>OSA is associated with increased rates of ventricular tachyarrhythmia.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,822 | Chronic Kidney Disease as a Possible Predictor of Left Atrial Thrombogenic Milieu Among Patients with Nonvalvular Atrial Fibrillation. | Patients with chronic kidney disease (CKD) experiencing atrial arrhythmia are hypothesized to have elevated CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc scores, thereby predisposed to left atrial (LA) thrombus formation and subsequent thromboembolism. We examined possible association of LA thrombogenic milieu (TM) with CKD in patients with nonvalvular atrial fibrillation. A total of 581 patients (181 women; mean age, 67 years) who underwent transesophageal echocardiography were examined. Patients were divided into 4 groups based on the estimated glomerular filtration rate (eGFR) (ml/min/1.73 m<sup>2</sup>): eGFR ≥90 (n = 29), 60≤ eGFR <90 (n = 329), 30≤ eGFR <60 (n = 209), and eGFR <30 (n = 14). TM was defined as the presence of LA thrombus, dense spontaneous echo contrast, or LA appendage velocity ≤25 cm/s. Of 581 patients, 147 (25%) had TM. The prevalence of TM increased with decreasing eGFR (4%, 18%, 36%, and 86% for each group, p <0.001). Similar trends were observed for some of the clinical and echocardiographic variables including CHA<sub>2</sub>DS<sub>2</sub>-VASc score and LA size. Multivariate logistic regression analysis revealed that every 10 ml/min/1.73 m<sup>2</sup> decrement in eGFR was a significant independent correlate of TM (odds ratio 0.80, p = 0.005), along with nonparoxysmal atrial fibrillation (AF) (odds ratio 0.45, p = 0.004), higher CHA<sub>2</sub>DS<sub>2</sub>-VASc score (odds ratio 1.24, p = 0.012), every 5 ml/m<sup>2</sup> increment in LA volume index (odds ratio 1.57, p <0.001), and every 10% decrement in left ventricular ejection fraction (odds ratio 0.51, p <0.001). In conclusion, CKD may be a significant risk factor for LA thrombus formation in patients with nonvalvular atrial fibrillation. |
18,823 | Management of Refractory Ventricular Fibrillation (Prehospital and Emergency Department). | Ventricular fibrillation is a life-threatening cardiac arrhythmia that leads to a loss of cardiac function and sudden cardiac death. In this review, we summarize therapeutic interventions and guidelines for providers managing patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation in prehospital and emergency settings. Additionally, we review invasive management, including urgent coronary angiography, extracorporeal membrane oxygenation, and novel strategies for managing refractory ventricular fibrillation arrest. Although the majority of patients with refractory VF do not respond to conventional therapy, recent trials of novel strategies demonstrate encouraging results. |
18,824 | Double Sequential Defibrillation. | Ventricular fibrillation (VF) is the most commonly encountered arrhythmia following out-of-hospital cardiac arrest. Previous studies have demonstrated early defibrillation and bystander cardiopulmonary resuscitation as essential in reducing patient mortality. What remains a clinical concern, however, is the treatment of patients experiencing VF refractory to defibrillation. Although current guidelines advocate pharmacotherapy for the management of shock-refractory VF, double sequential defibrillation has become a popular topic of discussion. This article provides a discourse regarding refractory VF, and a review of double sequential defibrillation literature. Further study is required before the recommendation for widespread implementation of this defibrillation technique. |
18,825 | Successful radiofrequency catheter ablation of atrial fibrillation is associated with improvement in left ventricular energy loss and mechanics abnormalities. | Dissipative energy loss (EL), an index of inefficient blood flow, has not been studied in patients with atrial fibrillation (AF). We therefore assessed the effect of AF and of successful catheter ablation on left ventricular (LV) EL and global longitudinal strain (GLS) to explore the effect of inefficient blood flow on LV remodeling. In 53 patients undergoing catheter ablation for AF (AF group), LV EL (in mW/m) was evaluated by vector flow mapping (VFM) during systole (ELsys), early diastole (ELed) and atrial contraction phase (ELac), and GLS was calculated by two-dimensional tissue tracking (2DTT). Of the 53 patients, 37 patients who sustained sinus rhythm and completed echocardiographic evaluation at baseline and at 3 and 6 months follow-up were examined for change in EL and GLS. The latter parameters also were assessed in 44 age- and sex-matched controls. At baseline in AF group, ELsys and ELed were significantly higher (3.97 ± 2.29 vs. 3.14 ± 1.01; and 9.22 ± 5.01 vs. 3.89 ± 1.51; both P < 0.05, respectively), and GLS was lower (- 16.66 ± 3.50 vs. - 19.95 ± 2.40, P < 0.05) than in controls. During follow-up after catheter ablation, ELsys and ELed significantly improved at 3 months, and almost normalized at 6 months (both P < 0.05); GLS also improved significantly (P < 0.05). In multivariate logistic regression analysis, ELed was the only independent predictor for maintenance of sinus rhythm at 1-year follow-up (hazard ratio, 1.254; 95% confidence interval 1.073-1.467). VFM and 2DTT revealed impaired LV EL and GLS in patients with AF. Successful catheter ablation appeared to ameliorate impairment in intraventricular flow and mechanics. |
18,826 | A novel tool to evaluate the implant position and predict defibrillation success of the subcutaneous implantable cardioverter-defibrillator: The PRAETORIAN score. | Suboptimal positioning of the subcutaneous implantable cardioverter-defibrillator (S-ICD) increases the defibrillation threshold and risk of conversion failure.</AbstractText>Our objective is to develop a tool to evaluate the implant position and predict defibrillation success of the S-ICD: the PRAETORIAN score.</AbstractText>The PRAETORIAN score is based on clinical and computer modeling knowledge of determinants affecting the defibrillation threshold: subcoil fat, subgenerator fat, and anterior positioning of the S-ICD generator. The score evaluates these determinants on the postoperative anterior-posterior and lateral chest radiographs and has 3 categories: 30-<90 points representing a low risk, 90-<150 points representing an intermediate risk, and ≥150 points representing a high risk of conversion failure. The score was developed using 2 separate S-ICD data sets for derivation and validation. The performance metrics are the positive and negative predictive values.</AbstractText>The development data set consisted of 181 patients with S-ICD, and the validation cohort consisted of 321 patients from the S-ICD Investigational Device Exemption trial. The distribution of scores was 93%-98% low risk (<90 points), 2%-5% intermediate risk (90-<150 points), and 1% high risk (≥150 points). The positive predictive value for an intermediate or high PRAETORIAN score for a failed conversion test was 51%, while a low PRAETORIAN score predicted a successful conversion in 99.8% of patients.</AbstractText>The PRAETORIAN score allows the identification of patients with high defibrillation thresholds by using the routine chest radiograph and provides feedback to implanters on S-ICD positioning. The PRAETORIAN-DFT trial will prospectively validate the score by randomizing to standard conversion testing vs using the score without conversion testing.</AbstractText>Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,827 | A 67-Year-Old Man With Palpitations During Sleep. | A 67-year-old man with a history of atrial fibrillation (AF) presented to his physician with symptoms of episodic, nighttime palpitations and excessive daytime sleepiness. Four years prior he underwent radiofrequency ablation after a confirmed diagnosis of AF with subsequent resolution of his palpitations. His palpitations returned approximately 1 year following the ablation. These events would occur only at night and awake him from sleep. Holter monitoring showed baseline sinus rhythm with multiple episodes of AF with rates of 75 to 169 beats/min. These events were all nocturnal and correlated with the symptom diary; episodes ranged from 45 min to 2 h. An echocardiogram showed normal left ventricular size and ejection fraction with a mildly enlarged right atrium (4.38 cm) and no evidence of pulmonary hypertension. |
18,828 | Deletion in mice of X-linked, Brugada syndrome- and atrial fibrillation-associated Kcne5 augments ventricular K<sub>V</sub> currents and predisposes to ventricular arrhythmia. | KCNE5 is an X-linked gene encoding KCNE5, an ancillary subunit to voltage-gated potassium (K<sub>V</sub>) channels. Human KCNE5 mutations are associated with atrial fibrillation (AF)- and Brugada syndrome (BrS)-induced cardiac arrhythmias that can arise from increased potassium current in cardiomyocytes. Seeking to establish underlying molecular mechanisms, we created and studied Kcne5 knockout ( Kcne5<sup>-/0</sup>) mice. Intracardiac ECG revealed that Kcne5 deletion caused ventricular premature beats, increased susceptibility to induction of polymorphic ventricular tachycardia (60 vs. 24% in Kcne5<sup>+/0</sup> mice), and 10% shorter ventricular refractory period. Kcne5 deletion increased mean ventricular myocyte K<sub>V</sub> current density in the apex and also in the subpopulation of septal myocytes that lack fast transient outward current ( I<sub>to,f</sub>). The current increases arose from an apex-specific increase in slow transient outward current-1 ( I<sub>Kslow,1</sub>) (conducted by K<sub>V</sub>1.5) and I<sub>to,f</sub> (conducted by K<sub>V</sub>4) and an increase in I<sub>Kslow,2</sub> (conducted by K<sub>V</sub>2.1) in both apex and septum. Kcne5 protein localized to the intercalated discs in ventricular myocytes, where K<sub>V</sub>2.1 was also detected in both Kcne5<sup>-/0</sup> and Kcne5<sup>+/0</sup> mice. In HL-1 cardiac cells and human embryonic kidney cells, KCNE5 and K<sub>V</sub>2.1 colocalized at the cell surface, but predominantly in intracellular vesicles, suggesting that Kcne5 deletion increases I<sub>K,slow2</sub> by reducing K<sub>V</sub>2.1 intracellular sequestration. The human AF-associated mutation KCNE5-L65F negative shifted the voltage dependence of K<sub>V</sub>2.1-KCNE5 channels, increasing their maximum current density >2-fold, whereas BrS-associated KCNE5 mutations produced more subtle negative shifts in K<sub>V</sub>2.1 voltage dependence. The findings represent the first reported native role for Kcne5 and the first demonstrated Kcne regulation of K<sub>V</sub>2.1 in mouse heart. Increased K<sub>V</sub> current is a manifestation of KCNE5 disruption that is most likely common to both mouse and human hearts, providing a plausible mechanistic basis for human KCNE5-linked AF and BrS.-David, J.-P., Lisewski, U., Crump, S. M., Jepps, T. A., Bocksteins, E., Wilck, N., Lossie, J., Roepke, T. K., Schmitt, N., Abbott, G. W. Deletion in mice of X-linked, Brugada syndrome- and atrial fibrillation-associated Kcne5 augments ventricular K<sub>V</sub> currents and predisposes to ventricular arrhythmia. |
18,829 | Prevalence of early repolarization syndrome and long-term clinical outcome in patients with the diagnosis of idiopathic ventricular fibrillation. | Idiopathic ventricular fibrillation (IVF) is diagnosed in up to 14% of sudden cardiac death (SCD) survivors. Early repolarization syndrome (ERS) in patients with ventricular tachyarrhythmia is characterized by an elevated J-point in inferior and/or antero-lateral leads. Our objectives were to determine the prevalence of ERS in IVF patients, and to evaluate potential differences in clinical outcome. Out of 3,552 implantable cardioverter defibrillator (ICD) carriers, 758 SCD survivors were retrospectively identified from the databases of the Medical Universities of Vienna and Innsbruck within the last three decades. Early repolarization pattern (ERP) was classified either as "notching" or "slurring". Endpoints were defined as appropriate ICD therapies for ventricular tachyarrhythmia, either anti-tachycardia pacing or shock, and all-cause mortality. After exclusion of recognized reasons for SCD, 50 patients were assigned to the diagnosis of IVF (6.6%). An ERP was identified in 10 patients, most of them with notching (n = 8). After a mean follow-up of 11.2 ± 6.7 years (539.3 patient years), appropriate ICD therapies were found in 50% of ERS and 43% of IVF patients without ERP (p = 0.732). In ERS patients, all ICD therapies were found in patients with notching pattern. Similarly, incidence of inappropriate ICD therapies, and all-cause mortality was comparable (30% vs. 23%, p = 0.707; 10% vs. 5%, p = 0.496, respectively). In 758 SCD survivors, we found a low prevalence of IVF and ERS. Similar event rates were reported concerning all-cause mortality and ICD therapies for ventricular tachyarrhythmia after long-term follow-up in this cohort. |
18,830 | [Sleep Apnea]. | In 2017 the German Sleep Society (Deutsche Gesellschaft für Schlafforschung und Schlafmedizin, DGSM) published the new S3 guideline "Nonrestorative Sleep/Sleep Disorders, chapter "Sleep-Related Breathing Disorders in Adults".Sleep apnea contributes to an increased morbidity and mortality in patients with cardiovascular diseases, e. g. coronary heart disease, heart failure and diabetes mellitus and is associated with an increased perioperative risk. It is also an important comorbidity in respiratory, neurologic and oncologic diseases. Treatment of sleep apnea can improve daytime sleepiness, quality of life und reduce blood pressure. In patients with atrial fibrillation, obstructive sleep apnea treatment should be optimized to improve treatment results. In addition to CPAP (continuous positive airway pressure) therapy and mandibular advancement devices, there are new therapies (e. g. hypoglossal nerve stimulation). Telemonitoring can help to improved therapy adherence. Nevertheless, in a current study CPAP could not prevent cardiovascular events in patients with moderate-to-severe obstructive sleep apnea and established cardiovascular disease. Patients with predominantly central sleep apnea and systolic hear failure (left ventricular ejection fraction ≤ 45 %) had an increased cardiovascular mortality when treated with adaptive servoventilation. Therefore, ASV is contraindicated in this small group of patients. Further studies are ongoing.<CopyrightInformation>© Georg Thieme Verlag KG Stuttgart · New York.</CopyrightInformation></Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Hetzenecker</LastName><ForeName>Andrea</ForeName><Initials>A</Initials><AffiliationInfo><Affiliation>Zentrum für Pneumologie, Klinik Donaustauf.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Fisser</LastName><ForeName>Christoph</ForeName><Initials>C</Initials><AffiliationInfo><Affiliation>Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Stadler</LastName><ForeName>Stefan</ForeName><Initials>S</Initials><AffiliationInfo><Affiliation>Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Arzt</LastName><ForeName>Michael</ForeName><Initials>M</Initials><AffiliationInfo><Affiliation>Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg.</Affiliation></AffiliationInfo></Author></AuthorList><Language>ger</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList><VernacularTitle>Schlafapnoe.</VernacularTitle><ArticleDate DateType="Electronic"><Year>2018</Year><Month>10</Month><Day>04</Day></ArticleDate></Article><MedlineJournalInfo><Country>Germany</Country><MedlineTA>Dtsch Med Wochenschr</MedlineTA><NlmUniqueID>0006723</NlmUniqueID><ISSNLinking>0012-0472</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D001794" MajorTopicYN="N">Blood Pressure</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005858" MajorTopicYN="N" Type="Geographic">Germany</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D011788" MajorTopicYN="N">Quality of Life</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012891" MajorTopicYN="Y">Sleep Apnea Syndromes</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="ger"><AbstractText Label="UNLABELLED">SCHLAFAPNOE UND KARDIOVASKULäRE ERKRANKUNGEN:  Die Schlafapnoe ist eine häufige Komorbidität, die zu einer erhöhten Morbidität und Letalität bei kardiovaskulären Erkrankungen, wie der koronaren Herzerkrankung, Herzinsuffizienz, Vorhofflimmern und Diabetes mellitus beiträgt. Bei einer kleinen Patientengruppe mit einer überwiegend zentralen Schlafapnoe und einer Herzinsuffizienz mit einer linksventrikulären Ejektionsfraktion im Echokardiogramm von ≤ 45 % ist eine Therapie mit adaptiver Servoventilation kontraindiziert (SERVE-Studie).<AbstractText Label="SCHLAFAPNOE UND DIABETES">Die obstruktive Schlafapnoe stellt einen unabhängigen Risikofaktor dar für die Entwicklung eines Typ-2-Diabetes. Ein signifikanter Effekt einer CPAP-Therapie auf den Glukosestoffwechsel konnte bisher noch nicht nachgewiesen werden.<AbstractText Label="SCHLAFAPNOE UND PNEUMOLOGISCHE ERKRANKUNGEN">Bei Patienten mit Asthma und chronisch obstruktiver Lungenerkrankung (COPD) kann eine zusätzlich vorliegende Schlafapnoe zu vermehrten Exazerbationen führen.<AbstractText Label="SCHLAFAPNOE UND PERIOPERATIVES RISIKO">Die obstruktive Schlafapnoe ist ein perioperativer Risikofaktor. Vor einem chirurgischen Eingriff sollte evaluiert werden, ob eine relevante obstruktive Schlafapnoe vorliegt und entsprechende Sicherheitsmaßnahmen im Rahmen der Intubation und der postoperativen Überwachung eingeleitet werden. Bei elektiven Operationen sollte der Beginn einer PAP (positive airway pressure)-Therapie erwogen werden.<AbstractText Label="SCHLAFAPNOE UND MALIGNE ERKRANKUNGEN">Es besteht ein möglicher Zusammenhang zwischen einer obstruktiven Schlafapnoe und malignen Erkrankungen.<AbstractText Label="SCHLAFAPNOE UND DEMENZ">Bei Patienten mit Demenz kann eine unbehandelte Schlafapnoe zu einem beschleunigten kognitiven Abbau führen. THERAPIEMöGLICHKEITEN:  Neben der klassischen CPAP (continuous positive airway pressure)-Therapie stehen auch neue Therapieoptionen zur Verfügung (z. B. Hypoglossusstimulation). Mit Telemonitoring besteht die Möglichkeit, die Therapieadhärenz zu verbessern. |
18,831 | Venoarterial Extracorporeal Membrane Oxygenation Increased Immune Function of Spleen and Decreased Reactive Oxygen Species During Post-Resuscitation. | We aimed to investigate the effect of venoarterial extracorporeal membrane oxygenation (VA-ECMO) on immune function of the spleen and reactive oxygen species (ROS) during post-resuscitation in a porcine model. After 8 min of untreated ventricular fibrillation and 6 min of basic life support, pigs were randomized into two groups: Group 1 received VA-ECMO and Group 2 received conventional cardiopulmonary resuscitation. After successful return of spontaneous circulation, the hemodynamic status was determined and blood samples were collected at 0, 1, 2, 4, and 6 h. Surviving pigs were euthanized 6 h after return of spontaneous circulation, their spleens were harvested and the T-cells were separated. Then, we investigated immune function parameters of the spleen and ROS levels. VA-ECMO increased the return of spontaneous circulation and 6 h survival rate after return of spontaneous circulation. Compared with the conventional cardiopulmonary resuscitation group, the VA-ECMO group showed increased superoxide dismutase and decreased malondialdehyde and ROS levels. Furthermore, VA-ECMO was associated with a high rate of CD4+ and CD4+/CD8+, high levels of interleukin 2, interferon γ, and interferon γ/interleukin 4, as well as high proliferation of lymphocytes. The apoptotic rate of T-cells was lower in the VA-ECMO group than it was in the conventional cardiopulmonary resuscitation group. VA-ECMO increased immune function of spleen and decreased ROS levels during post-resuscitation. Further research is expected to illustrate whether the differences in immune responses are due to ROS or some other perfusion related effect on spleen. |
18,832 | Mapping and Ablation of Idiopathic Ventricular Fibrillation. | Idiopathic ventricular fibrillation (IVF) is the main cause of unexplained sudden cardiac death, particularly in young patients under the age of 35. IVF is a diagnosis of exclusion in patients who have survived a VF episode without any identifiable structural or metabolic causes despite extensive diagnostic testing. Genetic testing allows identification of a likely causative mutation in up to 27% of unexplained sudden deaths in children and young adults. In the majority of cases, VF is triggered by PVCs that originate from the Purkinje network. Ablation of VF triggers in this setting is associated with high rates of acute success and long-term freedom from VF recurrence. Recent studies demonstrate that a significant subset of IVF defined by negative comprehensive investigations, demonstrate in fact subclinical structural alterations. These localized myocardial alterations are identified by high density electrogram mapping, are of small size and are mainly located in the epicardium. As reentrant VF drivers are often colocated with regions of abnormal electrograms, this localized substrate can be shown to be mechanistically linked with VF. Such areas may represent an important target for ablation. |
18,833 | Long-standing persistent effects of atrial volume reduction combined with pulmonary vein isolation. | Although surgical left atrial (LA) volume reduction combined with mitral valve surgery and/or surgical ablation for atrial fibrillation has been reported to be effective, its long-term outcomes in the absence of mitral procedure are not well established. A 74-year-old man with two previous sternotomies-the first for pericardiectomy due to constrictive pericarditis and the second for mitral valve replacement with mechanical valve and tricuspid annuloplasty-presented with heart failure and thrombus in his giant left atrium (1291 mL), complicated by cerebral infarction. His electrocardiogram showed rate-controlled persistent atrial fibrillation. His mechanical valve was functioning well. A third atrial volume reduction combined with pulmonary vein isolation, without valve surgery, was performed. The postoperative course was uneventful, and the patient has remained asymptomatic with regular junctional rhythm and without any episodes of thromboembolism or re-dilation of LA (approximately 550 mL). His left ventricular filling improved with end-diastolic volume (96 mL vs 140 mL) and forced vital capacity (2.60 L vs 2.89 L) increased. Both remained relatively constant for 6 years. The combination of atrial volume reduction with pulmonary vein isolation prevented thromboembolism, improved left ventricular filling, and continued to improve symptoms associated with heart failure and respiratory condition for 6 years. <<b>Learning objective:</b> The long-term outcomes of surgical left atrial volume reduction combined with ablation for atrial fibrillation in the absence of mitral valve procedure are not well established. We hereby report a case of left atrial volume reduction combined with pulmonary vein isolation, without valve surgery, whose beneficial effects on symptoms associated with heart failure, particularly left ventricular filling, respiratory function, and stroke prevention, have persisted for 6 years postoperatively.>. |
18,834 | Pacemaker malfunction after acute myocardial infarction in a patient with wrap-around left anterior descending artery supplying the right ventricular apex. | A 50-year-old man with a dual-chamber pacemaker was admitted to our hospital complaining of chest pain. Anterior ST segment elevation myocardial infarction (STEMI) was diagnosed. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery (LAD), and primary percutaneous coronary intervention was performed. Angiograms showed that the LAD was wrapped around the apex of both ventricles. On day 8, ventricular fibrillation and cardiopulmonary arrest occurred due to elevation of the pacing threshold because of pacemaker malfunction. The pacemaker was upgraded to an implantable cardioverter-defibrillator and the lead was inserted into the right ventricular septum. Myocardial scintigraphy with thallium-201 and technetium-99m pyrophosphate located the infarct zone around the apex of both ventricles. We conclude that pacing failure of the right ventricular lead occurred in this case of LAD occlusion due to a LAD supplying the right ventricular apex. Clinicians should be aware of the possibility of pacemaker failure in patients presenting with anterior STEMI due to a wrap-around LAD. <<b>Learning objective:</b> Pacemaker failure due to right ventricular lead malfunction can also occur in patients presenting with myocardial infarction of the left coronary arteries. In our case the culprit lesion was located in the left anterior descending artery, which wrapped around the apex to supply parts of the right ventricle.>. |
18,835 | Multiple coronary artery spasms triggering life-threatening ventricular arrhythmia associated with the radiofrequency ablation of ganglionated plexuses of the left atrium. | We report a case of multiple coronary spasms leading to life-threatening ventricular arrhythmia, during left atrium (LA) ablation. Coronary artery spasm is a rare complication during radiofrequency catheter ablation of atrial fibrillation (AF). Previous reports mention that autonomic imbalance leads to coronary artery spasm and ST-segment elevation in the inferior leads, during trans-septal LA catheterization and AF ablation procedures. However, there are few reports detailing the association between ablation sites and changes in the electrocardiogram. We encountered transient ST-segment elevation and refractory ventricular arrhythmia, associated with coronary artery spasm, during radiofrequency ablation of ganglionated plexuses (superior surface of left and right atrium). <<b>Learning objective:</b> Our case report shows that ablation of ganglionated plexus sites during pulmonary vein isolation, can induce ST-segment elevation in various leads, and cause multiple coronary spasms associated with refractory ventricular fibrillation. There is an inherent risk of multiple coronary spasms during catheter ablation of atrial fibrillation (AF), in patients with vasospastic angina. We recommend continuous intravenous infusion of nitroglycerin during ablation for AF to prevent coronary spasms in patients with vasospastic angina.>. |
18,836 | Ablate and his bundle pace. | Atrioventricular junction (AVJ) ablation and pacing therapy is a safe and effective method to control heart rate in patients with atrial fibrillation and rapid ventricular rates who have failed pharmacologic rate control therapies. Usually, the pacing lead of the pacemaker is located at the right ventricular apex or septum, and sometimes the patient has a cardiac resynchronization therapy device with an additional lead implanted through the coronary sinus for left ventricular pacing. We present a 72-year-old woman with permanent atrial fibrillation who developed tachycardia-induced cardiomyopathy. She underwent AVJ ablation following pacemaker implantation with a single lead located at the His bundle region resulting in significant clinical and hemodynamic improvement at follow-up. <<b>Learning objective:</b> We present a case report of a 72-year-old woman with permanent atrial fibrillation who developed tachycardia-induced cardiomyopathy. She underwent atrioventricular junction ablation following pacemaker implantation with a single lead located at the His bundle region, as an alternative to the standard right ventricular apical pacing, with significant clinical and hemodynamic improvement at follow-up.>. |
18,837 | An African loss-of-function CACNA1C variant p.T1787M associated with a risk of ventricular fibrillation. | Calcium regulation plays a central role in cardiac function. Several variants in the calcium channel Ca<sub>v</sub>1.2 have been implicated in arrhythmic syndromes. We screened patients with Brugada syndrome, short QT syndrome, early repolarisation syndrome, and idiopathic ventricular fibrillation to determine the frequency and pathogenicity of Ca<sub>v</sub>1.2 variants. Ca<sub>v</sub>1.2 related genes, CACNA1C, CACNB2 and CACNA2D1, were screened in 65 probands. Missense variants were introduced in the Ca<sub>v</sub>1.2 alpha subunit plasmid by mutagenesis to assess their pathogenicity using patch clamp approaches. Six missense variants were identified in CACNA1C in five individuals. Five of them, A1648T, A1689T, G1795R, R1973Q, C1992F, showed no major alterations of the channel function. The sixth C-terminal variant, Ca<sub>v</sub>α<sub>1c</sub>-T1787M, present mostly in the African population, was identified in two patients with resuscitated cardiac arrest. The first patient originated from Cameroon and the second was an inhabitant of La Reunion Island with idiopathic ventricular fibrillation originating from Purkinje tissues. Patch-clamp analysis revealed that Ca<sub>v</sub>α<sub>1c</sub>-T1787M reduces the calcium and barium currents by increasing the auto-inhibition mediated by the C-terminal part and increases the voltage-dependent inhibition. We identified a loss-of-function variant, Ca<sub>v</sub>α<sub>1c</sub>-T1787M, present in 0.8% of the African population, as a new risk factor for ventricular arrhythmia. |
18,838 | Improvement of left ventricular function after successful radiofrequency catheter ablation in persistent atrial fibrillation with preserved left ventricular ejection fraction: a comprehensive echocardiographic assessment using two-dimensional speckle tracking analysis. | A limited number of studies have investigated the effects of radiofrequency catheter ablation (RFCA) on left ventricular (LV) function and the left atrial (LA) size in patients with atrial fibrillation (AF). The purpose of this study was to conduct a comprehensive assessment of LV function in patients with AF with preserved left ventricular ejection fraction (LVEF) before and after RFCA.</AbstractText>A total of 30 consecutive patients with no recurrences after RFCA for persistent AF (age, 57.7 ± 8.4 years) were enrolled. Transthoracic echocardiography was performed at the baseline and 6 months after the final RFCA using speckle tracking derived LV strain analysis.</AbstractText>After RFCA, we measured decreases in the LA volume index (33.7 ± 10.4 ml/m2</sup> vs. 24.6 ± 8.6 ml/m2</sup>, p < 0.0001), while we observed improvements in systolic indices such as LVEF (56.8 ± 9.8% vs. 65.1 ± 9.1%, p < 0.0001), global longitudinal strain (- 16.8 ± 4.4% vs. - 18.8 ± 3.4%, p = 0.0055) and twist (8.12 ± 3.66° vs. 12.33 ± 6.75°, p = 0.0050), and also in diastolic indices such as strain rate during early diastole (SRE</sub>) (0.73 ± 0.10 s-1</sup> vs. 1.32 ± 0.29 s-1</sup>, p < 0.0001) and early transmitral inflow velocity (E)/SRE</sub> (1.11 ± 0.36 m vs. 0.61 ± 0.19 m, p < 0.0001). Logistic regression analysis showed that ΔE/SRE</sub> was a contributing factor for improvement in LVEF (odds ratio 126.9; p = 0.021).</AbstractText>In persistent AF with preserved LVEF, further improvement in LVEF and reverse remodeling of the LA are achieved after RFCA. LV filling pressure may play significant roles in the mechanisms.</AbstractText> |
18,839 | Association Between Therapeutic Hypothermia and Outcomes in Patients with Non-shockable Out-of-Hospital Cardiac Arrest Developed After Emergency Medical Service Arrival (SOS-KANTO 2012 Analysis Report). | <AbstractText Label="BACKGROUND/OBJECTIVE">The outcomes of patients with non-shockable out-of-hospital cardiac arrest (non-shockable OHCA) are poorer than those of patients with shockable out-of-hospital cardiac arrest (shockable OHCA). In this retrospective study, we selected patients from the SOS-KANTO 2012 study with non-shockable OHCA that developed after emergency medical service (EMS) arrival and analyzed the effect of therapeutic hypothermia (TH) on non-shockable OHCA patients.</AbstractText>Of 16,452 patients who have definitive data on the 3-month outcome in the SOS-KANTO 2012 study, we selected 241 patients who met the following criteria: age ≥ 18 years, normal spontaneous respiration or palpable pulse upon emergency medical services arrival, no ventricular fibrillation or pulseless ventricular tachycardia before hospital arrival, and achievement of spontaneous circulation without cardiopulmonary bypass. Patients were divided into two groups based on the presence or absence of TH and were analyzed.</AbstractText>Of the 241 patients, 49 underwent TH. Univariate analysis showed that the 1-/3-month survival rates and favorable 3-month cerebral function outcome rates in the TH group were significantly better than the non-TH group (46% vs 19%, respectively, P < 0.001, 35% vs 12%, respectively, P < 0.001, 20% vs 7%, respectively, P = 0.01). Multivariate logistic regression analysis showed that TH was a significant, independent prognostic factor for cerebral function outcome.</AbstractText>In this study, TH was an independent prognostic factor for the 3-month cerebral function outcome. Even in patients with non-shockable OHCA, TH may improve outcome if the interval from the onset of cardiopulmonary arrest is relatively short, and adequate cardiopulmonary resuscitation is initiated immediately after onset.</AbstractText> |
18,840 | Positive impact of pulmonary vein isolation on biventricular pacing in nonresponders to cardiac resynchronization therapy. | Cardiac resynchronization therapy (CRT) is less effective in patients with atrial fibrillation (AF) because of impaired ventricular CRT capture.</AbstractText>We investigated the effects of catheter ablation in patients with AF and previous nonresponse to CRT.</AbstractText>Consecutive patients with AF and CRT nonresponse who underwent catheter ablation for AF were analyzed. CRT nonresponse was defined as one of the following: (1) reduced biventricular capture <95% due to rapidly conducted AF, (2) <1 point improvement in New York Heart Association (NYHA) class after CRT implantation, or (3) insufficient increase in left ventricular ejection fraction (LVEF; ≤5%) after CRT implantation.</AbstractText>Thirty-eight patients (8 women [21%]; mean age 68 ± 10 years; LVEF 30% ± 7%, biventricular capture 88.0% [25th, 75th percentile 75.3%, 98.5%]) underwent catheter ablation. One major and 1 minor complication occurred (1 lethal atrioesophageal fistula and 1 hemodynamically nonrelevant pericardial effusion). The Kaplan-Meier estimates for arrhythmia-free survival after single and multiple ablation procedures were 29% (95% confidence interval 16%-51%) and 67% (95% confidence interval 53%-86%) after 24 months. After a median follow-up of 817 days (25th, 75th percentile 179, 1741 days), biventricular capture and LVEF were significantly higher (median [25th, 75th percentile] 99% [96%, 99%], difference 8% [0.2%, 3.75%], P < .0001; mean 32.1% ± 9.1%, difference 2.2% ± 7.1%, P = .0225) and patients had a significantly lower functional NYHA class (28 of 37 patients with improvement of at least 1 point; P < .0001).</AbstractText>Catheter ablation of AF significantly improves CRT response in patients with heart failure and concomitant AF in terms of increased biventricular capture and LVEF and improved functional NYHA class.</AbstractText>Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,841 | Association of oral ciprofloxacin, levofloxacin, ofloxacin and moxifloxacin with the risk of serious ventricular arrhythmia: a nationwide cohort study in Korea. | To evaluate whether oral ciprofloxacin, levofloxacin, ofloxacin and moxifloxacin increase the risk of ventricular arrhythmia in Korea's general population.</AbstractText>Population-based cohort study using administrative claims data on a national scale in Korea.</AbstractText>All primary, secondary and tertiary care settings from 1 January 2015 to 31 December 2015.</AbstractText>Patients who were prescribed the relevant study medications at outpatient visits.</AbstractText>Each patient group that was prescribed ciprofloxacin, levofloxacin, ofloxacin or moxifloxacin was compared with the group that was prescribed cefixime to assess the risk of serious ventricular arrhythmia (ventricular tachycardia, fibrillation, flutter and cardiac arrest). Using logistic regression analysis with inverse probability of treatment weighting using the propensity score, OR and 95% CI for serious ventricular arrhythmia were calculated for days 1-7 and 8-14 after the patients commenced antibiotic use.</AbstractText>During the study period, 4 888 890 patients were prescribed the study medications. They included 1 466 133 ciprofloxacin users, 1 141 961 levofloxacin users, 1 830 786 ofloxacin users, 47 080 moxifloxacin users and 402 930 cefixime users. Between 1 and 7 days after index date, there was no evidence of increased serious ventricular arrhythmia related to the prescription of ciprofloxacin (OR 0.72; 95% CI 0.49 to 1.06) and levofloxacin (OR 0.92; 95% CI 0.66 to 1.29). Ofloxacin had a 59% reduced risk of serious ventricular arrhythmia compared with cefixime during 1-7 days after prescription. Whereas the OR of serious ventricular arrhythmia after the prescription of moxifloxacin was 1.87 (95% CI 1.15 to 3.11) compared with cefixime during 1-7 days after prescription.</AbstractText>During 1-7 days after prescription, ciprofloxacin and levofloxacin were not associated with increased risk and ofloxacin showed reduced risk of serious ventricular arrhythmia. Moxifloxacin increased the risk of serious ventricular arrhythmia.</AbstractText>© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
18,842 | Quantitative assessment of myocardial scar heterogeneity using cardiovascular magnetic resonance texture analysis to risk stratify patients post-myocardial infarction. | To determine whether heterogeneity of cardiac scar, as assessed by cardiovascular magnetic resonance (CMR) texture analysis, may provide insight into better risk stratification for patients with previous myocardial infarction (MI).</AbstractText>Patients with previous MI (n=76) were followed for a median of 371.5 days after late gadolinium enhancement (LGE) CMR. The primary endpoint was a composite of ventricular tachycardia, ventricular fibrillation, or unexplained syncope. Areas of LGE were identified and manually segmented on a short-axis projection. The characteristics of the scar heterogeneity were evaluated via CMR texture analysis. This is a filtration-histogram technique, where images are filtered using the Laplacian of a Gaussian filter to extract features different sizes (2-6 mm in radius) corresponding to fine, medium, and coarse texture scales followed by a quantification step using histogram analysis (skewness and kurtosis).</AbstractText>Patients suffering arrhythmic events during the follow-up period demonstrated significantly higher kurtosis (coarse-scale, p=0.005) and lower skewness (fine-scale, p=0.046) compared to those suffering no arrhythmic events. Furthermore, Kaplan-Meier analysis showed significantly higher coarse kurtosis (p=0.004), and lower fine skewness (p=0.035) were able to predict increased incidence of ventricular arrhythmic events.</AbstractText>In this pilot study, indices of texture analysis reflecting textural heterogeneity were significantly associated with a greater incidence of arrhythmic events. Further work is required to delineate the role of texture analysis techniques in risk stratification post-MI.</AbstractText>Copyright © 2018. Published by Elsevier Ltd.</CopyrightInformation> |
18,843 | AV hysteresis causing initiation of recurrent atrial arrhythmias. | A 73-year-old male with dual-chamber implantable cardioverter defibrillator (Teligen, Boston Scientific, Marlborough, MA, USA) had multiple episodes of automatic mode switch (AMS) during clinical follow-up. Over 50% of these demonstrated a similar pattern of initiation. AV Search+ in combination with sensor rate pacing can cause short-coupled atrial paced intervals that can be proarrhythmic. After programming changes were made AMS burden has significantly decreased. |
18,844 | Pulmonary Congestion Complicating Atrial Fibrillation Cardioversion. | Acute pulmonary congestion (APC) may occur within hours after electrical cardioversion of atrial fibrillation (AF). There is scarce data about its incidence, risk factors, and the outcome. In the present study, data of consecutive patients admitted for first electrical cardioversion for AF between 2007 and 2016 were retrospectively reviewed. APC within the 48 hours following cardioversion was defined as dyspnea and at least one of the following: drop in saturation to <90%, administration of intravenous diuretic or an emergent chest X-ray with new pulmonary congestion. All-cause mortality was determined from the national registry. Total of 1,696 patients had first cardioversion for AF, of whom 66 (3.9%) had APC. In a multivariate logistic regression model independent predictors of APC included (OR [CI], p): older age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.02 to 1.08, p = 0.001), rapid ventricular response (OR 1.98, 95% CI 1.17 to 3.34, 0.010), previous heart failure (OR 3.53, 95% CI 2.09 to 5.97, p <0.001), Amiodarone loading (OR 2.38, 95% CI 1.18 to 4.79, p = 0.016) and diabetes mellitus (OR 1.77 95% CI 1.05 to 3.00, p = 0.033). There was no difference in cardioversion success rate (overall 94%). In-hospital mortality was 1.5% within the APC group and 0.5% without (p = 0.301). Patients with APC had higher rate of 6-month readmissions (28.8% vs 18.1% p <0.028). Within a median follow-up of 2.9 years, APC following cardioversion was an independent predictor of overall mortality (hazard ratio 1.73, 95% CI (1.17 to 2.56) p = 0.006). In conclusion, APC occurs in 3.9% of hospitalized patients following electrical AF cardioversion. Risk factors include increased age, diabetes mellitus, heart failure, Amiodarone loading and rapid ventricular response. APC following cardioversion is associated with increased rates of readmissions and mortality. |
18,845 | A retrospective study on atrial fibrillation after coronary artery bypass grafting surgery at The National Heart Institute, Kuala Lumpur. | <b>Background:</b> Atrial fibrillation (AF) is common after cardiac surgery and has been associated with poor outcome and increased resource utilization. The main objective of this study is to determine the incidence of POAF in Malaysia and identify the predictors of developing POAF. The secondary outcome of this study would be to investigate the difference in mortality and morbidity rates and the duration of intensive care unit (ICU), high dependency unit (HDU) and hospital stay between the two. <b>Methods:</b> This is a retrospective single-center, cross sectional study conducted at the National Heart Institute, Malaysia. Medical records of 637 who underwent coronary artery bypass grafting (CABG) surgery in 2015 were accrued. Pre-operative, operative and post-operative information were subsequently collected on a pre-formulated data collection sheet. Data were then analyzed using IBM SPSS v23. <b>Results:</b> The incidence of POAF in our study stands at 28.7% with a mean onset of 45±33 hours post operatively. Variables with independent association with POAF include advancing age, Indian population, history of chronic kidney disease, left ventricular ejection fraction and beta-blocker treatment. The mortality rate is significantly higher statistically ( <i>p</i> < 0.05), and similarly the incidence of stroke. The incidence of other post-operative complications was also significantly higher statistically. The duration of ICU, HDU and hospital stays were statistically longer ( <i>p</i> < 0.001) with higher rates of ICU readmissions and reintubations seen. <b>Conclusion:</b> We conclude that the incidence of POAF in Malaysia is comparable to the figures in Western countries, making POAF one of the most commonly encountered condition after CABG with similar higher rates of mortality, poor outcomes and longer duration of stay, and therefore increased cost of care. Strategies to reduce the incidence of AF after cardiac surgery should favorably affect surgical outcomes and reduce utilization of resources and thus lower cost of care. |
18,846 | Effects of dronedarone on all-cause mortality and on cardiovascular events in patients treated for atrial fibrillation: a meta-analysis of RCTs. | The efficacy and safety profiles of the dronedarone were rather praised when the molecule was placed on the market (2009). However, there are today some safety concerns (in particular, risk of liver toxicity) that have led to limit the use of this drug to paroxysmal or persistent atrial fibrillation, and to exclude it from therapy protocols for ventricular tachyarrhythmias. The aim of the present study was to explore some efficacy and safety endpoints concerning dronedarone, by analyzing the evidence derived from quantitative evaluation (meta-analysis) of literature data.</AbstractText>We comprised in the meta-analysis exclusively randomized controlled trials (RCTs) that reported relevant clinical outcomes with dronedarone. In addition, eligible RCTs had to have randomized 100 patients at least in order to have adequate statistical power, and they had to have clearly reported the outcomes of interest. Primary efficacy outcomes were a) all-cause mortality,b) major acute cardiovascular events and c) worsening heart failure. Secondary outcomes of interest were ventricular tachyarrhythmias, stroke and systemic embolism. We performed a number of sensitivity analyses to better ascertain the sources of heterogeneity. We also performed a number of subgroup analyses.</AbstractText>At the end of the selection process, the studies regarded suitable for meta-analysis were seven. Dronedarone use was not associated with any significant advantage as regards all-cause mortality(pooled odds ratio =1.31; 95% CI: 0.78 to 2.18; P= 0.31) and major cardiovascular events (pooled odds ratio=1.45; 95% CI: 0.7 to 3.01; P=0.28), as well as regarding the endpoint" worsening heart failure" (pooled odds ratio =1.32; 95% CI: 0.87 to 2.01; P= 0.20). Moreover, using subgroup analyses, in patients with permanent AF, dronedarone use was associated with increased all-cause mortality compared to placebo(P=0.03),as well as with higher risk of major acute cardiovascular events (P=0.04) and episodes of worsening heart failure(P=0.02). In addition, when data from ATHENA study were excluded, dronedarone use was associated with increased all-cause mortality (post exclusion pooled odds ratio=1.77; 95% CI: 1.15 to 2.72; P=0.0089), increased risk of major cardiovascular events (post exclusion pooled odds ratio=2.16; 95% CI: 1.34 to 3.47; P= 0.0014) and increased risk of worsening heart failure(post exclusion pooled odds ratio= 1.618; 95% CI: 1.14 to 2.3; P=0.006).</AbstractText>In our meta-analysis, dronedarone did not provide any significant benefit with regard to all-cause mortality and major cardiovascular events, as well as regarding the risk of worsening heart failure. Sensitivity analyses then showed that the exclusion of a study, namely ATHENA study, caused a shift in the overall odds ratio, so as to convert the dronedarone use to the ominous role of predictor of higher mortality, worse cardiovascular morbidity and increased risk of worsening heart failure. Thus, dronedarone should be used with caution as second-line medication and exclusively for the secondary prevention of paroxysmal or persistent atrial fibrillation, in patients without signs or symptoms of cardiac decompensation, preferably for limited periods of time and under assiduous clinical and laboratory surveillance.</AbstractText> |
18,847 | Posaconazole-digoxin drug-drug interaction mediated by inhibition of P-glycoprotein. | Drug-drug interactions between digoxin and the triazole antifungal agents, mediated via various cytochrome P450 isozymes, have been described in the literature. Posaconazole is not extensively metabolized by these isozymes but is both a p-glycoprotein (P-gp) substrate and inhibitor. To our knowledge, there have been no published cases of clinically significant posaconazole-digoxin drug-drug interactions. We report an interaction between posaconazole (300 mg by mouth daily) and digoxin (0.25 mg by mouth daily, Monday through Friday) resulting in atrial fibrillation with slow ventricular response and degenerating into polymorphic ventricular tachycardia. |
18,848 | Risk of Left Atrial Enlargement in Obese Patients With Obesity-Induced Hypoventilation Syndrome vs Obstructive Sleep Apnea. | Obstructive sleep apnea (OSA) is a known risk factor for atrial fibrillation (AF) that is principally driven by left atrial enlargement. The impact of hypoventilation caused by obesity-induced hypoventilation syndrome (OHS) on left atrial diameter has not been examined. We investigated the association between OHS and left atrial diameter in obese patients.</AbstractText>We performed a retrospective review of 210 consecutive medical records of patients diagnosed as obese (body mass index [BMI] >30 kg/m2</sup>) and as having OHS and OSA for the period January 2010 through December 2016 at St. Vincent Charity Medical Center in Cleveland, OH. Logistic regression analysis was performed for left atrial diameter ≥4 cm in 2 groups of patients: those with OHS+OSA and those with OSA alone.</AbstractText>A total of 104 obese patients with OHS+OSA and 106 obese patients with OSA alone were identified. Statistically significant differences were found in 6 demographic and baseline characteristics: median BMI, median left atrial diameter, history of type 2 diabetes mellitus, history of stroke, history of coronary artery disease, and history of congestive heart failure. The median left atrial diameter for the OHS+OSA and OSA alone groups was 4.45 cm and 4.20 cm, respectively (P</i> = 0.014). Left ventricular ejection fraction <50% was found in 22% of the patients with OHS+OSA and in 21% of the patients with OSA alone (P</i> = 0.777). Multivariate logistic regression analysis showed that patients in the OHS+OSA group had 2 times higher odds (odds ratio 2.151, 95% confidence interval 1.016-4.550, P</i> = 0.045) of exhibiting a larger left atrial diameter vs patients in the OSA alone group.</AbstractText>The results of this study indicate that OHS may be an independent risk factor for left atrial enlargement and may possibly contribute to AF development irrespective of left ventricular function.</AbstractText> |
18,849 | Amiodarone plus Ranolazine for Conversion of Post-Cardiac Surgery Atrial Fibrillation: Enhanced Effectiveness in Reduced Versus Preserved Ejection Fraction Patients. | Ranolazine (RAN) added to amiodarone (AMIO) has been shown to accelerate termination of postoperative atrial fibrillation (POAF) following coronary artery bypass surgery in patients without heart failure (HF). This study aimed to investigate if treatment efficacy with AMIO or AMIO + RAN differs between patients with concomitant HF with reduced or preserved ejection fraction (HFrEF or HFpEF).</AbstractText>Patients with POAF and HFrEF (n = 511, 446 males; 65 ± 9 years) and with HFpEF (n = 301, 257 males; 66 ± 10 years) were enrolled. Onset of AF occurred 2.15 ± 1.0 days after cardiac surgery, and patients within each group were randomly assigned to receive either AMIO monotherapy (300 mg in 30 min + 1125 mg in 36 h iv) or AMIO+RAN combination (500 mg po + 375 mg, after 6 h and 375 mg twice daily thereafter). Primary endpoint was the time to conversion of POAF within 36 h after initiation of treatment.</AbstractText>AMIO restored sinus rhythm earlier in HFrEF vs. in HFpEF patients (24.3 ± 4.6 vs. 26.8 ± 2.8 h, p < 0.0001). AMIO + RAN converted POAF faster than AMIO alone in both HFrEF and HFpEF groups, with conversion times 10.4 ± 4.5 h in HFrEF and 12.2 ± 1.1 h in HFpEF patients (p < 0.0001). Left atrial diameter was significantly greater in HFrEF vs. HFpEF patients (48.2 ± 2.6 vs. 35.2 ± 2.9 mm, p < 0.0001). No serious adverse drug effects were observed during AF or after restoration to sinus rhythm in any of the patients enrolled.</AbstractText>AMIO alone or in combination with RAN converted POAF faster in patients with reduced EF than in those with preserved EF. Thus, AMIO + RAN seems to be a valuable alternative treatment for terminating POAF in HFrEF patients.</AbstractText> |
18,850 | [Bachmann bundle pacing]. | In pacemaker and ICD therapy, atrial leads are usually implanted in the right atrial appendage (RAA). This is easy but associated with a risk of negative hemodynamic and electrophysiological effects. Atrial depolarization, atrial contraction, and atrioventricular conduction can be delayed and desynchronized by RAA pacing leading to atrial fibrillation, pacing-induced long first-degree AV block, right ventricular pacing and the development of heart failure. High-septal atrial pacing near Bachmann's bundle that connects the right and left atrium can prevent the negative effects of RAA pacing and synchronize atrial excitation as demonstrated by the shortening of the PQ time and P wave duration during Bachmann bundle pacing. This review presents techniques to implant atrial leads at Bachmann's bundle. Apart from fluoroscopy in left anterior oblique projection, no additional effort compared to RAA implantation is required. Clinical studies on Bachmann bundle pacing are sparse; our own results suggest beneficial effects in patients with sick sinus syndrome and paroxysmal atrial fibrillation who receive atrial pacing for ≥50% of the time. Bachmann bundle pacing represents an interesting and simple option for atrial pacing. It is desirable to make this technique known to a wider spectrum of implanters and to generate more data on its clinical potential. |
18,851 | Role of Cardiac Magnetic Resonance Imaging in Patients with Idiopathic Ventricular Arrhythmias. | Ventricular Arrhythmias (VAs) may present with a wide spectrum of clinical manifestations ranging from mildly symptomatic frequent premature ventricular contractions to lifethreatening events such as sustained ventricular tachycardia, ventricular fibrillation and sudden cardiac death. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias which are commonly associated with Structural Heart Diseases (SHD) such as ischemic heart disease, healed myocarditis and non-ischemic cardiomyopathies. However, the arrhythmogenic substrate may remain unclear in up to 50% of the cases after a routine diagnostic workup, comprehensive of 12-lead surface ECG, transthoracic echocardiography and coronary angiography/ computed tomography. Whenever any abnormality cannot be identified, VAs are referred as to "idiopathic". In the last decade, Cardiac Magnetic Resonance (CMR) imaging has acquired a growing role in the identification and characterization of myocardial arrhythmogenic substrate, not only being able to accurately and reproducibly quantify biventricular function, but, more importantly, providing information about the presence of myocardial structural abnormalities such as myocardial fatty replacement, myocardial oedema, and necrosis/ fibrosis, which may otherwise remain unrecognized. Moreover, CMR has recently demonstrated to be of great value in guiding interventional treatments, such as radiofrequency ablation, by reliably identifying VA sites of origin and improving long-term outcomes. In the present manuscript, we review the available data regarding the utility of CMR in the workup of apparently "idiopathic" VAs with a special focus on its prognostic relevance and its application in planning and guiding interventional treatments. |
18,852 | Initial experience with a leadless pacemaker (Micra™) implantation in a low volume center in South East Asia. | <b>Aim:</b> The Micra™ Transcatheter Pacing System is a leadless pacemaker that has been introduced recently. We share our experience in a low volume center and the use of right ventricular angiography (RVA) during implantation. <b>Materials & methods:</b> Patients underwent Micra implantation and RVA was performed to predetermine the implant site.<b>Results:</b> Nine patients underwent Micra implantation. The most common indication was atrial fibrillation with bradycardia. The device was implanted at apical-septum in seven and mid-septum in two. The procedure time ranged from 30 to 100 min and fluoroscopic time 4-18 min. Pacing parameters remained stable after 1-month follow-up. <b>Conclusion:</b> The Micra implantation technique can be easily learnt. RVA was helpful in selecting an appropriate site for the Micra implant. |
18,853 | Delayed ventricular pacing failure and correlations between pacing thresholds, left ventricular ejection fraction, and QTc values in a male with Takotsubo cardiomyopathy. | Transient pacing failure caused by transient increased pacing threshold has been reported in patients with transient left ventricular apical dysfunction (Takotsubo cardiomyopathy [TC]). Normal pacing thresholds usually recover after normalization of systolic dysfunction.</AbstractText>Pacing failure correlates with clinics of TC.</AbstractText>We report the case of a 76-year-old man with a dual chamber pacemaker, admitted for acute chest pain and dyspnea and final diagnosis of TC. One month after index admission, the patient came back complaining again of chest pain. Unexpectedly, admission electrocardiogram showed ventricular pacing failure and an increased pacing threshold. In the following weeks, pacing threshold gradually recovered with left ventricular ejection fraction and QTc values.</AbstractText>Ventricular pacing threshold correlated directly to QTc values and inversely to left ventricular ejection fraction over time (P < 0.05).</AbstractText>This is one of the first cases of delayed transient ventricular pacing failure in a male patient with transient left ventricular apical ballooning, in the presence of spared right ventricular function. Given the possibility of acute transient anomalies in myocardial impedance and pacing failure even in the subacute phase of TC several weeks after clinical onset of transient systolic dysfunction, pacing threshold should be carefully monitored in subjects with TC, both during the acute phase of the disease and in first months of follow-up after discharge. Ventricular pacing threshold correlated directly to QTc values and inversely to left ventricular ejection fraction over time.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,854 | Sudden death by arrythmia in a 4-year-old boy. | Cardiac arrhythmia with sudden death is rare in children but mainly due to ventricular tachycardia. In case of pulseless ventricular tachycardia, prehospital treatment is crucial with immediate cardiopulmonary resuscitation and external electrical cardioversion. We report the case of pulseless ventricular tachycardia in a child with no past medical history. Sinus rhythm was obtained after 12min of cardiorespiratory resuscitation and three external electrical shocks. An exhaustive diagnostic approach allow us to find its origin. The clinical progression was marked by a severe encephalopathy. The authors discuss different etiologies and treatment of arrhythmia in children, reviewing the pediatric algorithm for shockable rhythm. |
18,855 | Reverse left ventricular structural remodeling after catheter ablation of atrial fibrillation in patients with preserved left ventricular function: Insights from cardiovascular magnetic resonance native T1 mapping. | Catheter ablation of atrial fibrillation (AF) improves left ventricular (LV) function in patients with LV systolic dysfunction, suggestive of underlying arrhythmia-induced adverse remodeling.</AbstractText>The objectives of this study were to evaluate whether arrhythmia-induced LV remodeling occurs in patients with AF and preserved LV systolic function and to assess whether this remodeling is reversible after restoration of sinus rhythm by catheter ablation.</AbstractText>Forty-three patients with AF and preserved LV systolic function (LV ejection fraction 62% ± 7%) underwent cardiovascular magnetic resonance (CMR) imaging before catheter ablation including native T1 mapping using a modified Look-Locker inversion recovery sequence. Twenty-five patients underwent follow-up CMR 3 months after catheter ablation. Twenty-two matched controls without AF underwent the same CMR protocol.</AbstractText>Patients with AF had higher baseline LV native T1 values than did controls (1296 ± 55 ms vs 1243 ± 55 ms; P < .01). During a median follow-up of 9 months (interquartile range 4-14 months), 17 patients (40%) experienced AF recurrence. No differences in baseline T1 values were observed between patients with and without AF recurrence. There was a significant decrease in native T1 values in patients with successful restoration of sinus rhythm after catheter ablation at 3 months of follow-up CMR (1300 ± 45 ms vs 1270 ± 55 ms; P < .01), while they remain unchanged in patients with AF recurrence (1303 ± 51 ms vs 1309 ± 31 ms; P = .64).</AbstractText>These preliminary results suggest that subclinical arrhythmia-induced LV structural remodeling occurs in patients with AF and preserved LV systolic function. This remodeling might be reversible after catheter ablation with successful restoration of sinus rhythm as quantified noninvasively and gadolinium-free by CMR native T1 mapping.</AbstractText>Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,856 | Patients diagnosed with long QT syndrome after repair of congenital heart disease. | Patients with repaired congenital heart disease (CHD) can have both depolarization and repolarization abnormalities. A coexisting long QT syndrome (LQTS) may cause electrical instability in these patients; however, diagnosing LQTS is difficult owing to intraventricular conduction delay or paced rhythm after the operation. We report on six patients diagnosed with LQTS after CHD repair.</AbstractText>We investigated two male and four female patients. Clinical data, electrocardiographic findings, and genetic analysis results were reviewed.</AbstractText>The range of patient age at LQTS diagnosis was 1.4-22 years. There were two patients with tetralogy of Fallot, four with septal defect, and one with tricuspid atresia. All patients underwent total correction or a staged operation, without events. The diagnosis of LQTS was made in four asymptomatic patients and two symptomatic patients with recurrent syncope and ventricular fibrillation. During the postoperative follow-up, their median QTc interval and QTc dispersion increased (from 474 and 41 ms preoperatively to 541 and 141 ms postoperatively, respectively; P = 0.043). T-wave notching over three leads was observed in three patients. Genetic analysis showed SCN5A mutation in one, KCNH2 mutation in three, KCNQ1 mutation in one, and no identified mutation in one patient. An implantable cardioverter defibrillator was placed in two patients.</AbstractText>A coexisting LQTS may confer additional risk for arrhythmia and sudden cardiac death in patients with CHD. Suspicion of LQTS and careful monitoring of the QT interval and T-wave morphology are important during the follow-up of patients with repaired CHD.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,857 | [Coronary spasm a diagnostic and therapeutic challenge]. | Vasospastic angina is a clinical and physio-pathological entity, which has been documented for many years, but its diagnosis is under-estimated despite the fact that though inadequately considered and investigated. This condition is potentially serious and can sometimes trigger severe arrhythmia resulting in ventricular fibrillation and sudden death. This pathology has a higher incidence in Asia, where it is, therefore, better documented with provocative testing being carried out more frequently, while in France, these tests are not sufficiently performed probably due to the fact that they often produce negative findings. Provocative tests with Ergonovine injection should be performed via intra-coronary to improve its sensibility. Should this test become more sensitive and more routinely performed, this condition, which often responds well to medical treatment, could regain appropriate recognition as a coronary disease. |
18,858 | Usefulness of Epicardial Adipose Tissue Volume to Predict Recurrent Atrial Fibrillation After Radiofrequency Catheter Ablation. | Although increasing evidence suggests that epicardial adipose tissue volume (EATV) is associated with post-ablation atrial fibrillation (AF), ranges of EATV predictive of post-ablation recurrence of AF remain unclear. In this study, we evaluated: (1) relationships between EATV and characteristics of AF, (2) impact of EATV on recurrent AF after radiofrequency ablation; , and (3) cut-off point for recurrent AF using a receiver operating characteristic curve. In 218 consecutive symptomatic patients undergoing who underwent ablation for AF (143 paroxysmal AF; 78 persistent AF), the EATV index (EATVI: EATV/body surface area, mL/m<sup>2</sup>) was measured using 320-row multidetector computed tomography. The high EATV group showed specific cardiometabolic derangements as well as left atrial dilatation and left ventricular dysfunction. Multivariate regression analysis showed that the EATVI was an independent predictor of recurrent AF after catheter ablation. High EATV (EATVI ≥ 85 mL/m<sup>2</sup>) or EATVI cutoff ≥116 mL/m<sup>2</sup> can predict recurrent AF after catheter ablation, independent of other risk factors. In conclusion, EATVI was an independent predictor of recurrent AF after catheter ablation; a high EATV tertile or EATVI cutoff may be useful for prediction of recurrent AF after catheter ablation. Future studies should determine the utility of the EATVI in the clinical setting of AF ablation. |
18,859 | Impact of left atrial compliance improvement on functional status after percutaneous mitral valvuloplasty. | Conventional hemodynamic parameters may not accurately predict symptomatic improvement after percutaneous mitral valvuloplasty (PMV). Changes in left heart chamber compliance following adequate relief o0066 mitral stenosis (MS) may be useful in determining functional capacity after PMV. This study aims to determine the acute effects of PMV on compliance of the left heart and whether its changes relate to the patient's functional capacity.</AbstractText>One-hundred thirty-seven patients with severe MS undergoing PMV were enrolled. Left atrial (Ca</sub> ) and left ventricular (Cv</sub> ) compliance were invasively estimated and net atrioventricular compliance (Cav</sub> ) was calculated before and immediately after the procedure. B-type natriuretic peptide (BNP) levels were obtained before and 24 hr after the procedure. The primary endpoint was functional status at 6-month follow-up, and the secondary endpoint was a composite of death, mitral valve (MV) replacement, repeat PMV, new onset of atrial fibrillation, or stroke in patients in whom PMV was successful.</AbstractText>The mean age was 43 ± 12 years, and 119 patients were female (87%). After PMV, Ca</sub> and Cav</sub> improved significantly from 5.3 [IQR 3.2-8.2] mL/mmHg to 8.7 [5.3-19.2] mL/mmHg (P < 0.001) and 2.2 [1.6-3.4] to 2.8 [2.1-4.1] mL/mmHg (P < 0.001), respectively, whereas Cv</sub> did not change (4.6 [3.2-6.8] to 4.4 [3.1-5.6]; P = 0.637). Plasma BNP levels significantly decreased after PMV, with no correlation between its variation and changes in left chamber compliance. At 6-month follow-up, NYHA functional class remained unchanged in 32 patients (23%). By multivariable analyses, changes in Ca</sub> immediately after PMV (adjusted OR 1.42; 95% CI 95% 1.02 to 1.97; P = 0.037) and younger age (adjusted OR 0.95; CI 95% 0.92-0.98; P = 0.004), predicted improvement in functional capacity at 6-month follow-up, independent of postprocedural data. The secondary endpoint were predicted by post-PMV mean gradient (adjusted HR 1.363; 95% CI 95% 1.027-1.809; P = 0.032), and lack of functional improvement at 6-month follow-up (adjusted HR 4.959; 95% 1.708-14.403; P = 0.003).</AbstractText>Ca</sub> and Cav</sub> increase significantly after PMV with no change in Cv</sub> . The improvement of Ca</sub> is an important predictor of functional status at 6-month follow up, independently of other hemodynamic data. Postprocedural mean gradient and lack of short-term symptomatic improvement were predictors of adverse outcome.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,860 | Single incision technique for implantation of subcutaneous implantable cardioverter defibrillators. | Subcutaneous implantable cardioverter defibrillators (S-ICDs) have gained increasing popularity because of certain advantages over transvenous ICDs. However, while conventional ICDs require a single surgical incision to implant, S-ICDS need two or three incisions, making them less appealing.</AbstractText>This study sought out to investigate the feasibility of using a single-incision technique to implant S-ICDs.</AbstractText>Patients qualifying for S-ICDs were considered for a single incision. A single incision is performed by making a left inframammary incision and then the subcutaneous tissue is dissected medially toward the lower sternum. Two sutures are placed in the fascia in the xiphoid area to anchor the lead and a tunneling tool is used to dissect the tissue to place the lead parallel to the sternum. Then subcutaneous tissues are dissected down the lateral chest wall over the muscle fascia to create the pulse generator pocket in the vicinity of the fifth and sixth intercostal spaces and near the mid-axillary line.</AbstractText>Eleven patients (six males and five females) successfully underwent S-ICD implantation with a single incision without acute complications (64% for primary prevention). The mean age is 47.4 ± 15.8 years. There were no lead dislodgements, inappropriate shocks, or any other issues during a median follow-up of 10 months (interquartile range 5-17). One patient had a successful appropriate shock for ventricular fibrillation about one year after device implant.</AbstractText>A single incision for subcutaneous ICDs is feasible and safe in our early experience.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,861 | The effect of nebulized salbutamol on atrial electrical properties in mechanically ventilated critically ill patients - a randomized, double-blind study. | Salbutamol is a short acting beta-2 mimetic commonly used among intensive care unit patients. There are data suggesting that his mechanism of action can be a potential factor triggering arrhythmias. The aim of this study was to assess whether nebulized salbutamol causes systemic effects resulting in electrocardiographic alterations associated with atrial fibrillation occurrence in mechanically ventilated patients.</AbstractText>50 individuals were randomly allocated to receive either 2.5 or 5 mg of nebulized salbutamol for 20 minutes. 60 minutes prior to the start of nebulization, 12 lead surface electrocardiogram has been recorded. Electrocardiographic parameters associated with atrial activity - P wave and PR interval, and their derivates: P wave dispersion and PR interval dispersion were analysed.</AbstractText>Both doses of inhaled salbutamol caused changes of P wave indices - maximal, minimal and mean P wave duration, from simultaneously recorded leads, and concomitant decrease of P wave dispersion. Prolongation of P wave affected predominantly minimal P wave duration (11.93 ms [95% CI: 8.69-15.17]) comparing with maximal P wave duration (2.61 [95% CI: 021-5.43]). Atrio-ventricular conduction - PR interval was also prolonged, however minimal PR interval duration from simultaneously recorded leads was shortened in group receiving 5 mg of salbutamol.</AbstractText>Nebulized salbutamol in ICU patient possess systemic effects which causes changes in P wave indices in surface ECG recordings. This electrophysiological influence may be associated with the increased risk of atrial fibrillation among this group of patients.</AbstractText> |
18,862 | Lessons learned in attempting catheter-based interatrial electrical disconnection for nonpharmacologic rate control of atrial fibrillation or flutter. | Ablation of atrioventricular (AV) conduction and pacemaker implantation is the therapy of last resort for symptomatic atrial tachyarrythmias when rhythm and rate control fail, but is far from ideal. To evaluate whether interatrial electrical disconnection as a result of catheter ablation is feasible and of potential clinical utility as a means of non-pharmacological heart rate control.</AbstractText>Eleven patients with medically refractory atrial fibrillation or left atrial flutter and symptomatic rapid ventricular response were included. The ablation strategy consisted primarily of right atrial ablation of the interatrial electrical connections, which were located by electroanatomical activation maps performed during coronary sinus stimulation. Successive activation maps were performed as each connection was blocked. If the procedure was considered unsuccessful AV nodal ablation was performed.</AbstractText>The coronary sinus ostium was earliest in 10/11 and could be ablated in 5/10 patients. Interatrial conduction block was only achieved in one patient (9.1%). An unexpected AV nodal modulation with an increase in the Wenckebach cycle length (> 50 ms) occurred in 8/11 patients. These patients remained without pacemaker implantation and only 1/8 required AV nodal ablation during the 1-year follow-up. Quality of life questionnaires indicated significant improvement in patients with AV nodal modulation.</AbstractText>Interatrial electrical disconnection by right atrial catheter ablation is a not feasible with present day technology. The extensive right atrial septal ablation performed resulted in significant AV nodal modulation in most patients, which persisted and resulted in improvement in quality of life.</AbstractText> |
18,863 | Mitral valve prolapse and sudden cardiac death: a systematic review and meta-analysis. | Mitral valve prolapse (MVP) is commonly observed as a benign finding. However, the literature suggests that it may be associated with sudden cardiac death (SCD). We performed a meta-analysis and systematic review to determine the: (1) prevalence of MVP in the general population; (2) prevalence of MVP in all SCD and unexplained SCD; (3) incidence of SCD in MVP and (4) risk factors for SCD.</AbstractText>The English medical literature was searched for: (1) MVP community prevalence; (2) MVP prevalence in SCD cohorts; (3) incidence SCD in MVP and (4) SCD risk factors in MVP. Thirty-four studies were identified for inclusion. This study was registered with PROSPERO (CRD42018089502).</AbstractText>The prevalence of MVP was 1.2% (95% CI 0.5 to 2.0) in community populations. Among SCD victims, the cause of death remained undetermined in 22.1% (95% CI 13.4 to 30.7); of these, MVP was observed in 11.7% (95% CI 5.8 to 19.1). The incidence of SCD in the MVP population was 0.14% (95% CI 0.1 to 0.3) per year. Potential risk factors for SCD include bileaflet prolapse, ventricular fibrosis complex ventricular ectopy and ST-T wave abnormalities.</AbstractText>The high prevalence of MVP in cohorts of unexplained SCD despite low population prevalence provides indirect evidence of an association of MVP with SCD. The absolute number of people exposed to the risk of SCD is significant, although the incidence of life-threatening arrhythmic events in the general MVP population remains low. High-risk features include bileaflet prolapse, ventricular fibrosis, ST-T wave abnormalities and frequent complex ventricular ectopy.</AbstractText>PROSPERO (CRD42018089502).</AbstractText>© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.</CopyrightInformation> |
18,864 | New Progress in Understanding the Cellular Mechanisms of Anti-arrhythmic Drugs. | Antiarrhythmic drugs are widely used, however, their efficacy is moderate and they can have serious side effects. Even if catheter ablation is effective for the treatment of atrial fibrillation and ventricular tachycardia, antiarrhythmic drugs are still important tools for the treatment of arrhythmia. Despite efforts, the development of antiarrhythmic drugs is still slow due to the limited understanding of the role of various ionic currents. This review summarizes the new targets and mechanisms of antiarrhythmic drugs. |
18,865 | Electrical parameters for physiological His-Purkinje pacing vary by implant location in an ex vivo canine model. | Permanent His-bundle pacing (HBP) is an attractive, perhaps more physiological, alternative to traditional right ventricular pacing.</AbstractText>The purpose of this study was to utilize direct visualization to more comprehensively understand the anatomy central to HBP, correlating electrical lead performance to implant locations along the His-bundle (HB) pathway.</AbstractText>Canine hearts (n = 5) were isolated and reanimated using Visible Heart methodologies. Medtronic 3830 SelectSecure leads were fixated where His potentials were present. The location of each implant was mapped/binned into 4 regions approximately analogous to the proximal, penetrating, and distal HB. Locational differences in HBP capture and resultant QRS morphology were assessed.</AbstractText>Average HBP capture thresholds did not significantly vary with respect to implant location (1.0-ms pulse width; P = .48). The resulting QRS morphologies from HB-paced beats varied in relation to implant location. As leads were placed further distally along the HB, the ratio of paced to native QRS complex duration increased (ΔQRSpaced</sub>/ΔQRSnative</sub> ratios-region 2: 0.84 ± 0.16; region 3: 1.04 ± 0.42; region 4: 1.74 ± 0.86).</AbstractText>We demonstrated correlation between the anatomic locations of HBP lead placement and resultant QRS morphologies in a reanimated canine heart model. Proximal placement along the HB pathway resulted in more favorable QRS morphologies, suggesting improved selective HBP capture, with no significant increase in HBP capture thresholds. Pacing the HB in more proximal pathway locations improved the selectivity of HBP and may confer electrical and anatomic benefits relative to distal HBP.</AbstractText>Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,866 | Registry report of the prevalence of ECG abnormalities and their relation to patient characteristics in an asymptomatic population. | Cardiovascular disease is the leading cause of morbidity and mortality in developed countries. Many patients do not experience symptoms before a first major cardiovascular event. Resting electrocardiogram (ECG) may help identify asymptomatic individuals with a high risk of cardiovascular disease.</AbstractText>We sought to determine the prevalence of ECG abnormalities in an apparently symptom-free adult population within a prospective registry.</AbstractText>The registry consisted of 4739 consecutive apparently healthy individuals [age 62.8 ± 6.2 (SD) years; 54% female], referred by their General Practitioners between 2009 and 2013. Patient demographics, and clinical data were obtained, alongside blood tests and a resting ECG.</AbstractText>ECG abnormalities were present in 1509 (31.8%) subjects and were commoner with increasing age (F = 0.161, p = 0.01), systolic (F = 0.134, p = 0.01) and diastolic (F = 0.44, p = 0.01) blood pressure and waist circumference (F = 0.53, p = 0.01). Left ventricular hypertrophy (LVH) was the most common abnormality (n = 281) and was positively associated with systolic (F = 0.12, p = 0.01) and diastolic blood pressure (F = 0.99, p = 0.01) and male gender (X2 = 60.5, p < 0.01). All ECG abnormalities (except for LVH) were associated with an increasing age, while right bundle branch block (F = 0.041, p = 0.01) and atrial fibrillation (n = 29; F = 0.036, p = 0.05) were associated with the presence of diabetes mellitus (n = 211). Only left bundle branch block (n = 50) was associated with angina (F = 0.05, p = 0.01).</AbstractText>Unrecognized cardiac abnormalities are common in middle-aged men and women with no overt symptoms. ECG offers the potential to identify these abnormalities and provide earlier intervention and treatment, and possibly improve cardiovascular outcome.</AbstractText> |
18,867 | Absence of natriuretic peptide clearance receptor attenuates TGF-β1-induced selective atrial fibrosis and atrial fibrillation. | TGF-β1 plays an important role in atrial fibrosis and atrial fibrillation (AF); previous studies have shown that the atria are more susceptible to TGF-β1 mediated fibrosis than the ventricles. Natriuretic peptides (NPs) play an important role in cardiac remodelling and fibrosis, but the role of natriuretic peptide clearance (NPR-C) receptor is largely unknown. We investigated the role of NPR-C in modulating TGF-β1 signalling in the atria.</AbstractText>MHC-TGF-β1 transgenic (TGF-β1-Tx) mice, which develop isolated atrial fibrosis and AF, were cross-bred with NPR-C knock-out mice (NPR-C-KO). Transverse aortic constriction (TAC) was performed in wild type (Wt) and NPR-C knockout mice to study. Atrial fibrosis and AF inducibility in a pathophysiologic model. Electrophysiology, molecular, and histologic studies were performed in adult mice. siRNA was used to interrogate the interaction between TGF-β1 and NP signalling pathways in isolated atrial and ventricular fibroblasts/myofibroblasts. NPR-C expression level was 17 ± 5.8-fold higher in the atria compared with the ventricle in Wt mice (P = 0.009). Cross-bred mice demonstrated markedly decreased pSmad2 and collagen expression, atrial fibrosis, and AF compared with TGF-β1-Tx mice with intact NPR-C. There was a marked reduction in atrial fibrosis gene expression and AF inducibility in the NPR-C-KO-TAC mice compared with Wt-TAC. In isolated fibroblasts, knockdown of NPR-C resulted in a marked reduction of pSmad2 (56 ± 4% and 24 ± 14% reduction in atrial and ventricular fibroblasts, respectively) and collagen (76 ± 15% and 35 ± 23% reduction in atrial and ventricular fibroblasts/myofibroblasts, respectively) in response to TGF-β1 stimulation. This effect was reversed by simultaneously knocking down NPR-A but not with simultaneous knock down of PKG-1.</AbstractText>The differential response to TGF-β1 stimulated fibrosis between the atria and ventricle are in part mediated by the abundance of NPR-C receptors in the atria.</AbstractText> |
18,868 | Myocardial Electrical Remodeling and the Arrhythmogenic Substrate in Hemorrhagic Shock-Induced Heart: Anti-Arrhythmogenic Effect of Liposome-Encapsulated Hemoglobin (HbV) on the Myocardium. | Prolonged low blood pressure <40 mmHg in hemorrhagic shock (HS) causes irreversible heart dysfunction, 'Shock Heart Syndrome' (SHS), which is associated with lethal arrhythmias (ventricular tachycardia or ventricular fibrillation [VT/VF]) leading to a poor prognosis.</AbstractText>To investigate whether the liposome-encapsulated human hemoglobin oxygen carrier (HbV) is comparable in effectiveness to autologous washed red blood cells (wRBCs) for improving arrhythmogenic properties in SHS, optical mapping analysis (OMP), electrophysiological study (EPS), and pathological examinations were performed in Sprague-Dawley rat hearts obtained from rats subjected to acute HS by withdrawing 30% of total blood volume. After acute HS, the rats were immediately resuscitated by transfusing exactly the same amount of saline (SAL), 5% albumin (5% ALB), HbV, or wRBCs. After excising the heart, OMP and EPS were performed in Langendorff-perfused hearts.</AbstractText>OMP showed a tendency for abnormal conduction and significantly impaired action potential duration dispersion (APDd) in both ventricles with SAL and 5% ALB. In contrast, myocardial conduction and APDd were substantially preserved with HbV and wRBCs. Sustained VT/VF was easily provoked by a burst pacing stimulus to the left ventricle with SAL and 5% ALB. No VT/VF was induced with HbV and wRBCs. Pathology showed myocardial structural damage characterized by worse myocardial cell damage and Connexin43 with SAL and 5% ALB, whereas it was attenuated with HbV and wRBCs.</AbstractText>Ventricular structural remodeling after HS causes VT/VF in the presence of APDd. Transfusion of HbV prevents VT/VF, similarly to transfusion of wRBCs, by preventing electrical remodeling and preserving myocardial structures in HS-induced SHS.</AbstractText> |
18,869 | Ventricular fibrillation recorded and analysed within an area the size of a mobile phone: could it enable cardiac arrest recognition? | Recognition of out-of-hospital-cardiac arrests (OHCAs) at emergency medical communication centres is based on questions of OHCA symptoms, resulting in 50-80% accuracy rates. However, OHCAs might be recognized more promptly using 'rhythm-based' recognition, whereby a victim's cardiac rhythm is recorded with mobile phone technology that analyses and transmits recordings to emergency medical communication centres for further interpretation.</AbstractText>To examine whether the quality of normal cardiac rhythm and the rhythm with the best prognosis in OHCA, ventricular fibrillation (VF), is sufficient for 'rhythm-based' OHCA recognition when recorded within a mobile phone-sized device.</AbstractText>mid-sternum within an area the size of a mobile phone and analysed by automated external defibrillator (AED) software and two cardiologists. The rhythms were categorized as shockable or nonshockable. The cardiologists assessed the quality of the recordings.</AbstractText>The AED software correctly analysed all normal rhythms and 15 of 22 VF rhythms. The VF duration was too short for automatic detection in seven cases. The cardiologists analysed all the normal rhythms and VF sequences correctly and graded them as high quality.</AbstractText>The recordings of normal ECG rhythm and VF within an area the size of a mobile phone are of sufficient quality and could be used in 'rhythm-based' OHCA recognition. The VF period was too short for an accurate analysis by the AED software in some cases.</AbstractText> |
18,870 | Catheter Ablation of Ventricular Tachycardia in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. | Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is predominantly an inherited cardiomyopathy with typical histopathological characteristics of fibro-fatty infiltration mainly involving the right ventricular (RV) inflow tract, RV outflow tract, and RV apex in the majority of patients. The above pathologic evolution frequently brings patients with ARVD/C to medical attention owing to the manifestation of syncope, sudden cardiac death (SCD), ventricular arrhythmogenesis, or heart failure. To prevent future or recurrent SCD, an implantable cardiac defibrillator (ICD) is highly desirable in patients with ARVD/C who had experienced unexplained syncope, hemodynamically intolerable ventricular tachycardia (VT), ventricular fibrillation, and/or aborted SCD. Notably, the management of frequent ventricular tachyarrhythmias in ARVD/C is challenging, and the use of antiarrhythmic drugs could be unsatisfactory or limited by the unfavorable side effects. Therefore, radiofrequency catheter ablation (RFCA) has been implemented to treat the drug-refractory VT in ARVD/C for decades. However, the initial understanding of the link between fibro-fatty pathogenesis and ventricular arrhythmogenesis in ARVD/C is scarce, the efficacy and prognosis of endocardial RFCA alone were limited and disappointing. The electrophysiologists had broken through this frontier after better illustration of epicardial substrates and broadly application of epicardial approaches in ARVD/C. In recent works of literature, the application of epicardial ablation also successfully results in higher procedural success and decreases VT recurrences in patients with ARVD/C who are refractory to the endocardial approach during long-term follow-up. In this article, we review the important evolution on the delineation of arrhythmogenic substrates, ablation strategies, and ablation outcome of VT in patients with ARVD/C. |
18,871 | Ivabradine Aggravates the Proarrhythmic Risk in Experimental Models of Long QT Syndrome. | Ivabradine has recently been demonstrated to have antiarrhythmic properties in atrial fibrillation. The aim of the present study was to assess the electrophysiologic profile of ivabradine in an experimental whole-heart model of long-QT-syndrome. In 12 isolated rabbit hearts long-QT-2-syndrome (LQT2) was simulated by infusion of D,L-sotalol (100 µM). 12 rabbit hearts were treated with veratridine (0.5 µM) to mimic long-QT-3-syndrome (LQT3). Sotalol induced a significant prolongation of QT-interval (+ 40 ms, p < 0.01) and action potential duration (APD, + 20 ms, p < 0.01). Similar results were obtained in veratridine-treated hearts (QT-interval: +52 ms, p < 0.01; APD: + 41 ms, p < 0.01). Of note, both sotalol (+ 26 ms, p < 0.01) and veratridine (+ 42 ms, p < 0.01) significantly increased spatial dispersion of repolarisation. Additional infusion of ivabradine (5 µM) did not change these parameters in sotalol-pretreated hearts but resulted in a further significant increase of QT-interval (+ 26 ms, p < 0.05) and APD (+ 49 ms, p < 0.05) in veratridine-treated hearts. Lowering of potassium concentration in bradycardic AV-blocked hearts resulted in the occurrence of early afterdepolarizations (EAD) or polymorphic ventricular tachycardias (VT) resembling torsade de pointes in 6 of 12 sotalol-treated hearts (56 episodes) and 6 of 12 veratridine-treated hearts (73 episodes). Additional infusion of ivabradine increased occurrence of polymorphic VT. Ivabradine treatment resulted in occurrence of EAD and polymorphic VT in 9 of 12 sotalol-treated hearts (212 episodes), and 8 of 12 veratridine-treated hearts (155 episodes). Treatment with ivabradine in experimental models of LQT2 and LQT3 increases proarrhythmia. A distinct interaction with potassium currents most likely represents a major underlying mechanism. These results imply that ivabradine should be employed with caution in the presence of QT-prolongation. |
18,872 | Pre-ablation levels of brain natriuretic peptide are independently associated with the recurrence of atrial fibrillation after radiofrequency catheter ablation in patients with nonvalvular atrial fibrillation. | Association between pre-ablation levels of biomarkers of cardiac and endothelial dysfunctions, CHADS2, CHA2DS2-VASc, and APPLE scores and the recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation has not been fully studied. A total of 254 patients with nonvalvular AF were prospectively followed for AF recurrence after a single ablation procedure. During a two-year follow-up period, AF recurred in 65 (25.6%) patients. Patients with AF recurrence had significantly greater baseline ln brain natriuretic peptide (BNP) than those without AF recurrence (P < 0.01), whereas there were no significant differences in the levels of biomarkers of endothelial dysfunction and points of scoring systems. In the Cox regression analyses, the baseline ln BNP was significantly independently associated with AF recurrence (adjusted HR =1.286, 95% CI =1.000-1.655, P < 0.05). The baseline levels of ln BNP were significantly associated with rhythm at blood collection, age, sex, and left atrial diameter, and left ventricular ejection fraction (P < 0.05).The subgroup analysis showed a significant interaction on the risk of AF recurrence between ln BNP, sex difference, and rhythm at blood collection (P for interaction < 0.05). In conclusion, the results suggest that the pre-ablation levels of ln BNP are useful to evaluate the risk of AF recurrence after ablation therapy; however, there is a need to be careful while using BNP as a biomarker for the risk of AF recurrence by taking account of the effects of rhythm status at blood collection and sex difference. |
18,873 | Ventricular arrhythmia and death among atrial fibrillation patients using anti-arrhythmic drugs. | The aim of the study was to assess and compare the safety of antiarrhythmic drugs (AADs) in an unselected real-world population of patients with atrial fibrillation (AF).</AbstractText>This is a study of all patients with diagnosed AF in the Swedish Patient register who filled a prescription for sotalol, amiodarone, dronedarone, flecainide or disopyramide during 2010 to 2015. The main end point consisted of arrhythmic death, successful resuscitation, new diagnosis of sustained ventricular tachycardia, ventricular fibrillation or implantation of ICD. All-cause mortality was a secondary end point. Minimum follow up was 1 year. Falsification end points were used to assess hidden confounding. 44,995 AF patients on AAD and 267,518 AF patients without AAD were studied during a total time at risk of over 1.1 million years. Compared to sotalol, the risk for the main end point was decreased with dronedarone (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.37-0.90), similar with flecainide (HR 0.95, 0.69-1.32) and disopyramide (HR 1.30, CI 0.83-2.05). All-cause mortality was lower with dronedarone (HR 0.44, CI 0.34-0.57) and flecainide (HR 0.55, CI 0.44-0.68) than with sotalol. Hidden confounding prevented reliable assessment of amiodarone.</AbstractText>Dronedarone was the only anti-arrhythmic drug with significantly lower risk for arrhythmic death, sustained ventricular arrhythmia or ICD implantation than sotalol among patients with atrial fibrillation. Both dronedarone and flecainide were associated with lower all-cause mortality than sotalol.</AbstractText>Copyright © 2018 Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,874 | Multifocal Ventricular Arrhythmias Originating From the His-Purkinje System: Incidence, Characteristics, and Outcome of Catheter Ablation. | This study sought to reveal the characteristics and radiofrequency catheter ablation (RFCA) outcomes of multifocal His-Purkinje system (HPS) ventricular arrhythmias (VAs).</AbstractText>The details of those VAs, especially the safety and efficacy of their RFCA treatment, remain unclear.</AbstractText>Thirty consecutive patients who underwent RFCA of focal HPS VAs between 2010 and 2016 (unifocal = 24, multifocal = 6) were studied by measuring the electrophysiological variables within the HPS.</AbstractText>Multifocal premature ventricular contractions (n = 1) and ventricular fibrillation (VF) (n = 5) were identified in the left posterior (n = 6), anterior (n = 4), and septal fascicles (n = 1), as well as the basal left bundle branch (LBB) (n = 2) and right bundle branch (RBB) (n = 2). In 2 patients with unifocal VAs and 4 patients with multifocal VAs, preferential conduction from an origin within the proximal fascicle (n = 4) or LBB (n = 2) to ≤3 breakout sites in the distal fascicles occurred with split or fractionated Purkinje potentials and/or conduction block at the site of origin. Among the multifocal VAs, 11 fascicle VAs, 1 RBB VA, and 1 LBB VA were successfully ablated with fascicular and/or bundle branch block, and complete atrioventricular block (CAVB), respectively. In the remaining LBB VAs and RBB VAs, RFCA was abandoned to avoid CAVB. Recurrence of ablated VAs or the incidence of VF did not differ between the unifocal and multifocal HPS VAs. Freedom from any HPS VA after RFCA was significantly higher in the patients with unifocal VAs than in the patients with multifocal VAs (92% vs. 33%; p = 0.001).</AbstractText>Multifocal HPS VAs could occur and often present with preferential conduction from proximal origins to distal breakout sites within the HPS with abnormal Purkinje potentials and/or conduction properties. RFCA was effective but was limited by the risk of HPS impairment.</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,875 | Clinical Significance of Early Repolarization in Long QT Syndrome. | This study sought to determine the prevalence of early repolarization pattern (ERP) within a large cohort of patients with long QT syndrome (LQTS) and examine the correlation and clinical significance of ERP with symptomatic status and subsequent risk of breakthrough cardiac events (BCEs).</AbstractText>The electrocardiographic ERP is associated with an increased risk of arrhythmic events and sudden cardiac death.</AbstractText>ERP was defined as an end-QRS notch or slur on the downslope of a prominent R-wave with a J point ≥0.1 mV in 2 or more contiguous leads of the 12-lead electrocardiogram, excluding V1 to V3. A patient was considered previously symptomatic if they had a suspected LQTS-triggered cardiac event prior to diagnosis. BCEs were defined as LQTS-attributable syncope/seizures, aborted cardiac arrest, appropriate ventricular fibrillation-terminating implantable cardioverter-defibrillator shocks, and sudden cardiac death following diagnosis and institution of a LQTS-directed treatment program.</AbstractText>In this study, 528 patients (57% female) with genotype-confirmed LQTS (283 with LQT1, 193 with LQT2, and 52 with LQT3) were reviewed from which 2,618 electrocardiograms were analyzed over a median follow-up of 6.7 (interquartile range, 3.6 to 10 years) years. Eighty-two (15.5%; female 51%) patients were identified as having ERP; 40 (50%) of these ERP-positive patients showed persistent ERP. One hundred twenty-four patients (23.5%) were classified as previously symptomatic LQTS and 39 (7.2%) experienced a subsequent BCE. ERP was not associated with either symptomatic status (p = 0.62) or BCE (p = 0.61).</AbstractText>Although ERP is common in LQTS, this extensive study suggests that the presence of concomitant ERP does not correlate with either those with a history of LQTS-triggered events prior to diagnosis or those with subsequent BCEs from their treated LQTS substrate.</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,876 | Impact of Coronary Artery Chronic Total Occlusion on Arrhythmic and Mortality Outcomes: A Systematic Review and Meta-Analysis. | This study aimed to examine the relationship between chronic coronary artery total occlusion (CTO) status and the occurrence of ventricular tachycardia (VT)/ventricular fibrillation (VF) or appropriate implantable cardioverter-defibrillator (ICD) therapy.</AbstractText>CTO is a significant problem in patients with ischemic heart disease. However, the extent to which it predisposes affected individuals to VT/VF and whether these arrhythmic events could be prevented by revascularization are unclear. Therefore, a systematic review and meta-analysis were conducted to examine the relationship between CTO status and the occurrence of VT/VF or appropriate ICD therapy.</AbstractText>PubMed and Embase databases were searched until November 16, 2017, identifying 137 studies.</AbstractText>Seventeen studies involving 54,594 subjects (mean age, 61 ± 21 years of age, 81% male) with a mean follow-up of 43 ± 31 months were included. The presence of CTO was associated with higher risk of VT/VF or appropriate ICD therapy (adjusted hazard ratio [aHR]: 1.99; 95% confidence interval (CI): 1.53 to 2.59; p < 0.0001, I2</sup> = 3%) but not in cardiac mortality (aHR: 2.59; 95% CI: 0.64 to 10.59; p = 0.18, I2</sup> = 86%) or in all-cause mortality (aHR: 1.70; 95% CI: 0.84 to 3.46; p = 0.14; I2</sup> = 64%). Compared to patients with non-infarct-related CTOs, those with infarct-related CTOs have a higher risk of VT/VF or appropriate ICD therapy (aHR: 2.47; 95% CI: 1.76 to 3.46; p < 0.0001; I2</sup> = 14%), cardiac mortality (aHR: 2.73; 95% CI: 1.02 to 7.30; p < 0.05; I2</sup> = 79%) and higher all-cause mortality (aHR: 1.69; 95% CI: 1.19 to 2.40; p < 0.01; I2</sup> = 40%). Nonrevascularization of CTOs tended to be associated with an increased risk of all-cause mortality compared to successful revascularization (unadjusted HR: 1.52; 95% CI: 0.96 to 2.43; p = 0.08; I2</sup> = 76).</AbstractText>CTOs, especially infarct-related, are associated with high risk of VT/VF or appropriate ICD therapy and mortality. ICD implantation could be beneficial. However, it is not clear that revascularization has an impact on the outcome of patients with CTOs.</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,877 | Predictors and Clinical Impact of Late Ventricular Arrhythmias in Patients With Continuous-Flow Left Ventricular Assist Devices. | This study aimed to evaluate the incidence, clinical impact, and predictors of late ventricular arrhythmias (VAs) in left ventricular assist device (LVAD) recipients aiming to clarify implantable cardioverter-defibrillator (ICD) indications.</AbstractText>The arrhythmic risk and need for ICD in patients implanted with an LVAD are not very well known.</AbstractText>This observational study was conducted in 19 centers between 2006 and 2016. Late VAs were defined as sustained ventricular tachycardia or fibrillation occurring >30 days post-LVAD implantation, without acute reversible cause and requiring appropriate ICD therapy, external electrical shock, or medical therapy.</AbstractText>Among 659 LVAD recipients, 494 (median 58.9 years of age; mean left ventricular ejection fraction 20.7 ± 7.4%; 73.1% HeartMate II, 18.6% HeartWare, 8.3% Jarvik 2000) were discharged alive from hospital and included in the final analysis. Late VAs occurred in 133 (26.9%) patients. Multivariable analysis identified 6 independent predictors of late VAs: VAs before LVAD implantation, atrial fibrillation before LVAD implantation, idiopathic etiology of the cardiomyopathy, heart failure duration >12 months, early VAs (<30 days post-LVAD), and no angiotensin-converting enzyme inhibitors during follow-up. The "VT-LVAD score" was created, identifying 4 risk groups: low (score 0 to 1), intermediate (score 2 to 4), high (score 5 to 6), and very high (score 7 to 10). The rates of VAs at 1 year were 0.0%, 8.0%, 31.0% and 55.0%, respectively.</AbstractText>Late VAs are common after LVAD implantation. The VT-LVAD score may help to identify patients at risk of late VAs and guide ICD indications in previously nonimplanted patients. (Determination of Risk Factors of Ventricular Arrhythmias [VAs] after implantation of continuous flow left ventricular assist device with continuous flow left ventricular assist device [CF-LVAD] [ASSIST-ICD]; NCT02873169).</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,878 | Mortality in Patients With Out-of-Hospital Cardiac Arrest Undergoing a Standardized Protocol Including Therapeutic Hypothermia and Routine Coronary Angiography: Experience From the HACORE Registry. | This study sought to analyze the impact of mandatory therapeutic hypothermia and cardiac catheterization in the absence of overt noncardiac cause of arrest as part of the Hannover Cardiac Resuscitation Algorithm before intensive care admission.</AbstractText>Despite advanced therapies, out-of-hospital cardiac arrest (OHCA) is still associated with high mortality rates. Recently, the TTM (Target Temperature Management 33°C Versus 36°C After Out-of-Hospital Cardiac Arrest)-trial caused severe uncertainty about the efficacy of and need for therapeutic hypothermia. Furthermore, the role of early coronary angiography in OHCA survivors without ST-segment elevation remains undetermined.</AbstractText>In the HACORE (HAnnover Cooling REgistry) we investigated 233 consecutive patients (median age 64 [interquartile range: 53 to 74] years) with OHCA admitted to our institution between January 2011 and December 2015 who were treated according to the algorithm.</AbstractText>A total of 73% had ventricular fibrillation as primary rhythm. Return of spontaneous circulation was achieved after 20 (interquartile range: 10 to 30) min. Immediate percutaneous coronary angiography was performed in 96% and coronary angioplasty in 59% of all cases. ST-segment elevation was present in 47%. Critical coronary stenosis requiring percutaneous coronary intervention was present in 67% of patients with and 52% of patients without ST-segment elevation. Overall 30-day intrahospital mortality in this real-world registry was 37%. Patients in our local registry who matched the inclusion/exclusion criteria of the TTM-trial (n = 145) had a markedly lower 30-day mortality (27%) compared with the published trial (44%).</AbstractText>Standardized treatment of patients with OHCA following a strict protocol incorporating computed tomography, cardiac catheterization and revascularization, liberal use of active hemodynamic support in presence of shock, and mandatory therapeutic hypothermia results in mortality rates lower than previously reported.</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,879 | Ventricular repolarization wave variations during the amiodarone treatment course. | The aim of this study was to assess ventricular repolarization wave variations during the amiodarone treatment course for patients with ventricular arrhythmias and atrial fibrillation.Sixty-nine patients with ventricular arrhythmias and 9 patients with persistent atrial fibrillation were treated with intravenous injection of a 150 mg loading dose of amiodarone, followed by 1 mg/minute for 6 hours and 0.5 mg/minute for 48 hours. After the initial 24 hours of intravenous injection, amiodarone was also administered orally at a dose of 0.2 g tid for 1 week; followed by 0.2 g bid for 1 week and 0.2 g qd for maintenance. During the procedure, the heart rate, QT, QTc, QTd, QTcd TpTe, TpTe-c, TpTe-d, TpTe/QT, and QTp were measured on days 1, 3, 7, 10, 14, 17, and 20 of amiodarone treatment.The control rate of arrhythmias was 91.0% (71/78). The heart rate dropped significantly on the 7th day after treatment initiation and reached the minimal value on day 14. The QT interval was prolonged from day 3; TpTe was prolonged from day 7 to day 14; QTp was prolonged from day 1 to day 20. The longest QT interval (441.2 ± 33.9 ms) and TpTe (95.0 ± 18.0 ms) occurred on day 14. QTc, QTd, QTcd, TpTe-c, TpTe-d, and TpTe/QT showed no significant changes throughout the treatment.Amiodarone lowers the heart rate, prolongs QT and QTp intervals, and transiently prolongs TpTe. However, it has no effects on QTc, QTd, QTcd, TpTe-c, TpTe-d or TpTe/QT. Amiodarone prolongs QT interval evenly, showing no effects on repolarization dispersion. TpTe/QT is a better indicator of ventricular transmural repolarization dispersion compared with TpTe. |
18,880 | Cardiac sarcoidosis and ventricular arrhythmias. A rare association of a rare disease. A retrospective cohort study from the National Inpatient Sample and current evidence for management. | Sarcoidosis is an increasingly recognized multi-systemic condition. Cardiac sarcoidosis is associated with ventricular arrhythmias and higher mortality rates. Little epidemiological data is available regarding the disease and associated ventricular arrhythmias.</AbstractText>Data from the National Inpatient Sample (NIS) database 2012-2014, were reviewed. Dis-charges associated with sarcoidosis were identified as the target population using relevant ICD-9-CM codes. Primary outcome was a diagnosis of ventricular tachycardia (VT) in the sarcoidosis population. Secondary outcomes include rate of ventricular fibrillation (VF) and cardiac arrest. Subgroup analyses were performed to examine the association of VT with multiple potential confounding clinical variables.</AbstractText>Of 18,013,878 health encounters, 46,289 (0.26%) subjects had a diagnosis of sarcoidosis. VT and VF were more prevalent among patients with sarcoidosis compared to those without a diagnosis of sarcoidosis (2.29% vs. 1.22%; p < 0.001 and 0.25% vs. 0.21%; p < 0.001, respectively). Sarcoidosis was also associated with a higher prevalence of cardiac arrest (0.72% vs. 0.6%; p < 0.001). In unadjusted analyses, all examined comorbidities were significantly more common in those with sar-coidosis, including diabetes mellitus (31.6% vs. 21.25%; p < 0.001), hypertension (65.2% vs. 51.74%; p < 0.001), chronic kidney disease (21.09% vs. 14.02%; p < 0.001), heart failure (24.87% vs. 15%; p < 0.001) and acute coronary syndrome (4.32% vs. 3.35%; p < 0.001).</AbstractText>The present study showed that sarcoidosis was associated with increased rates of ven-tricular tachyarrhythmia, which can affect the overall disease morbidity and mortality.</AbstractText> |
18,881 | Risk stratification for complex ventricular arrhythmia complicating ST-segment elevation myocardial infarction. | The primary aim of the study was to evaluate risk factors for ventricular fibrillation/sustained ventricular tachycardia (VF/VT) and to develop the risk score for prediction of VF/VT in patients with ST-segment elevation myocardial infarction (STEMI) treated invasively. The secondary aim was to assess the effect of VF/VT on mortality depending on timing of arrhythmia.</AbstractText>We analyzed 4363 consecutive patients with STEMI treated invasively. Among them, 163 patients with pre-reperfusion arrhythmia were excluded from the study. Group ventricular arrhythmias (VA) encompassed patients with VF/VT - those with reperfusion-induced arrhythmia were included into group VA1, whereas group VA2 consisted of patients with postreperfusion arrhythmia. The control group comprised patients free of VF/VT.</AbstractText>VF or VT occurred in 313 (7.45%) patients - group VA1 encompassed 103 (32.9%) and group AV2 210 (67.1%) patients. Cardiogenic shock on admission [hazard ratio (HR) 3.5], new-onset atrial fibrillation (HR 2.1), incomplete revascularization (HR 1.7), prior myocardial infarction (HR 1.6) and symptom-to-balloon time more than 3 h (HR 1.3) were the independent predictors of VF/VT occurrence. In group VA2, the in-hospital and long-term mortality were 4- and 1.5-fold higher than in the arrhythmia-free population (20.5 vs. 4.5% and 36.2 vs. 22.6%, respectively; P<0.001). On the contrary, in group VA1, the long-term mortality was not significantly higher compared with the control group (26.2 vs. 22.6%; P=NS), whereas in-hospital mortality was almost three-fold increased (12.5 vs. 4.5%, respectively; P<0.001).</AbstractText>The risk score based on simple clinical parameters might be useful for risk stratification for VF/VT in patients with STEMI. The predictive value of VF/VT was strongly dependent on timing of arrhythmia.</AbstractText> |
18,882 | Effects of Polyethylene Glycol-20k on Postresuscitation Myocardial and Cerebral Function in a Rat Model of Cardiopulmonary Resuscitation. | Polyethylene glycol-20k is a hybrid cell impermeant that reduces ischemia injury and improves microcirculatory flow during and following low flow states through nonenergy-dependent water transfer in the microcirculation. We investigated the effects of polyethylene glycol-20k on postresuscitation microcirculation, myocardial and cerebral function, and duration of survival in a rat model of cardiopulmonary resuscitation.</AbstractText>Ventricular fibrillation was induced in 20 male Sprague Dawley rats and untreated for 6 minutes. Animals were randomized into two groups (n = 10 for each group): polyethylene glycol-20k and control. Polyethylene glycol-20k (10% solution in saline, 10% estimated blood volume) and vehicle (saline) were administered at the beginning of cardiopulmonary resuscitation by continuous IV infusion. Resuscitation was attempted after 8 minutes of cardiopulmonary resuscitation.</AbstractText>University-Affiliated Research Laboratory.</AbstractText>Sprague Dawley Rats.</AbstractText>Polyethylene glycol-20k.</AbstractText>Buccal microcirculation was measured at baseline, 1, 3, and 6 hours after return of spontaneous circulation using a side-stream dark-field imaging device. Myocardial function was measured by echocardiography at baseline and every hour postresuscitation for 6 hours. The animals were then returned to their cage and observed for an additional 72 hours. Neurologic Deficit Scores were recorded at 24, 48, and 72 hours after resuscitation. Postresuscitation ejection fraction, cardiac output, and myocardial performance index were significantly improved in animals treated with polyethylene glycol-20k (p < 0.05). Perfused buccal vessel density and microcirculatory flow index values were significantly higher at all time points in the polyethylene glycol-20k group compared with the control group. Postresuscitation cerebral function and survival rate were also significantly improved in animals that received polyethylene glycol-20k.</AbstractText>Administration of polyethylene glycol-20k following cardiopulmonary resuscitation improves postresuscitation myocardial and cerebral function, buccal microcirculation, and survival in a rat model of cardiopulmonary resuscitation.</AbstractText> |
18,883 | Effects of atrial fibrillation on complications and prognosis of patients receiving emergency PCI after acute myocardial infarction. | The effects of atrial fibrillation on complications and prognosis of patients receiving emergency percutaneous coronary intervention after acute myocardial infarction (AMI) were investigated. Eighty AMI patients treated with interventional vascular recanalization in the Affiliated Hospital of Weifang Medical University (Weifang, China) from July 2015 to October 2016 were selected, including 40 patients complicated with atrial fibrillation before operation (control group) and 40 patients without atrial fibrillation before operation (observation group). The systolic blood pressure, diastolic blood pressure, heart rate, arrhythmia and common complications after MI were compared. Changes in the coronary artery thrombolysis in myocardial infarction (TIMI) flow grade and left ventricular ejection fraction (LVEF) of patients were also recorded. Moreover, changes in brain natriuretic peptide (BNP) levels were compared. The recovery time of myocardial enzyme and total troponin in both groups was recorded. The systolic and diastolic blood pressure in the observation group were significantly higher than those in the control group (p<0.05). During the intervention, the total proportion of patients with ventricular arrhythmia, atrial arrhythmia, atrioventricular block and sinus tachycardia in the observation group was significantly lower than that in the control group (p<0.05). The total proportion of common complications after MI in the observation group was obviously lower than that in the control group (p<0.05). Coronary artery TIMI flow grades and LVEFs in the observation group were obviously higher than those in the control group. BNP levels in the observation group were significantly lower than those in the control group. The recovery time of myocardial enzyme and total troponin in the observation group was significantly earlier than that in the control group. Atrial fibrillation has a certain negative effect on the circulatory function in patients with AMI after the interventional therapy, and the proportions of arrhythmia and complications in patients after MI are increased at the same time, so the postoperative recovery of patients is slow with many complications. |
18,884 | Effects of different CYP2C19 genotypes on prognosis of patients complicated with atrial fibrillation taking clopidogrel after PCI. | The effects of different cytochrome P450 2C19 (CYP2C19) genotypes on the prognosis of clopidogrel resistance in patients complicated with atrial fibrillation taking clopidogrel after percutaneous coronary intervention (PCI) were investigated. Eighty patients who were complicated with atrial fibrillation and treated with clopidogrel antiplatelet therapy after PCI in Meizhou Hospital Affiliated to Zhongshan University from September 2015 to January 2017 were selected, and divided into two groups according to the CYP2C19 genotype: extensive metabolism (EM) group and poor metabolism (PM) group. The related risk factors of clopidogrel resistance were determined, and the platelet aggregation rate and clopidogrel resistance rate were compared between the two groups during treatment. Non-fatal myocardial infarction and serious life-threatening complications in the two groups were observed. The increased total cholesterol level and the history of smoking and drinking were the independent risk factors of atrial fibrillation after PCI. The platelet aggregation rates in the EM group at 1, 3 and 12 months after medication were significantly lower than those in the PM group in the same period (P<0.05). The clopidogrel resistance rates in EM group before medication and at 1, 3 and 12 months after medication were higher than those in PM group in the same period (P<0.05). The onset time of non-fatal myocardial infarction in EM group was earlier than that in PM group (P<0.05), the infarct area was larger than that in PM group (P<0.05), and the left ventricular ejection fraction (EF) after onset was lower than that in PM group (P<0.05). In conclusion, the increased total cholesterol level and the history of smoking and drinking are the independent risk factors of clopidogrel resistance in patients complicated with atrial fibrillation after PCI. The incidence rates of cardiac complications are increased significantly in patients with PM CYP2C19 genotype. |
18,885 | Computational Modeling of Electrophysiology and Pharmacotherapy of Atrial Fibrillation: Recent Advances and Future Challenges. | The pathophysiology of atrial fibrillation (AF) is broad, with components related to the unique and diverse cellular electrophysiology of atrial myocytes, structural complexity, and heterogeneity of atrial tissue, and pronounced disease-associated remodeling of both cells and tissue. A major challenge for rational design of AF therapy, particularly pharmacotherapy, is integrating these multiscale characteristics to identify approaches that are both efficacious and independent of ventricular contraindications. Computational modeling has long been touted as a basis for achieving such integration in a rapid, economical, and scalable manner. However, computational pipelines for AF-specific drug screening are in their infancy, and while the field is progressing quite rapidly, major challenges remain before computational approaches can fill the role of workhorse in rational design of AF pharmacotherapies. In this review, we briefly detail the unique aspects of AF pathophysiology that determine requirements for compounds targeting AF rhythm control, with emphasis on delimiting mechanisms that promote AF triggers from those providing substrate or supporting reentry. We then describe modeling approaches that have been used to assess the outcomes of drugs acting on established AF targets, as well as on novel promising targets including the ultra-rapidly activating delayed rectifier potassium current, the acetylcholine-activated potassium current and the small conductance calcium-activated potassium channel. Finally, we describe how heterogeneity and variability are being incorporated into AF-specific models, and how these approaches are yielding novel insights into the basic physiology of disease, as well as aiding identification of the important molecular players in the complex AF etiology. |
18,886 | Therapeutic Effects of Wenxin Keli in Cardiovascular Diseases: An Experimental and Mechanism Overview. | Cardiovascular diseases (CVDs) are the major public health problem and a leading cause of morbidity and mortality on a global basis. Wenxin Keli (WXKL), a formally classical Chinese patent medicine with obvious efficacy and favorable safety, plays a great role in the management of patients with CVDs. Accumulating evidence from various animal and cell studies has showed that WXKL could protect myocardium and anti-arrhythmia against CVDs. WXKL exhibited its cardioprotective roles by inhibiting inflammatory reaction, decreasing oxidative stress, regulating vasomotor disorders, lowering cell apoptosis, and protection against endothelial injure, myocardial ischemia, cardiac fibrosis, and cardiac hypertrophy. Besides, WXKL could effectively shorten the QRS and Q-T intervals, decrease the incidence of atrial/ventricular fibrillation and the number of ventricular tachycardia episodes, improve the severity of arrhythmias by regulating various ion channels with different potencies, mainly comprising peak sodium current (I<sub>Na</sub>), late sodium current (I<sub>NaL</sub>), transient outward potassium current (I<sub>to</sub>), L-type calcium current (I<sub>CaL</sub>), and pacemaker current (I<sub>f</sub>). |
18,887 | Single and dual coil shock efficacy and predictors of shock failure in patients with modern implantable cardioverter defibrillators-a single-center paired randomized study. | Implantable cardioverter defibrillators (ICDs) can treat life-threatening tachyarrhythmia with high-voltage shocks. The aims were to compare the efficacy of single and dual coil shock vectors in modern ICDs and to identify predictors of shock failure.</AbstractText>This is a single-center paired randomized study including 216 patients with mixed indications and ICDs from four manufacturers. All patients underwent two implant defibrillation tests using single and dual coil vectors with the test order randomized. Tested shock energy differed slightly between manufacturers because of differences in device programmability: first shock approximately 15 J below maximal output-if failed, second shock approximately 10 J below maximal output-if failed, third shock at maximal output.</AbstractText>First shock success rate was 399/432 (92.4%). Comparing single and dual coil vectors, no differences were seen in first shock efficacy (91.7% vs. 93.1%, P = 0.629) or lowest tested succesfully stored energy (27.2 J vs. 27.1 J, P = 0.620). All successive internal shocks failed in 4/432 (0.9%) of inductions requiring external rescue shocks to restore circulation. Multivariate predictors of first shock failure were QRS duration (relative risk 0.81 per 10 ms, P = 0.001), amiodarone treatment (relative risk 3.30, P = 0.003), and body height (relative risk 1.70 per 10 cm, P = 0.019).</AbstractText>Implant defibrillation testing of modern intravenous ICD systems demonstrates high shock efficacy with no difference between single and dual coil vectors.</AbstractText> |
18,888 | Comparison of Early and Long-Term Outcomes After Transcatheter Aortic Valve Implantation in Patients with New York Heart Association Functional Class IV to those in Class III and Less. | Our aim was to investigate the impact of a baseline New York Heart Association (NYHA) class IV on clinical outcomes of a large real-world population who underwent transcatheter aortic valve implantation (TAVI). The primary end points were all-cause mortality, cardiovascular mortality, and re-hospitalization, evaluated at the longest available follow-up and by means of a 3-month landmark analysis. The secondary end points were: change in NYHA class, left ventricular ejection fraction, pulmonary pressure and mitral regurgitation. Out of 2,467 patients, 271 (11%) had a NYHA functional class IV at the admission. The latter had higher Society of Thoracic Surgeons (STS) score (9.2% vs 5.5%; p < 0.001) compared to NYHA ≤ III patients, owing to more comorbidities (prior myocardial infarction, severe long-term kidney disease, atrial fibrillation, left ventricular dysfunction, significant mitral regurgitation, pulmonary hypertension). Device success was similar between the two groups (93.7% vs 94.5%; p = 0.583). At a median follow-up of 15 months (interquartile range 4 to 36 months) a lower freedom from primary end points was observed among NYHA IV versus NYHA ≤ III group (survival from all-cause death: 52% vs 58.4%; p = 0.002; survival from cardiovascular death: 72.5% vs 76.5%; p = 0.091; freedom from re-hospitalization: 81.5% vs 85.4%; p = 0.038). However, after adjustment for baseline imbalance, NYHA IV did not influence the relative risk of long-term primary end points. A 3-month landmark analysis showed that NYHA IV independently predicted 3-month all-cause and cardiovascular mortality (hazard ratio: 1.77; 95% CI [1.10 to 2.83]; p = 0.018 and hazard ratio: 1.64; 95% CI [1.03 to 2.59]; p = 0.036, respectively). Instead, after 3-month follow-up NYHA IV did not affect the risk of primary end points. A significant improvement of the secondary end points was noted in both NYHA IV and NYHA ≤≤ III groups. In conclusion, the presence of NYHA class IV in TAVI candidates was associated to a significant increased risk of mortality within 3 months. Patients with baseline NYHA IV who survived at 3 months had a long-term outcome comparable to that of other subjects. Left ventricular systolic function, pulmonary pressure, and mitral insufficiency significantly improved after TAVI regardless of baseline NYHA class IV. |
18,889 | Cochlear implantation in children with congenital long QT syndrome: Introduction of an evidence-based pathway of care. | Congenital long QT syndrome (cLQTS) is an inherited cardiac ion channelopathy characterized by a long corrected-QT interval on the ECG, associated with a risk of syncope and sudden death as a result of arrhythmias. The archetypal arrhythmia associated with cLQTS is torsade de pointes which may degenerate into ventricular fibrillation. Children with Jervell and Lange-Neilsen syndrome have the combination of cLQTS and congenital sensorineural deafness and may present for cochlear implantation (CI). Sympathetic stimulation and administration of QT-prolonging medications may trigger arrhythmias in children with cLQTS and thus the perioperative period is a time of increased risk of adverse events, with deaths reported in the CI literature. Our Paediatric Cochlear Implant Programme had previously elected to discontinue offering CI to children with cLQTS following a perioperative death. However, subsequent demand for this service by parents led us to develop and introduce a multidisciplinary, evidence-based pathway of care. This pathway modifies the perioperative management of these children to reduce the associated risk. We present the cases of four children with cLQTS who underwent CI in our specialist children's hospital. |
18,890 | Changes in mitral annular velocities after cardioversion of atrial fibrillation. | The early diastolic mitral annular velocity (e') and mitral E/e' criteria for clinically evaluating diastolic dysfunction in patients with atrial fibrillation (AF) are almost the same as in patients with sinus rhythm. In this study, we aimed to investigate whether e' is useful to assess diastolic function in AF patients.</AbstractText>Thirty patients who underwent successful electric cardioversion (EC) due to persistent AF and who maintained sinus rhythm for 1 month after EC were enrolled in this study. Transthoracic echocardiography was performed on all patients before and 1 month after EC. Standard diastolic parameters, the global longitudinal strain (GLS), and left ventricular (LV) twist were measured.</AbstractText>Conventional Doppler parameters measured before EC were not significantly different from 1 month after EC. However, the lateral and septal e' were significantly decreased 1 month after EC (from 12.8 ± 2.5 to 9.8 ± 2.3 cm/s and from 9.5 ± 1.9 to 7.1 ± 1.5 cm/s, respectively, P < 0.001). Likewise, the lateral and septal E/e' were also significantly increased 1 month after EC (P < 0.001). The GLS was significantly improved from -15.9 ± 2.2% to -19.4 ± 2.4% after EC (P < 0.001), as was the LV twist (from 5.8 ± 1.7° to 9.1 ± 2.4°, P < 0.001).</AbstractText>We demonstrated that e' was significantly higher in AF compared with during sinus rhythm in the same patients. Thus, in AF patients, diastolic dysfunction should be suspected even when e' values are normal.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,891 | Sudden cardiac arrest in end-stage renal disease patients on dialysis: A nationwide study. | Sudden cardiac arrest (SCA) is frequently encountered in end-stage renal disease (ESRD) patients on dialysis. There is a dearth of national data on SCA-associated outcomes in this specific patient population. The aim of the present study is to study these parameters from a nationally representative US population.</AbstractText>Data were extracted from National Inpatient Sample database from October 2005 to December 2014. All patients with clinical encounter of dialysis during the study period were enrolled. Patients who underwent SCA, ventricular fibrillation, ventricular tachycardia, and ventricular flutter were then identified by applying relevant International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients with acute kidney injury and prior renal transplant were excluded. Propensity matching was done to balance covariates among study groups. Logistic regression analysis was done to assess for predictors of SCA-associated mortality in ESRD patients on dialysis.</AbstractText>A total of 1 147 760 patients were included in the final analyses. Patients who suffered SCA were older when compared to the non-SCA cohort and had a higher burden of comorbidities. About half (52.10%) of ESRD patients who suffered SCA died. Advanced age, metabolic acidosis, and cardiogenic shock were independently associated with reduced survival after SCA. New implantable cardioverter defibrillator implantation continues to be low in this patient population at discharge.</AbstractText>SCA in settings of ESRD on dialysis carries high mortality and frequent morbidity. Further research in therapeutic interventions that could prevent SCA in this vulnerable population is utmost needed.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,892 | Anti-Ischemic Activity of n-Tyrozol under Conditions of Repeated Transient Myocardial Ischemia in Rats. | We studied anti-ischemic activity of n-tyrozol under conditions of repeated transient myocardial ischemia in rats caused by repeated (5×3 min) occlusion of the left coronary artery. n-Tyrozol administered intraperitoneally in a dose of 20 mg/kg daily over 4 days before the ischemia modeling (the last injection 15 min prior to the start of the experiment) produced a clear-cut anti-ischemic effect: it reduced ST elevation and promoted more complete recovery of ECG during reperfusion. During reperfusion periods, n-tyrozol significantly decreased the risk of ventricular fibrillation and shortened the duration of tachyarrhythmia episodes (ventricular tachycardia and fibrillation). |
18,893 | T-Wave Indices and Atherosclerosis. | Tpeak-Tend interval, the time difference between the peak and the end of the T-wave, reflects the degree of dispersion of repolarization. Its prolongation has been associated with higher risks of developing ventricular arrhythmias and sudden cardiac death in different pro-arrhythmic conditions such as Brugada and long QT syndromes. In this review, we will provide a comprehensive overview on how Tpeak-Tend is altered in different atherosclerotic conditions such as hypertension, stable coronary artery disease, acute coronary obstruction, and coronary slow flow as well as inflammatory diseases affecting the arterial tree. We will explore its relationship with arterial function and dysfunction, ventricular remodeling, and arrhythmic and mortality outcomes. The published literature shows that patients with coronary atherosclerosis, whether in the form of stable coronary artery disease, chronic total occlusion, slow flow, or acute coronary obstruction, have prolonged Tpeak-Tend intervals and Tpeak-Tend/QT ratios. These can be used to predict the occurrence of ventricular arrhythmias and sudden cardiac death. They also correlate with the extent and severity of arterial stenosis and structural remodeling of the ventricles as well as arterial function and dysfunction. Finally, they can be normalized following revascularization and may therefore be used as a surrogate measure of treatment success. |
18,894 | Bioprosthetic tricuspid valve dysfunction in patients with transvalvular or epicardial pacing leads. | Dysfunction of native tricuspid valves due to transvenous pacing leads is well described. Patients with bioprosthetic tricuspid valve (BTV) who need ventricular pacing are often advised epicardial lead placement to avoid potential damage to the BTV although there are no data to support this.</AbstractText>The aim of the study was to assess the frequency of BTV dysfunction in patients with permanent transvenous right ventricular pacemaker lead and compare it to patients with epicardial leads.</AbstractText>A retrospective review of patients with BTV with ventricular pacing lead was conducted. Demographics, lead, BTV, and echocardiographic data were collected. Frequency of BTV dysfunction (moderate or severe) regurgitation or stenosis was compared between epicardial and transvalvular lead groups.</AbstractText>Forty-six patients with BTV and ventricular pacing lead (20 transvalvular and 26 epicardial leads) were identified. Mean age was 46 years with the majority being female (85%) and with rheumatic heart disease (87%). Both groups were similar in age, sex, and indications for BTV. Mean echocardiographic follow-up was for 5.5 years (±4.1 years). BTV dysfunction was similar between the transvalvular group with six (30%) patients and the epicardial group with five (19.2%) patients. The incidence of BTV dysfunction was greater in patients in sinus rhythm compared to patients in atrial fibrillation (50% vs 10%, P  =  0.004).</AbstractText>Development of BTV dysfunction is similar in patients with transvalvular ventricular leads and epicardial leads. The incidence of BTV dysfunction was higher in patients with sinus rhythm compared to atrial fibrillation.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
18,895 | Tricuspid Regurgitation Pressure Gradient as a Useful Predictor of Adverse Cardiovascular Events and All-Cause Mortality in Patients With Atrial Fibrillation. | Tricuspid regurgitation pressure gradient (TRPG) is reportedly a predictor of cardiovascular (CV) mortality in patients without atrial fibrillation (AF); its relationship with cardiac outcomes in patients with AF has never been evaluated. This study aimed to examine the ability of TRPG to predict CV events and all-cause mortality in patients with AF.</AbstractText>Comprehensive echocardiography was performed in 155 patients with persistent AF. Combined CV events were defined as CV mortality, stroke and hospitalization for heart failure.</AbstractText>During an average follow-up period of 27 months, 57 CV events and 31 all-cause deaths occurred. According to multivariate analysis, predictors of CV events included diuretic use, decreased left ventricular ejection fraction (LVEF), increased ratio of transmitral E velocity (E) to early diastolic mitral annular velocity (E') and TRPG. Predictors of all-cause mortality included old age, decreased LVEF, increased E/E' and TRPG. Notably, the addition of TRPG to a model containing clinical significant parameters, LVEF and E/E' significantly improved the values in predicting adverse CV events and all-cause mortality.</AbstractText>The TRPG is not only a useful predictor of adverse CV events and all-cause mortality in patients with AF, it may also provide additional prognostic values for CV outcome and all-cause mortality over conventional parameters in such patients.</AbstractText>Copyright © 2018 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
18,896 | Burden of cardiovascular disease in Japanese cancer patients and survivors: a single cancer-center study in Niigata City. | Cardiovascular disease (CVD) and cancer are major causes of death in Japan. As most CVDs are chronic and often aggravate, long-term follow-up is necessary. Although some cancer patients and survivors have CVD, its prognostic significance and prevalence are unknown. Therefore, we conducted a retrospective study at our center to determine the prevalence of cancer patients with CVD.</AbstractText>In 2015, our 10-year (2005-2014) cancer registry was summarized. Comorbidities including left ventricular dysfunction, atrial fibrillation (AF), ischemic heart disease, aortic stenosis, venous thromboembolism (VTE), and elevation of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) were examined.</AbstractText>In total, 26,235 de novo cancer patients were registered and 16,130 survived until January 1, 2015. The 5-year survival rate was 64.0% for all cancer patients and 44.2% for cancer patients with CVD. Cox proportional hazards analysis adjusting for age, cancer stage, and body mass index revealed that AF [hazard ratio (HR) 1.219, male; P = 0.038], VTE (HR 1.517, male; P = 0.003 and HR 2.089, female; P < 0.001), and NT-proBNP elevation (HR 1.861, female; P = 0.002) were significantly associated with death. The CVD prevalence among cancer survivors in 2015 was 8.7% vs 3.5% for males vs females. AF was the most common CVD (prevalence: male, 4.0%; female, 1.0%). The prevalence of most CVD in adults increased progressively with age, with male predominance (12.1% for male and 7.5% for female patients in the 80 s age group).</AbstractText>One in 10 elderly cancer survivors has serious CVD. AF, VTE, and heart failure were critical comorbidities. Cardiologists and cancer-care providers should recognize CVD presence and monitor patients closely, providing medications or interventions concurrently with cancer therapy.</AbstractText> |
18,897 | Can one detect atrial fibrillation using a wrist-type photoplethysmographic device? | This study aims at evaluating the potential of a wrist-type photoplethysmographic (PPG) device to discriminate between atrial fibrillation (AF) and other types of rhythm. Data from 17 patients undergoing catheter ablation of various arrhythmias were processed. ECGs were used as ground truth and annotated for the following types of rhythm: sinus rhythm (SR), AF, and ventricular arrhythmias (VA). A total of 381/1370/415 10-s epochs were obtained for the three categories, respectively. After pre-processing and removal of segments corresponding to motion artifacts, two different types of feature were derived from the PPG signals: the interbeat interval-based features and the wave-based features, consisting of complexity/organization measures that were computed either from the PPG waveform itself or from its power spectral density. Decision trees were used to assess the discriminative capacity of the proposed features. Three classification schemes were investigated: AF against SR, AF against VA, and AF against (SR&VA). The best results were achieved by combining all features. Accuracies of 98.1/95.9/95.0 %, specificities of 92.4/88.7/92.8 %, and sensitivities of 99.7/98.1/96.2 % were obtained for the three aforementioned classification schemes, respectively. Graphical Abstract Atrial fibrillation detection using PPG signals. |
18,898 | Optimizing flecainide plasma concentration profile for atrial fibrillation conversion while minimizing adverse ventricular effects by rapid, low-dose intratracheal or intravenous administration. | We investigated whether rapid administration of a low dose of flecainide, either intratracheally or intravenously (IV), could accelerate conversion of atrial fibrillation (AF) while reducing adverse ventricular effects.</AbstractText>Flecainide was delivered via intratracheal administration at 1.5 mg/kg bolus and compared to IV infusion at 1.0 mg/kg over 2 min (lower-dose, rapid) and 2.0 mg/kg over 10 min (ESC guideline) in closed-chest, anesthetized Yorkshire pigs. Catheters were fluoroscopically positioned in right atrium to measure atrial depolarization (Pa</sub>) duration and left ventricle (LV) to measure QRS complex duration and contractility (LV dP/dt) during atrial pacing at 140 beats/min. Flecainide was delivered intratracheally via a catheter positioned at the bifurcation of the main bronchi. AF was induced by intrapericardial administration of acetylcholine followed by burst pacing.</AbstractText>Flecainide reduced AF duration similarly by intratracheal and IV delivery. Peak plasma levels were comparable but Tmax</sub> differed and coincided with peaks in Pa</sub> prolongation. The area under the curve indicating sustained plasma levels was greater for higher-dose, slow IV flecainide than for either intratracheal instillation (by 32%) or lower-dose, rapid IV infusion (by 88%). As a result, higher-dose, slow IV flecainide caused 58% (p < 0.03) and 48% (p < 0.006) greater increases in QRS complex duration and 61% and 96% (both, p < 0.02) greater reductions in contractility compared to intratracheal and lower-dose, rapid IV flecainide, respectively.</AbstractText>Lower-dose, rapid flecainide, delivered either intratracheally or IV, optimizes the plasma concentration profile for effective conversion of AF while minimizing adverse effects on QRS complex duration and LV contractility.</AbstractText>Copyright © 2018 Elsevier B.V. All rights reserved.</CopyrightInformation> |
18,899 | Automatic Detection of Atrial Fibrillation Based on Continuous Wavelet Transform and 2D Convolutional Neural Networks. | Atrial fibrillation (AF) is the most common cardiac arrhythmias causing morbidity and mortality. AF may appear as episodes of very short (i.e., proximal AF) or sustained duration (i.e., persistent AF), either form of which causes irregular ventricular excitations that affect the global function of the heart. It is an unmet challenge for early and automatic detection of AF, limiting efficient treatment strategies for AF. In this study, we developed a new method based on continuous wavelet transform and 2D convolutional neural networks (CNNs) to detect AF episodes. The proposed method analyzed the time-frequency features of the electrocardiogram (ECG), thus being different to conventional AF detecting methods that implement isolating atrial or ventricular activities. Then a 2D CNN was trained to improve AF detection performance. The MIT-BIH Atrial Fibrillation Database was used for evaluating the algorithm. The efficacy of the proposed method was compared with those of some existing methods, most of which implemented the same dataset. The newly developed algorithm using CNNs achieved 99.41, 98.91, 99.39, and 99.23% for the sensitivity, specificity, positive predictive value, and overall accuracy (ACC) respectively. As the proposed algorithm targets the time-frequency feature of ECG signals rather than isolated atrial or ventricular activity, it has the ability to detect AF episodes for using just five beats, suggesting practical applications in the future. |
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