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19,400 | Atrial fibrillation and hypertension: State of the art. | Atrial fibrillation and hypertension are often coexistent. Their incidence increases with advancing age and they are responsible for considerable morbidity and mortality. The relation between theses 2 diseases has long been discussed and determined by clinical studies. Left ventricular hypertrophy and left atrial remodeling during hypertension favor the development of atrial fibrillation. AF during hypertension increases the risk of thromboembolic complications and heart failure. In patients with hypertension, pharmacological treatment may control the cardiac structural changes and retard or prevent the occurrence of atrial fibrillation. In case of atrial fibrillation, treatment should be focused on the control of heart rate and rhythm and the prevention of thromboembolic accidents. A strict control of blood pressure is highly required in this situation. |
19,401 | Clinical significance of fragmented QRS complexes or J waves in patients with idiopathic ventricular arrhythmias. | Idiopathic ventricular fibrillation (IVF) can cause sudden cardiac death. Previous studies have reported that J waves and fragmented QRS complexes (f-QRS) are arrhythmogenic markers and predictors of cardiac events. We evaluated the prevalence and clinical significance of J waves and f-QRS in patients with IVF.</AbstractText>We studied 81 patients who received an implantable cardioverter defibrillator (ICD) due to IVF between October 1999 and June 2015. We assessed the prevalence of J waves and f-QRS using electrocardiograms (ECGs). Patients were classified into three groups: J wave group (n = 35), f-QRS group (n = 20), or normal ECG group (n = 26). The control group included 81 subjects without heart disease who were matched for age, sex, and race. We compared syncope, sudden cardiac arrest, and appropriate ICD shock between the three groups.</AbstractText>The follow-up duration was 4.1 years. J waves and f-QRS were more frequent in patients with IVF than in control subjects (43.2%, 21% vs. 24.7%, 19.7%, P < 0.001). Out of the three groups, clinical cardiac events were most frequent in the f-QRS group (50% vs. 45.7% vs. 11.5%, P = 0.028). A comparison of the combined group of J wave and f-QRS versus the normal ECG group revealed that the combined group had a higher frequency of clinical cardiac events than the normal ECG group (47.3% vs. 11.5%, respectively, P = 0.009).</AbstractText>Patients with IVF had higher prevalence of f-QRS or J waves. And patients with f-QRS or J waves were at higher risk of recurrent ventricular fibrillation.</AbstractText> |
19,402 | A Case of Sudden Shock during Caesarean Section in whi ch Amniotic Fluid Embolism is Suspected. | We report a case of sudden shock during caesarean section under combined spinal epidural anesthesia. The patient was a 29-year-old woman. During the operation vital signs had been almost stable until a female-baby was born. But after the delivery of the placenta, the patient developed an episode of coughing and dyspnea followed by unconsciousness and bradycardia. She was given adrenaline and intubated, appearing ventricular fibrillation on a EKG. Cardiopulmonary resuscitation was immediately started and sinus rhythm returned. Hypotension followed and a small dose of adrenaline was infused for three days. She made good progress and was discharged without significant sequela. Cardiopulmonary collapse type of amniotic fluid embolism (AFE) is doubtful in this case. The necessity of rapid and appropriate treatment for emergency obstetric cases was discussed. |
19,403 | Safety and Efficacy of Triple Therapeutic Targets with Rivaroxaban after Acute Myocardial Infarction Complicated by Left Ventricular Thrombi in a Case of Nonvalvular Atrial Fibrillation. | We present the complex case of a high-risk patient with nonvalvular atrial fibrillation, who experienced a non-ST elevation myocardial infarction complicated by left ventricular (LV) thrombi and underwent percutaneous coronary intervention with drug-eluting stent implantation. The patient was initially treated with short-term triple therapy including aspirin, clopidogrel, and rivaroxaban 15 mg/die. Following aspirin dropping one month after discharge, the patient continued on dual therapy with clopidogrel and rivaroxaban, and a clinical and imaging follow-up at 6 and 12 months confirmed the LV thrombi resolution, with no thromboembolic episodes and a good safety profile. |
19,404 | Incremental value of left atrial mechanical dispersion over CHA<sub>2</sub> DS<sub>2</sub> -VASc score in predicting risk of thrombus formation. | To assess the potential ability of two-dimensional speckle tracking analysis (STE) during atrial fibrillation (AF) to identify patients with LA appendage thrombi (LAAT).</AbstractText>This study involved 93 patients with AF (39% female, 67.1 ± 9.5 years) who were referred for a clinical indication for transesophageal echocardiography (TEE). TEE revealed LAAT in 39 (42%) patients. We analyzed standard parameters of the left ventricle (LV) and LA in transthoracic echocardiography. Using STE, we assessed LV global longitudinal strain (LVGLS), peak atrial longitudinal strain (PALS), and intra-atrial asynchrony. The PALS was calculated using the global strain curve (GPALS) and as the mean of peaks derived from segmental strain curves (MPALS).</AbstractText>Patients were comparable with regard to the clinical data. A subgroup with LAAT had lower LV ejection fraction (LVEF) and a lower absolute value of the LVGLS, as well as greater impairment in the LA standard parameters, PALS, and asynchrony. Receiver operating characteristic curve analysis revealed that the LVEF of 30% (P < .001), the LVGLS of -7% (P < .0001), the GPALS of 11% (P < .005), and the LA asynchrony of 22% (P < .01) were the optimal cutoff values for distinguishing both subgroups. LA asynchrony, LVEF, and LVGLS were independently associated with the presence of LAAT in multivariate analyses, and PALS had additional significance over the CHA2</sub> DS2</sub> -VASc score.</AbstractText>Left ventricular systolic dysfunction characterized by both LVEF and LVGLS is an independent factor for LAAT. LA asynchrony provides additional diagnostic value for discriminating between patients with and without LAAT.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
19,405 | Mental stress test: a rapid, simple, and efficient test to unmask long QT syndrome. | QT prolongation during mental stress test (MST) has been associated with familial idiopathic ventricular fibrillation. In long QT syndrome (LQTS), up to 30% of mutation carriers have normal QT duration. Our aim was to assess the QT response during MST, and its accuracy in the diagnosis of concealed LQTS.</AbstractText>All patients who are carrier of a KCNQ1 or KCNH2 mutations without QT prolongation were enrolled. A control group was constituted of patients with negative exercise and epinephrine tests. Electrocardiogram were recorded at rest and at the maximum heart rate during MST and reviewed by two physicians. Among the 70 patients enrolled (median age 41±2.1 years, 46% male), 36 were mutation carrier for LQTS (20 KCNQ1 and 16 KCNH2), and 34 were controls. KCNQ1 and KCNH2 mutation carriers presented a longer QT interval at baseline [405(389; 416) and 421 (394; 434) ms, respectively] compared with the controls [361(338; 375)ms; P < 0.0001]. QT duration during MST varied by 9 (4; 18) ms in KCNQ1, 3 (-6; 16) ms in KCNH2, and by -22 (-29; -17) ms in controls (P < 0.0001). These QT variations were independent of heart rate (P < 0.3751). Receiver operating characteristic curve analysis identified a cut-off value of QT variation superior to -11 ms as best predictor of LQTS. It provided 97% sensitivity and 97% specificity of QT prolongation in the diagnosis of LQTS.</AbstractText>We identified a paradoxical response of the QT interval during MST in LQTS. Easy to assess, MST may be efficient to unmask concealed LQTS in patients at risk of this pathology.</AbstractText> |
19,406 | Can sudden cardiac death in the young be predicted and prevented? Lessons from autopsy for the emergency physician. | Sudden unexpected death in the young, though rare, is devastating for both the family and the community. Although only 1.3 to 8.5 cases of sudden cardiac death (SCD) occur per 100 000 young people, autopsy is often inconclusive. Many causes of SCD are related to autosomal dominant inherited risk, however; therefore, answers are important for survivors. Causes of autopsy-positive SCD in young patients include hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysplasia. Autopsy-negative SCD has been related to inherited arrhythmogenic causes such as long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, Wolff- Parkinson-White syndrome, and idiopathic ventricular fibrillation. The important question for the emergency physician is how SCD can be predicted and prevented in the young so that there is no need for an autopsy.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>White</LastName><ForeName>Jennifer L</ForeName><Initials>JL</Initials><AffiliationInfo><Affiliation>Department of Emergency Medicine; Mayo Clinic College of Medicine, Rochester, Minnesota, EE.UU.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Chang</LastName><ForeName>Anna Marie</ForeName><Initials>AM</Initials><AffiliationInfo><Affiliation>Department of Emergency Medicine; Sidney Kimmel Medical College of Thomas Jefferson University and the National Academic Center of Telehealth, Filadelfia, Pensilvania, EE.UU.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Cesar</LastName><ForeName>Sergi</ForeName><Initials>S</Initials><AffiliationInfo><Affiliation>Departamento de Cardiología Pediátrica, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Sarquella-Brugada</LastName><ForeName>Georgia</ForeName><Initials>G</Initials><AffiliationInfo><Affiliation>Departamento de Arritmias Pediátricas, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España.</Affiliation></AffiliationInfo></Author></AuthorList><Language>eng</Language><Language>spa</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList><VernacularTitle>¿Se puede predecir y prevenir la muerte súbita cardiaca en sujetos jóvenes? Algunas indicaciones para el urgenciólogo.</VernacularTitle></Article><MedlineJournalInfo><Country>Spain</Country><MedlineTA>Emergencias</MedlineTA><NlmUniqueID>9805751</NlmUniqueID><ISSNLinking>1137-6821</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D000293" MajorTopicYN="N">Adolescent</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D000328" MajorTopicYN="N">Adult</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D001344" MajorTopicYN="N">Autopsy</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D002423" MajorTopicYN="Y">Cause of Death</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D002648" MajorTopicYN="N">Child</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D016757" MajorTopicYN="N">Death, Sudden, Cardiac</DescriptorName><QualifierName UI="Q000209" MajorTopicYN="N">etiology</QualifierName><QualifierName UI="Q000517" MajorTopicYN="Y">prevention & control</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D004562" MajorTopicYN="N">Electrocardiography</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D004632" MajorTopicYN="N">Emergency Medical Services</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D030342" MajorTopicYN="N">Genetic Diseases, Inborn</DescriptorName><QualifierName UI="Q000175" MajorTopicYN="N">diagnosis</QualifierName><QualifierName UI="Q000401" MajorTopicYN="N">mortality</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008875" MajorTopicYN="N">Middle Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012307" MajorTopicYN="N">Risk Factors</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D055815" MajorTopicYN="N">Young Adult</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="spa">La muerte súbita e inesperada en jóvenes es un evento raro pero devastador. Aunque su incidencia es baja, se registran de 1,3 a 8,5 casos de muerte súbita cardiaca (MSC) por cada 100.000 jóvenes y se asocia frecuentemente con una autopsia negativa. Muchas de las causas de la MSC con autopsia negativa se heredan de forma autosómica dominante. Algunas causas de MSC con autopsia positiva en pacientes jóvenes incluyen la miocardiopatía hipertrófica (MCH) y la displasia arritmogénica de ventriculo derecho. Las causas de autopsia negativa incluyen causas arritmogénicas heredadas, como el síndrome de QT largo, el síndrome de Brugada, la taquicardia ventricular polimórfica catecolaminérgica, el syndrome de Wolff-Parkinson-White (WPW) y la fibrilación ventricular idiopática. La pregunta importante para los profesionales de urgencias es: ¿cómo podemos predecir y prevenir la MSC en los jóvenes antes de la autopsia? |
19,407 | How to manage various arrhythmias and sudden cardiac death in the cardiovascular intensive care. | In the clinical practice of cardiovascular critical care, we often observe a variety of arrhythmias in the patients either with (secondary) or without (idiopathic) underlying heart diseases. In this manuscript, the clinical background and management of various arrhythmias treated in the CCU/ICU will be reviewed. The mechanism and background of lethal ventricular tachyarrhythmias vary as time elapses after the onset of MI that should be carefully considered to select a most suitable therapy. In the category of non-ischemic cardiomyopathy, several diseases are known to be complicated by the various ventricular tachyarrhythmias with some specific mechanisms. According to the large-scale registry data, the most common arrhythmia is atrioventricular block. It is essential for the decision of permanent pacemaker indication to rule out the presence of transient causes such as ischemia and electrolyte abnormalities. The prevalence of atrial fibrillation (AF) is very high in the patients with heart failure (HF) and myocardial infarction (MI). AF and HF have a reciprocal causal relationship; thus, both are associated with the poor prognosis. Paroxysmal AF occurs in 5 to 20% during the acute phase of MI and triggered by several specific factors including pump failure, atrial ischemia, and autonomic instability. After the total management of patients with various arrhythmias and basic heart diseases, the risk of sudden cardiac death should be stratified for each patient to assess the individual need for preventive therapies. Finally, it is recommended that the modalities of the treatment and prophylaxis should be selected on a case-by-case basis in the scene of critical care. |
19,408 | Association between atrial fibrillation, atrial enlargement, and left ventricular geometric remodeling. | This study investigated the relationship between atrial fibrillation (AF) and left ventricular (LV) geometric patterns in a hospital-based population in Japan. We retrospectively analyzed 4444 patients who had undergone simultaneous scheduled transthoracic echocardiography (TTE) and electrocardiography during 2013. A total of 430 patients who had findings of previous myocardial infarctions (n = 419) and without the data on body surface area (n = 11) were excluded from the study. We calculated the LV mass index (LVMI) and relative wall (RWT) and categorized 4014 patients into four groups as follows: normal geometry (n = 3046); concentric remodeling (normal LVMI and high RWT, n = 437); concentric hypertrophy (high LVMI and high RWT, n = 149); and eccentric remodeling (high LVMI and normal RWT, n = 382). The mean left atrial volume indices (LAVI) were 22.5, 23.8, 33.3, and 37.0 mm/m<sup>2</sup> in patients with normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy, respectively. The mean LV ejection fractions (LVEF) were 62.7, 62.6, 60.8, and 53.8%, respectively, whereas the prevalence of AF was 10.4%, 10.5%, 14.8%, and 16.8% in patients with normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy, respectively. In conclusion, the prevalence of AF was increasing according to LV geometric remodeling patterns in association with LA size and LVEF. |
19,409 | Usefulness of a Low Resting Heart Rate to Predict Recurrence of Atrial Fibrillation After Catheter Ablation in People ≥65 Years of Age. | A low resting heart rate (RHR) is associated with an increased risk of atrial fibrillation (AF), and this is common in older people. Whether a low RHR in older people can predict recurrence of AF after catheter ablation is unclear. A total of 329 consecutive patients ≥65 years of age with paroxysmal AF who underwent index circumferential pulmonary vein isolation were prospectively enrolled. A 10-second standard resting 12-lead electrocardiogram in sinus rhythm was recorded to measure the RR interval, P-wave duration, and PR interval. The RHR was calculated based on the mean RR interval. During a mean follow-up period of 17.0 ± 8.3 months (range, 3 to 32 months), 96 (29.2%) patients developed recurrence of AF. The AF recurrence rate was 46.2%, 32.3%, and 25.4% in patients with an RHR <50, 50 to 59, and ≥60 beats/min, respectively (log-rank test, p = 0.009). Cox regression analysis with adjustment for P-wave duration and the CHADS<sub>2</sub> score showed that an RHR <50 beats/min (hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.12 to 3.28, p = 0.017), advanced interatrial block (HR 1.82, 95% CI 1.09 to 3.04, p = 0.022), and left atrial diameter (HR 1.05, 95% CI 1.00 to 1.09, p = 0.029) were independent predictors of recurrence of AF after catheter ablation. In conclusion, in people ≥65 years of age, an RHR <50 beats/min is an independent predictor of AF recurrence in patients who have undergone catheter ablation for paroxysmal AF. |
19,410 | Relation of Cannabis Use and Atrial Fibrillation Among Patients Hospitalized for Heart Failure. | Left ventricular dysfunction triggers the activation of the sympathetic nervous system, providing inotropic support to the failing heart and concomitantly increasing the risk of atrial fibrillation (AF). The cardiovascular effects of cannabis have been characterized as biphasic on the autonomic nervous system with an increased sympathetic effect at low doses and an inhibitory sympathetic activity at higher doses. It is unknown if the autonomic effect of cannabis impacts the occurrence of AF in patients with heart failure (HF). We used data from the Healthcare Cost and Utilization Project-National Inpatient Sample for patients admitted with a diagnosis of HF in 2014. The outcome variable was the diagnosis of AF, with the main exposure being cannabis use. We identified a cannabis user group and a 1:1 propensity-matched non-cannabis user group, each having 3,548 patients. We then estimated the odds of AF diagnosis in cannabis users. An estimated 3,950,392 patients were admitted with a diagnosis of HF in the United States in 2014. Among these, there were 17,755 (0.45%) cannabis users. In the matched cohort, cannabis users were less likely to have AF (19.08% vs 21.39%; AOR 0.87 [0.77 to 0.98]). In conclusion, cannabis users have lower odds of AF when compared with nonusers, which was not explained by co-morbid conditions, age, insurance type, and socioeconomic status. |
19,411 | Importance of beta-blocker dose in prevention of ventricular tachyarrhythmias, heart failure hospitalizations, and death in primary prevention implantable cardioverter-defibrillator recipients: a Danish nationwide cohort study. | There is a paucity of studies investigating a dose-dependent association between beta-blocker therapy and risk of outcome. In a nationwide cohort of primary prevention implantable cardioverter-defibrillator (ICD) patients, we aimed to investigate the dose-dependent association between beta-blocker therapy and risk of ventricular tachyarrhythmias (VT/VF), heart failure (HF) hospitalizations, and death.</AbstractText>Information on ICD implantation, endpoints, comorbidities, beta-blocker usage, type, and dose were obtained through Danish nationwide registers. The two major beta-blockers carvedilol and metoprolol were examined in three dose levels; low (metoprolol ≤ 25 mg; carvedilol ≤ 12.5 mg), intermediate (metoprolol 26-199 mg; carvedilol 12.6-49.9 mg), and high (metoprolol ≥ 200 mg; carvedilol ≥ 50 mg). Time to events was investigated utilizing multivariate Cox models with beta-blocker as a time-dependent variable. From 2007 to 2012, 2935 first-time ICD devices were implanted. During follow-up, 399 patients experienced VT/VF, 728 HF hospitalizations and 361 died. As compared with patients not on beta-blockers, low, intermediate, and high dose had significantly reduced risk of HF hospitalizations {hazard ratio (HR) = 0.68 [0.54-0.87], P = 0.002; HR = 0.53 [0.42-0.66], P < 0.001; HR = 0.43 [0.34-0.54], P < 0.001} and death (HR = 0.47 [0.35-0.64], P < 0.001; HR = 0.29 [0.22-0.39], P = 0.001; HR = 0.24 [0.18-0.33], P < 0.001). For the endpoint of VT/VF, only intermediate and high dose beta-blocker was associated with significantly reduced risk (HR = 0.58 [0.43-0.79], P < 0.001; HR = 0.53 [0.39-0.72], P < 0.001). No significant difference was found between comparable doses of carvedilol and metoprolol on any endpoint (P = 0.06-0.94).</AbstractText>In primary prevention ICD patients, beta-blocker therapy was associated with significantly reduced risk of all endpoints, as compared with patients not on beta-blocker, with the suggestion of a dose-dependent effect. No detectable difference was found between comparable doses of carvedilol and metoprolol.</AbstractText> |
19,412 | LifeMap: towards the development of a new technology in sudden cardiac death risk stratification for clinical use. | Sudden cardiac death (SCD) is a major cause of mortality presenting a significant unmet clinical need. Patients at risk of SCD are implanted with implantable cardioverter-defibrillators (ICDs) according to international guidelines based on clinical trial evidence. Implantable cardioverter-defibrillators are not inexpensive and not without problem in terms of inappropriate shocks and infection risk. Also, only a minority of patients implanted with the ICD ever use the device during its battery lifetime highlighting the fact that methods used for SCD risk stratification are inadequate. Better ways of predicting who is at risk of SCD are needed. In addition, there is no effective prevention due to the lack of understanding of the electrical mechanisms underlying SCD. Our group has been investigating the electrophysiological basis of ventricular fibrillation and have successfully applied our preclinical findings to translational studies in patients with ischaemic cardiomyopathy. We have developed two ECG markers which have been shown to be strong predictors of ventricular arrhythmias and SCD. Ongoing clinical studies are being carried out including a multicentre UK study to consolidate the evidence base. They are being incorporated into the technology, LifeMap, with the aim to develop a successful clinical tool for the assessment of SCD risk. We hereby present the scientific data leading to the technology and the development to date. The information provided here was presented at the European Heart Rhythm Association (EHRA) Europace/Cardiostim conference at which LifeMap won the EHRA Inventors Award 2016. |
19,413 | Atrial fibrillation in patients with inherited cardiomyopathies. | Atrial fibrillation (AF) often complicates the course of inherited cardiomyopathies and, in some cases, may be the presenting feature. Each inherited cardiomyopathy has its own peculiar pathogenetic characteristics that can contribute to the development and maintenance of AF. Atrial fibrillation may occur as a consequence of disease-specific defects, non-specific cardiac chamber changes secondary to the primary illness, or a combination thereof. The presence of AF can denote a turning point in the progression of the disease, promoting clinical deterioration and increasing morbidity and mortality. Furthermore, the management of AF can be particularly challenging in patients with inherited cardiomyopathies. In this article, we review the current information on the prevalence, pathophysiology, risk factors, and treatment of AF in three different inherited cardiomyopathies: hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia/cardiomyopathy, familial dilated cardiomyopathy, and left ventricular non-compaction cardiomyopathy. |
19,414 | Sinus Standstill in a Patient after Intracoronary Papaverine Administration for a Coronary Fractional Flow Reserve. | A 78-year-old woman had paroxysmal atrial fibrillation and effort angina. Two months before she was admitted for a coronary angiography, she had been feeling dizzy. A Holter 24-hour electrocardiography monitor exhibited an asymptomatic episode of 2.9 seconds of RR interval. She underwent a coronary angiography, which showed intermediate stenosis in the left descending artery. Fractional flow reserve (FFR) measurement using intracoronary papaverine administration was performed. After intracoronary papaverine (12 mg) administration, pause of 4 seconds led to polymorphic ventricular tachycardia (VT), although the VT terminated spontaneously. Premature ventricular beat occurred and led to sustained polymorphic VT. In cardiac electrophysiology study, pacing from the right atrium showed that the maximum sinus node recovery time (SRT) was 910 ms. After procainamide (10 mg/kg) administration, the maximum SRT was 16.3 seconds with some junctional escapes. After intravenous papaverine administration, there was a slight change. Intracoronary papaverine administration induced about 9-seconds pause with some junctional escapes. We conclude that intracoronary papaverine administration reveals potential sinus node dysfunction. The patient has been asymptomatic since the implantation of the pacemaker. Patients with suspicious sinus dysfunction should be careful. |
19,415 | Fulminant primary cardiac lymphoma with sudden cardiac death: A case report and brief review. | Primary cardiac lymphoma (PCL) is very rare, with the variable clinical manifestations potentially leading to a delayed diagnosis. PCL is usually detected incidentally through image studies, whereas the diagnosis can be confirmed via analysis of pericardial effusion, endomyocardial biopsy tissue, or surgical specimens. Although no standard therapy has been established for PCL, without treatment, the prognosis is grave, with the estimated overall survival being approximately 1 year. We report a difficult diagnosis and complicated case of fulminant PCL, which is the first comprehensively reported case of PCL with secondary hemophagocytosis. A man presented with progressive dyspnea for 3 weeks, and then sudden cardiac death with ventricular fibrillation occurred. After resuscitation, echocardiography revealed a thickened left ventricular wall and severe mitral regurgitation, and computed tomography showed a right atrial mass with diffuse myocardial lesions. PCL was confirmed through a pathological analysis of specimens collected during mitral valvuloplasty, which also implied extensive myocardial involvement. Bone marrow biopsy demonstrated no evidence of lymphoma involvement, but secondary hemophagocytosis was noted. Despite aggressive chemotherapy, the patient died of sepsis with multiorgan failure 26 days after the operation. |
19,416 | Left atrial deformation as a potent predictor for paroxysmal atrial fibrillation in patients with end-stage renal disease. | It is widely known that various factors contribute to left atrial (LA) mechanical dysfunction in patients with end stage renal disease (ESRD). However, the connection between atrial dysfunction and arrhythmic events such as paroxysmal atrial fibrillation (PAF), in this group of patients, remains unclear. The purpose of our study was to evaluate prospectively the association between LA deformation indices and PAF in ESRD patients. 79 patients (41 men, mean age 57 ± 17) with ESRD and preserved left ventricular systolic function comprised the study population. All patients underwent a baseline comprehensive echocardiography study and were followed for a mean period of 16 ± 5 months. PAF episodes, first and the following events, were reported. LA longitudinal strain reflecting LA reservoir function and LA longitudinal strain rate reflecting LA pump function were specifically evaluated as LA deformation indices of interest, using 2D speckle tracking echocardiography. At the end of follow up period nine patients died. 15 of the rest 70 reported one or more episodes of PAF. LA indexed volumes were significantly higher in patients with PAF (32 ± 26 vs. 21.5 ± 9 ml/m<sup>2</sup>, p = 0.002), mean LA strain was significantly reduced (17 ± 7 vs. 27 ± 9%, p < 0.001) as well as mean LA stain rate (- 1.19 ± 0.5 vs. - 1.95 ± 0.5 1/s, p < 0.001). Multivariate analysis showed that LA strain rate when adjusted with age together with PAF history remained the single most significant echocardiographic parameter for PAF prediction. Impaired LA strain and LA strain rate are associated with PAF in ESRD patients. LA strain rate might be a better independent predictor of PAF, compared to standard echocardiographic indices. Further prospective studies are needed to validate its relevance in routine clinical practice. |
19,417 | Estimated Cardiac Risk Associated With Macrolides and Fluoroquinolones Decreases Substantially When Adjusting for Patient Characteristics and Comorbidities. | Some studies have found that antimicrobials, especially macrolides, increase the risk of cardiovascular death. We investigated potential cardiac-related events associated with antimicrobial use in a population of patients with acute myocardial infarction.</AbstractText>For 185 010 Medicare beneficiaries, we recorded prescriptions for azithromycin, clarithromycin, levofloxacin, moxifloxacin, doxycycline, and amoxicillin-clavulanate. In the following week, we recorded death, acute myocardial infarction, atrial fibrillation or atrial flutter, a non-atrial fibrillation/atrial flutter arrhythmia, or ventricular arrhythmia. We fit unadjusted and adjusted logistic regression models using generalized estimating equations. Adjusted models included patients' comorbidities, medications, procedures, demographics, insurance status, time since index acute myocardial infarction, number of visits, and the influenza rate. In unadjusted analyses, macrolides and fluoroquinolones were associated with a risk of cardiac events. However, the risk associated with macrolide use was substantially attenuated after adjustment for a wide range of variables, and the risk associated with fluoroquinolones was no longer statistically significant. For example, for azithromycin, the odds ratio for any cardiac event or death was 1.35 (95% confidence interval, 1.27-1.44; P</i><0.0001), but after controlling for a wide range of covariates, the odds ratio decreased to 1.01 (95% confidence interval, 0.95-1.08; P</i><0.6688).</AbstractText>Controlling for covariates explains much of the adverse cardiac risk associated with antimicrobial use found in other studies. Most antimicrobials are not associated with risk of cardiac events, and others, specifically azithromycin and clarithromycin, may pose a small risk of certain cardiac events. However, the modest potential risks attributable to these antimicrobials must be weighed against the drugs' considerable and immediate benefits.</AbstractText>© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
19,418 | Phenotypic description of cardiac findings in a population of Dogue de Bordeaux with an emphasis on atrial fibrillation. | The aim of this study was to describe the clinical phenotype of Dogue de Bordeaux (DdB) referred for cardiac investigation, with particular reference to the prevalence of atrial fibrillation and associated features. Review of canine medical records of two United Kingdom veterinary referral hospitals identified 64 DdB with available echocardiographic and electrocardiographic (ECG)/Holter data. Atrial fibrillation was documented in 25 (39%) dogs and supraventricular tachycardia was recorded in five (7.8%) dogs. In a subset of 34 dogs, excluding congenital heart disease (n=17), presence of a cardiac mass (n=7) and non-cardiac neoplasia (n=6), 19 (56%) dogs had atrial fibrillation, with a median heart rate of 200 beats per min (bpm) on presentation. Atrial fibrillation was inconsistently associated with cardiac chamber remodelling, but was frequently associated with systolic dysfunction (13/19, 68.4%) and right sided atrial or ventricular dilatation (14/19, 73.7%) in dogs with atrial fibrillation in this subset. No dogs in this subset had right sided atrial or ventricular dilatation in the absence of supraventricular arrhythmia or systolic dysfunction. The absence of structural heart disease in some dogs with supraventricular arrhythmias suggests that an underlying primary arrhythmic process might be responsible for initiating remodelling, although a primary cardiomyopathy cannot be ruled out. |
19,419 | Determinants of Reverse Remodeling of the Left Atrium After Transaortic Myectomy. | In patients with hypertrophic cardiomyopathy (HCM), enlargement of the left atrium (LA) is associated with increased morbidity and mortality because of risk of atrial fibrillation (AF), stroke, and heart failure. In this study, we investigated whether LA reverse remodeling occurs after septal myectomy.</AbstractText>Between August 2007 and July 2015, 656 patients underwent myectomy at our institution and had preoperative and postoperative transthoracic echocardiographic (TTE) recording of LA volume index (LAVI). We reviewed clinical and echocardiographic data of these patients, and assessed for changes over time by comparing preoperative and postoperative measurements.</AbstractText>The median age was 56 (interquartile range [IQR], 46, 65) years, and 370 (56%) were male. New York Heart Association Class III/IV dyspnea was present in 581 (89%). Preoperative TTE showed LAVI of 48 (IQR, 38, 60) mL/m2</sup>. In patients with history of AF, preoperative LAVI was 57 (IQR, 45, 68) mL/m2</sup>, and in those without AF, LAVI measured 45 (IQR, 37, 57) mL/m2</sup> (p < 0.001). All patients underwent transaortic septal myectomy. Early postoperative TTE (4 [IQR, 3, 5] days) demonstrated LAVI of 43 (IQR, 36, 52) mL/m2</sup> (p < 0.001), and late postoperative TTE (2.0 [IQR, 1.1, 4.1] years) showed LAVI of 38 (29, 47) mL/m2</sup> (p < 0.001). Preoperative LAVI was associated with late development of AF (p = 0.002).</AbstractText>Left atrial volume decreases significantly after surgical relief of left ventricular outflow tract obstruction. Early changes likely reflect lower LA pressure due to gradient relief and abolishment of mitral regurgitation, and late reduction suggests continued reverse remodeling.</AbstractText>Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,420 | Safety and efficacy of stereotactic radioablation targeting pulmonary vein tissues in an experimental model. | Stereotactic radioablation (SR), a commonly used therapy to treat malignant tumors, has been used to treat refractory ventricular tachycardia, but the feasibility of treating atrial fibrillation with SR is unknown.</AbstractText>We evaluated the safety and efficacy of SR targeting pulmonary vein (PV) antral tissues as a potential therapy for atrial fibrillation.</AbstractText>Seventeen adult canines and 2 adult swine underwent surgical fiducial marker placement, 3-dimensional anatomic rendering computed tomography angiogram of the left atrium, and creation of a treatment plan targeting the right superior PVs. Four treatment doses (15, 20, 25, and 35 Gy) were administered to 4 cohorts. Subjects were monitored for 3-6 months, followed by electrophysiological testing, gross pathological examination, and histopathology in 2 subjects.</AbstractText>All subjects received SR treatment without complication. Electrophysiology study and gross pathological analysis demonstrated treatment effect in all treated PVs at 35 Gy and 25 Gy (n = 11 of 11 [100%]), with a partial effect at 20 Gy (n = 4 of 5 [80%]; 1 did not undergo repeat electrophysiology study) and 15 Gy (n = 1 of 2 [50%]). No evidence of collateral injury was found in tissues directly adjacent to the treated PVs. In 2 subjects, detailed histopathology demonstrated evidence of circumferential, transmural scar at the PV ablation sites, with sparing of the surrounding structures.</AbstractText>SR is safe and effective for creating precise circumferential scar and electrical isolation of the right superior PV in an experimental model, with dose dependence between delivered radioablative energy and observed electrical effects.</AbstractText>Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,421 | Experience with the wearable cardioverter-defibrillator in older patients: Results from the Prospective Registry of Patients Using the Wearable Cardioverter-Defibrillator. | Use of the wearable cardioverter-defibrillator (WCD) in older patients has not been described previously.</AbstractText>The purpose of this study was to assess WCD wear time, risk of arrhythmic events during WCD use, and implantable cardioverter-defibrillator (ICD) implantation rates after the end of WCD use in patients with age ≥65 years vs <65 years.</AbstractText>We stratified 1732 patients with ischemic and nonischemic cardiomyopathy from the Prospective Registry of Patients Using the Wearable Defibrillator Registry into 2 subgroups by age: those with age ≥65 years and those with age <65 years. Wear time, arrhythmic events, and end-of-use decisions, specifically ICD implantation or improvement in ejection fraction, were evaluated for each age group.</AbstractText>There were 722 patients with age ≥65 years (41.7%) and 1010 patients with age <65 years (58.3%). Daily WCD wear time was longer in the older population (median 22.8 h/d (IQR 21.5 - 23.2) vs 22.3 h/d (IQR 19.5 - 23.0); P < .001). Patients with age ≥65 years experienced higher event rates, per 100 patient-years, for any sustained ventricular tachycardia/ventricular fibrillation (31.95 vs 9.82; P = .027) and ventricular tachycardia/ventricular fibrillation treated with WCD shock (6.92 vs 2.37; P = .034), particularly with ischemic cardiomyopathy. Younger patients experienced a trend toward a higher event rate for atrial arrhythmias with nonischemic cardiomyopathy (150.07 vs 74.86; P = .055). At the end of WCD use, ICD implantation was more frequent in older patients (41.8% vs 36.5%; P = .034).</AbstractText>Older patients had good compliance with the WCD, presented with more frequent ventricular arrhythmias, and were more likely to receive an ICD at the end of WCD use. The WCD may play a role in risk stratification of the older population.</AbstractText>Copyright © 2018. Published by Elsevier Inc.</CopyrightInformation> |
19,422 | Arrhythmic Risk Stratification in Patients With Idiopathic Dilated Cardiomyopathy. | Arrhythmic risk stratification in idiopathic dilated cardiomyopathy (IDC) remains a major concern. As the ventricles remodel in time, risk factors for arrhythmic death may change. A cohort of 710 patients with idiopathic dilated cardiomyopathy, without previous ventricular arrhythmias, was retrospectively studied to understand how risks vary in time. The primary end point was a composite of sudden cardiac death, ventricular fibrillation, sustained ventricular tachycardia, and appropriate implantable cardioverter-defibrillator interventions. The prediction of the arrhythmic outcome was assessed dynamically through landmark analysis. Patients were assessed at baseline, short term (12 months, interquartile range 6 to 18), and long-term (72 months, interquartile range 60 to 84). The strongest risk predictors at each evaluation were combined in 3 multivariate models. During a median follow-up of 102 months, 80 patients (11%) experienced the primary end point. At baseline, QRS duration (p = 0.008), disease duration (p <0.001), and mitral regurgitation (p = 0.010) were significantly associated with the primary end point. The 12 months' landmark model included disease duration (p = 0.049), syncope (p = 0.005), New York Heart Association classes III and IV (p = 0.02), and indexed left ventricular end-diastolic volume (p = 0.001). Finally, the 72 months' landmark model combined the indexed left ventricular end-diastolic volume (p = 0.048), the left ventricular ejection fraction (p = 0.008), and the left atrial area (p = 0.001). All the 3 models provided a satisfactory accuracy (area under the curve ranging from 0.76 to 0.82, p <0.001). With an implantable cardioverter-defibrillator, the natural course of the disease influences the effect of arrhythmic risk factors overtime. Different predictors should be considered for the risk stratification according to the timing of assessment. Impaired left ventricular ejection fraction was significantly associated with major arrhythmias only in the long term. |
19,423 | Electrocardiographic predictors of atrial fibrillation in nonhypertensive and hypertensive individuals. | The aim of this study was to compare the predictive value of ECG abnormalities for atrial fibrillation in nonhypertensive versus hypertensive individuals.</AbstractText>We recorded ECG and measured conventional cardiovascular risk factors in a nationwide population-based sample of 5813 Finns. We divided the participants into nonhypertensive (n = 3148) and hypertensive (n = 2665) individuals and followed the participants for incident atrial fibrillation events. We evaluated the predictive ability of 12 ECG abnormalities for atrial fibrillation using multivariable-adjusted Fine-Gray models.</AbstractText>During a follow-up of 11.9 ± 2.9 years, 111 nonhypertensive and 301 hypertensive participants developed atrial fibrillation. Negative T wave in lateral leads predicted atrial fibrillation in both nonhypertensive [hazard ratio (HR), 4.59; 95% confidence interval (95% CI) 1.84-11.44] and hypertensive participants (HR, 1.81; 95% CI 1.16-2.84). In nonhypertensive participants, 1-SD increments in corrected QT interval (HR, 1.42; 95% CI, 1.18-1.71) and T-wave amplitude in lead augmented vector R (aVR) (HR, 1.40; 95% CI, 1.10-1.80) were related to atrial fibrillation. In hypertensive participants, prolonged PR interval (HR, 1.59; 95% CI 1.05-2.41), prolonged P-wave duration (HR, 1.43; 95% CI 1.07-1.91), left ventricular hypertrophy by Sokolow-Lyon criteria (HR, 1.55; 95% CI, 1.12-2.14) and poor R-wave progression (HR, 1.59; 95% CI, 1.02-2.48) predicted atrial fibrillation. Corrected QT interval and T-wave amplitude in lead aVR were stronger predictors of atrial fibrillation in nonhypertensive than in hypertensive participants. ECG abnormalities improved risk prediction only marginally (delta area under receiver-operating-characteristic curve = 0.000-0.005).</AbstractText>Several ECG abnormalities associate with incident atrial fibrillation in hypertensive and nonhypertensive individuals but provide only marginal incremental predictive value. Corrected QT interval and T-wave amplitude in lead aVR may relate stronger to incident atrial fibrillation in nonhypertensive than in hypertensive individuals.</AbstractText> |
19,424 | Heart rate variability parameters in children with ventricular preexcitation. | The autonomic nervous system has a regulatory effect on cardiac electrophysiology and arrhythmogenesis. We aimed to assess cardiac autonomic status using heart rate variability (HRV) parameters in children with ventricular preexcitation.</AbstractText>The electrocardiography, Holter monitoring, transesophageal electrophysiological study (TEEPS), and invasive electrophysiological study (EPS) results of ventricular preexcitation patients obtained over a 7-year period in our clinic were evaluated. According to the TEEPS results, patients' accessory pathway conduction was classified as adverse (n = 40) or nonadverse (n = 25). The HRV parameters of patients were compared according to tachycardia inducibility that assessed by TEEPS and EPS. Also, HRV parameters were compared in patients with adverse and nonadverse pathway conduction. Further, the HRV parameters of preexcitation patients were compared with those of healthy controls.</AbstractText>LF/HF, the best measure of sympathovagal balance, was statistically higher in patients with adverse conduction than in patients without adverse conduction and controls (P  =  0.001). The LF/HF ratio was higher in ventricular preexcitation patients with inducible tachycardia than those without in EPS (P  =  0.001). In addition, the LF/HF ratio was higher in symptomatic ventricular preexcitation patients than asymptomatic ones (P  =  0.001). No difference in HRV parameters was found between preexcitation patients and controls.</AbstractText>Autonomic tonus in patients with ventricular preexcitation may affect accessory pathway conduction properties, tachycardia inducibility, and symptomology. The indicator of sympathovagal balance, LF/HF ratio, increased in ventricular preexcitation patients with inducible tachycardia and those that were symptomatic.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
19,425 | Impact of Thoracoscopic Pulmonary Vein Isolation on Right Ventricular Function: A Pilot Study. | Thoracoscopic surgical pulmonary vein isolation (sPVI) has been added to the treatment of atrial fibrillation (AF), showing excellent efficacy outcomes. However, data on right ventricular (RV) function following sPVI has never been studied. Our aim was to investigate RV function following sPVI and compare it to patients who underwent endocardial cryoballoon PVI.</AbstractText>25 patients underwent sPVI and were pair-matched according to age, sex, and AF type with 21 patients who underwent cryoballoon PVI. RV function was measured using tricuspid annular plane systolic excursion (TAPSE) and RV strain with 2D speckle tracking. Echocardiography was performed at baseline and at median 6-month follow-up.</AbstractText>Age was 54 ± 9 years and 84% were male; AF was paroxysmal in 92%. In the sPVI group, TAPSE was reduced with 31% at follow-up echocardiography (p</i> < 0.001) and RV strain showed a 25% reduction compared to baseline (p</i> = 0.018). In the control group, TAPSE and RV strain did not change significantly (-3% and +13%, p</i> = 0.410 and p</i> = 0.148). Change in TAPSE and RV strain was significantly different between groups (p</i> ≤ 0.001 and p</i> = 0.005).</AbstractText>This study shows that RV function is significantly decreased following sPVI. This effect was not observed in the cryoballoon PVI control group.</AbstractText> |
19,426 | The nightmare ECG of a spontaneously aborted sudden cardiac death. | We present the case of a spontaneously aborted sudden cardiac death related to an high-rate ventricular tachycardia in an healthy man with bileaflet mitral valve prolapse. An effective treatment of the patient, with complete suppression of ventricular ectopic activity, was achieved only combining medical therapy, ICD and catheter ablation, thus overcoming the limitations of each approach. |
19,427 | Increased left atrial size is associated with higher atrial fibrillation recurrence in patients treated with antiarrhythmic medications. | Atrial fibrillation (AF) is highly prevalent, and antiarrhythmic therapy is often used to help with rhythm control. Some common echocardiographic parameters may be useful in predicting AF recurrence among these patients. The purpose of this study was to evaluate the association between 3 common echocardiographic parameters (left atrial [LA] size, left ventricular ejection fraction [LVEF], and mitral regurgitation [MR]) and AF recurrence among patients treated with antiarrhythmic medications.</AbstractText>We hypothesized that LA size, LVEF, and severity of MR are predictors of AF recurrence in this population.</AbstractText>A real-world cohort of AF patients who had transthoracic echocardiograms was analyzed. Data on LA size, LVEF, and MR were collected retrospectively from echocardiography reports. Patients were followed from the time of the echocardiogram until first recurrence of AF.</AbstractText>A total of 2522 patients had echocardiography reports available for review. LA size showed the strongest prognostic relationship with AF recurrence; neither LVEF nor MR was significantly associated with AF recurrence. These results persisted after adjusting for age, sex, race, tobacco use, alcohol use, drug use, body mass index, and Charlson Comorbidity Index in a multivariable model.</AbstractText>In a cohort of patients treated with antiarrhythmic medications that had transthoracic echocardiogram data, LA size was a significant predictor of AF recurrence. The clinical utility of this finding would be strengthened by replication in a multicenter setting.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
19,428 | Atrial remodeling and ectopic burden in recreational athletes: Implications for risk of atrial fibrillation. | Atrial remodeling, vagal tone, and atrial ectopic triggers are suggested to contribute to increased incidence of atrial fibrillation (AF) in endurance athletes. How these parameters change with increased lifetime training hours is debated.</AbstractText>Atrial remodeling occurs in proportion to total training history, thus contributing to elevated risk of AF.</AbstractText>We recruited 99 recreational endurance athletes, subsequently grouped according to lifetime training hours, to undergo evaluation of atrial size, autonomic modulation, and atrial ectopy. Athletes were grouped by self-reported lifetime training hours: low (<3000 h), medium (3000-6000 h), and high (>6000 h). Left atrial (LA) volume, left ventricular (LV) dimensions, and LV systolic and diastolic function were assessed by echocardiography. We used 48-hour ambulatory electrocardiographic monitoring to determine heart rate, heart rate variability, premature atrial contractions, and premature ventricular contractions.</AbstractText>LA volume was significantly greater in the high (+5.1 mL/m2</sup> , 95% CI: 1.3-8.9) and medium (+4.2 mL/m2</sup> , 95% CI: 0.2-8.1) groups, compared with the low group. LA dilation was observed in 19.4%, 12.9%, and 0% of the high, medium, and low groups, respectively (P = 0.05). No differences were observed between groups for measures of LV dimensions or function. Minimum heart rate, parasympathetic tone expressed using heart rate variability indices, and premature atrial contraction and premature ventricular contraction frequencies did not differ between groups.</AbstractText>In recreational endurance athletes, increased lifetime training is associated with LA dilation in the absence of increased vagal parameters or atrial ectopy, which may promote incidence of AF in this cohort.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
19,429 | Mapping and ablation of RVOT-type arrhythmias: comparison between the conventional and reversed U curve methods. | We assessed conventional and reversed U curve methods for mapping and ablation of RVOT-type VAs.</AbstractText>Single-center data were reviewed from consecutive cases of symptomatic VAs of RVOT-type origin that were mapped and ablated successfully using conventional method in RVOT (pulmonary artery might be included) from January 2014 to December 2015 (cohort 1, n = 75) or conventional method in RVOT and reversed U curve in PSC (for first ablation attempt) from January 2016 to March 2017 (cohort 2, n = 60).</AbstractText>At least 90% of RVOT-VAs could be eliminated using conventional method in RVOT or reversed U curve in PSC. For RVOT-VAs, if the earliest activation site was in midposterior free wall, midposterior septal side of RVOT, or anterior free wall/septal side of RVOT with conventional method, it was likely eliminated in right, left, and anterior PSC with reversed U curve method, respectively. Nearly the same earliest potential in almost the same region could be recorded by both methods. Compared with conventional method, the reversed U curve method showed better catheter stability and contact force during mapping and ablation, and showed distinctive features in presystolic potential recording, unipolar mapping, and ablation response.</AbstractText>Most of RVOT-VAs could be eliminated using conventional method in RVOT or reversed U curve in PSC. However, the reversed U curve method has superiority in catheter stability and contact force, especially for VAs form free wall of RVOT.</AbstractText> |
19,430 | Effects of Postconditioning with Fructose on Arrhythmias and the Size of Infarct Caused by Global Ischemia and Reperfusion in Isolated Rat Heart. | <b><i>Purpose:</i></b> In the present study, postconditioning effect of fructose against ischemia/reperfusion (I/R)-induced arrhythmias and infarct size were investigated in isolated rat heart. <b><i>Methods:</i></b> The isolated hearts were divided into 7 groups, mounted on a Langendorff apparatus at constant pressure then subjected to 30 min zero flow global ischemia followed by 120 min reperfusion. In the control group, normal Krebs-Henseleit (K/H) solution was perfused into the hearts throughout the experiment. In two separate sets of experiments, the treatment groups received 12, 24 and 48 mM of fructose with/without normal glucose in K/H solution for 20 min at the beginning of reperfusion. Cardiac arrhythmias including number of ventricular tachycardia (VT), total ventricular ectopic beats, incidence and duration of VT, reversible and irreversible ventricular fibrillation were recorded and analyzed during the first 30 min of reperfusion. Computerized planimetry method was used to determine volume and percentage of infarct size. <b><i>Results:</i></b> Administration of fructose as a postconditioning agent clearly reduced volume and percentage of infarct size in the all treatment groups. The effect was statistically significant especially in the hearts that treated by fructose plus glucose (P<0.05). However, fructose alone or its co-administration with glucose had no significant inhibitory effect against reperfusion arrhythmias. <b><i>Conclusion:</i></b> The results showed that perfusion of high concentration of fructose alone or coincident with glucose in globally ischemic-reperfused isolated rat hearts can reduce infarct size without inhibitory effect against reperfusion arrhythmias. Probably, fructose by providing adequate ATP for cardiac functions may inhibit necrosis and death of cardiomyocytes during I/R. |
19,431 | Effects of microRNA-292-5p on myocardial ischemia-reperfusion injury through the peroxisome proliferator-activated receptor-α/-γ signaling pathway. | Ischemia-reperfusion injury (IRI) is a major cause of cardiac damage following various pathological processes, such as free radical damage and cell apoptosis. This study aims to investigate whether microRNA-292-5p (miR-292-5p) protects against myocardial ischemia-reperfusion injury (IRI) via the peroxisome proliferator-activated receptor (PPAR)-α/-γ signaling pathway in myocardial IRI mice models. Mouse models of myocardial IRI were established. Adult male C57BL/6 mice were divided into different groups. The hemodynamic indexes, levels of related inflammatory factors and serum myocardial enzymes, and malondialdehyde (MDA) content and the activity of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) were detected. The 2,3,5-triphenyltetrazolium chloride (TTC) staining was applied to determine infarct size. TUNEL staining was used to detect cardiomyocyte apoptosis. RT-qPCR and western blotting were performed to measure the related gene expressions. Compared with the model group and the T0070907 + miR-292-5p inhibitor, the miR-292-5p inhibitor group exhibited decreased incidence and duration time of ventricular tachycardia and ventricular fibrillation, serum myocardial enzymes, TNF-α, IL-6, IL-1β, MDA, cardiomyocyte apoptosis, expressions of Bax and p53 in addition to increased SOD and GSH-Px activity, and increased expressions of Bcl-2, PPARα, PPARγ, PLIN5, AQP7, and PCK1. The T0070907 group exhibited opposite results compared to the miR-292-5p inhibitor group. The results indicate that miR-292-5p downregulation protects against myocardial IRI through activation of the PPAR-α/PPAR-γ signaling pathway. |
19,432 | A delayed diagnosis of catecholaminergic polymorphic ventricular tachycardia with a mutant of RYR2 at c.7580T>G for 6 years in a 9-year-old child. | Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare but potentially lethal inherited arrhythmia syndrome induced by adrenergic stress. Due to the atypical clinical manifestations in early age, limited recognition and experience of pediatric cardiologists, and low awareness of the significance of genetic diagnosis in some underdeveloped areas in China, a delayed or missed diagnosis of CPVT in children is common and concerning.</AbstractText>A 9-year and 3-month male child with recurrent exercise-induced syncope accompanied by convulsion was initially misdiagnosed as epilepsy since the first manifestation at the age of 3 years. Due to the identification of polymorphic ventricular premature beats, nonsustained ventricular tachycardia (VT), and supraventricular tachycardia, a cardiogenic etiology was established. The patient received a successive treatment by propafenone, amiodarone, a combination of amiodarone with metoprolol, and metoprolol alone for up to 6 years.</AbstractText>Given the poor response to conventional antiarrhythmics, excise-induced syncope, QRS morphology and a structurally normal heart, the diagnosis of CPVT was suspected, and ultimately confirmed by detection of polymorphic and bidirectional VT with degeneration into ventricular fibrillation during exercise testing. In addition, a heterozygous mutant of RYR2 at c.7580T > G was identified by genetic testing.</AbstractText>Due to the unavailability of flecainide in China and the refusal of implantable cardioverter defibrillator implantation by his parents, this patient continued to be treated with oral metoprolol.</AbstractText>Unfortunately, the effect was unfavorable during 4 months outpatient follow-up.</AbstractText>CPVT should be suspected in young patients with a normal baseline electrocardiogram (EKG), a structurally normal heart and polymorphic and/or bidirectional ventricular tachycardia induced by exercise or emotional stress. Exercise and genetic testing is essential and significant for a timely and accurate diagnosis of CPVT. The current study firstly reported a case with CPVT associated with a mutant of RYR2 at c.7580T > G in children.</AbstractText> |
19,433 | Early repolarization is involved in ventricular fibrillation in patients with variant angina. | Variant angina (VA) is caused by reversible coronary artery spasm, which is characterized by chest pain with ST segment elevations on a standard 12-lead electrocardiogram (ECG) at rest. VA attack often causes lethal ventricular arrhythmia. The early repolarization (ER) pattern is associated with ventricular fibrillation (VF). However, whether the ER pattern is involved in VF in patients with VA is not known. We investigated the association between the ER pattern and VF in patients with VA.</AbstractText>Fifty patients underwent induction of ST elevation on 12-lead ECGs with total or nearly total occlusion by provocation test (VA patients). Twelve of these patients underwent induction of VF or had documented VF before hospital admission (VF occurrence group). The J-wave morphology was characterized as exhibiting notching or slurring. The amplitude of each J wave was measured manually with amplified waveforms.</AbstractText>ER patterns were observed significantly more often in the VF occurrence group than in the non-VF occurrence group (P = 0.007). The J-wave amplitude was significantly higher in the VF occurrence group compared with the non-VF occurrence group (P = 0.02). Univariate analyses suggested that age, smoking, and ER patterns were associated with VF. Upon multivariate analyses, age (odds ratio [OR] = 0.880; 95% confidence interval [CI]: 0.794-0.975; P = 0.014) and ER patterns (OR = 8.937; 95% CI:1.661-48.06; P = 0.011) predicted VF independently.</AbstractText>These data suggest that an ER pattern in VA patients is a risk factor for VF. The ER pattern may be one of the useful factors for adaptation of implantation of implantable cardioverter-defibrillator in patients with coronary spasm-induced VF.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
19,434 | Revisiting Atrioventricular Nodal Ablation and Cardiac Pacing of Atrial Fibrillation in a Patient with Dextrocardia. | BACKGROUND Poorly controlled ventricular rate associated with atrial fibrillation (AF) leads to tachycardia-induced left ventricular dysfunction. Atrioventricular (AV) nodal ablation and cardiac pacing is the standard of care in refractory congestive heart failure (CHF) due to AF with moderate to rapid ventricular response that failed conventional medical therapy. If the patient is not a candidate for AF ablation with pulmonary vein isolation and elimination of AF foci, this is an effective approach, but it does have some challenges when done in a patient with dextrocardia and situs inversus. CASE REPORT Our patient was a 77-year-old woman with dextrocardia and situs inversus, with a history of permanent AF due to severe coronary artery disease (CAD), who suffered from recurrent CHF exacerbations from permanent AF with moderate to rapid ventricular response with underlying hypertensive cardiovascular disease. She was a poor candidate for pulmonary vein isolation because of her permanent AF status and high risk of recurrence. She underwent a technically challenging AV nodal ablation with cardiac pacing due to the complex anatomy, with drastic improvement of symptoms within the next 24 h. CONCLUSIONS AV nodal ablation with cardiac pacing is the standard of care in patients with refractory AF with moderate to rapid ventricular response who have failed medical therapy and are not candidates for pulmonary vein isolation. |
19,435 | EEG Artifact Versus Subclinical Status Epilepticus in a Patient Following Cardiac Arrest. | A challenge in ICU EEG interpretation is identifying subclinical status epilepticus versus patterns on the ictal-interictal continuum versus other repetitive patterns. In the electrically noisy intensive care unit, identifying and eliminating interference and artifact allow accurate diagnoses from the EEG, avoiding unnecessary treatment or sedation.</AbstractText>We present a case during Impella (Abiomed Inc, Danvers, MA) continuous flow left ventricular assist device use where the EEG artifact was initially misinterpreted as seizure by the resident and treated as status epilepticus because of the "focal" sharply contoured repetitive pattern. During percutaneous coronary intervention (PCI), an 88-year-old developed ventricular tachycardia followed by ventricular fibrillation requiring chest compressions for 10 min, multiple defibrillations, and treatment with epinephrine, amiodarone, calcium, bicarbonate, and magnesium. The patient had an Impella placed during PCI with therapeutic hypothermia initiated after the cardiopulmonary arrest. His neurological exam demonstrated preserved pupillary, corneal, gag and cough reflexes and spontaneous respirations.</AbstractText>Long-term video EEG monitoring is included in our institution's hypothermia protocol. Initial baseline EEG performed 2 h after PCI showed a persistent rhythmic sharp discharge from the left central temporal region resembling left hemisphere status epilepticus. The sharp waves have an alternating repeating 2:1 relationship with the EKG rhythm strip. This is best seen in the left hemisphere, which we posit is related to the Impella's positioning across the aortic valve pointing toward the patient's left side. A chest x-ray confirmed the device's position immediately before EEG monitoring. Arterial pressure tracings were not available in the chart.</AbstractText>There is a low-amplitude spiky artifact; however, there was no pacing at that time. It is possible that synergistic flow with systole/diastole reinforced the pulsatility with movement of the Impella, resulting in the alternating pattern. The patient's hemodynamic instability precluded extensive troubleshooting with the Impella device, but after EEG repositioning, the artifact was eliminated.</AbstractText> |
19,436 | Combining early post-resuscitation EEG and HRV features improves the prognostic performance in cardiac arrest model of rats. | Early and reliable prediction of neurological outcome remains a challenge for comatose survivors of cardiac arrest (CA). The purpose of this study was to evaluate the predictive ability of EEG, heart rate variability (HRV) features and the combination of them for outcome prognostication in CA model of rats.</AbstractText>Forty-eight male Sprague-Dawley rats were randomized into 6 groups (n=8 each) with different cause and duration of untreated arrest. Cardiopulmonary resuscitation was initiated after 5, 6 and 7min of ventricular fibrillation or 4, 6 and 8min of asphyxia. EEG and ECG were continuously recorded for 4h under normothermia after resuscitation. The relationships between features of early post-resuscitation EEG, HRV and 96-hour outcome were investigated. Prognostic performances were evaluated using the area under receiver operating characteristic curve (AUC).</AbstractText>All of the animals were successfully resuscitated and 27 of them survived to 96h. Weighted-permutation entropy (WPE) and normalized high frequency (nHF) outperformed other EEG and HRV features for the prediction of survival. The AUC of WPE was markedly higher than that of nHF (0.892 vs. 0.759, p<0.001). The AUC was 0.954 when WPE and nHF were combined using a logistic regression model, which was significantly higher than the individual EEG (p=0.018) and HRV (p<0.001) features.</AbstractText>Earlier post-resuscitation HRV provided prognostic information complementary to quantitative EEG in the CA model of rats. The combination of EEG and HRV features leads to improving performance of outcome prognostication compared to either EEG or HRV based features alone.</AbstractText>Copyright © 2018. Published by Elsevier Inc.</CopyrightInformation> |
19,437 | The usefulness of ventricular pacing during atrial fibrillation ablation in a persistent left superior vena cava: A case report. | A 69-year-old woman with palpitations was referred to our hospital for a second session of atrial fibrillation (AF) catheter ablation. She had a history of AF ablation including pulmonary vein (PV) isolation and persistent left superior vena cava (PLSVC) isolation. Electrophysiologic studies showed the veno-atrial connections that had recovered. After PV isolation was performed, AF was induced by atrial premature contraction (APC) from the PLSVC, and AF storm occurred. During PLSVC isolation, AF was not induced by APC from the PLSVC. PLSVC isolation continued during sinus rhythm. The elimination of the PLSVC potential was difficult to confirm because of the far-field potential of the left ventricle. Then, we performed right ventricular pacing. The remaining PLSVC potential was identified. After that, the PLSVC isolation was successful during right ventricular pacing. Complications were not observed. The patient had no recurrence of AF thereafter. |
19,438 | Use of digoxin in atrial fibrillation: One step further in the mortality controversy from the AFFIRM study. | Whether there is a causal association between digoxin and mortality among patients with atrial fibrillation (AF), with or without congestive heart failure (HF), has been controversial; in particular, two prior analyses of data from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial have yielded conflicting results. We sought to investigate how digoxin impacts mortality, in the full AFFIRM cohort and for various subgroups, by applying marginal structural modeling (MSM) to AFFIRM data.</AbstractText>MSM is a newer statistical approach, which estimates causal association in the absence of randomization. MSM more effectively accounts for time-varying treatment and mitigates potential biases, in contrast to the two statistical approaches used in prior analyses of the AFFIRM data.</AbstractText>Among 4,060 patients in AFFIRM, 660 (16.3%) died during follow-up. Digoxin was associated with significantly higher mortality in the full cohort (estimated hazard ratio [HR] 1.33, 95% confidence interval [CI] 1.11-1.60, P  =  0.002) and in 3,121 patients without HF (HR 1.36, 95% CI 1.07-1.72, P  =  0.011). There was a trend toward higher mortality with digoxin in 939 patients with HF (HR 1.29, 95% CI 0.96-1.72, P  =  0.090). Associations were nonsignificant in 463 patients with HF and left ventricular ejection fraction (EF) ≥40% and in 155 patients with EF ≤30%.</AbstractText>Digoxin is associated with significantly increased mortality among AFFIRM patients collectively, as determined by MSM statistical methodology. However, the impact of digoxin among AFFIRM patients with coexisting HF is inconclusive.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
19,439 | Nitrite circumvents platelet resistance to nitric oxide in patients with heart failure preserved ejection fraction and chronic atrial fibrillation. | Heart failure (HF) is a pro-thrombotic state. Both platelet and vascular responses to nitric oxide (NO) donors are impaired in HF patients with reduced ejection fraction (HFrEF) compared with healthy volunteers (HVs) due to scavenging of NO, and possibly also reduced activity of the principal NO sensor, soluble guanylate cyclase (sGC), limiting the therapeutic potential of NO donors as anti-aggregatory agents. Previous studies have shown that nitrite inhibits platelet activation presumptively after its reduction to NO, but the mechanism(s) involved remain poorly characterized. Our aim was to compare the effects of nitrite on platelet function in HV vs. HF patients with preserved ejection fraction (HFpEF) and chronic atrial fibrillation (HFpEF-AF), vs. patients with chronic AF without HF, and to assess whether these effects occur independent of the interaction with other formed elements of blood.</AbstractText>Platelet responses to nitrite and the NO donor sodium nitroprusside (SNP) were compared in age-matched HV controls (n = 12), HFpEF-AF patients (n = 29), and chronic AF patients (n = 8). Anti-aggregatory effects of nitrite in the presence of NO scavengers/sGC inhibitor were determined and vasodilator-stimulated phosphoprotein (VASP) phosphorylation was assessed using western blotting. In HV and chronic AF, both nitrite and SNP inhibited platelet aggregation in a concentration-dependent manner. Inhibition of platelet aggregation by the NO donor SNP was impaired in HFpEF-AF patients compared with healthy and chronic AF individuals, but there was no impairment of the anti-aggregatory effects of nitrite. Nitrite circumvented platelet NO resistance independently of other blood cells by directly activating sGC and phosphorylating VASP.</AbstractText>We here show for the first time that HFpEF-AF (but not chronic AF without HF) is associated with marked impairment of platelet NO responses due to sGC dysfunction and nitrite circumvents the 'platelet NO resistance' phenomenon in human HFpEF, at least partly, by acting as a direct sGC activator independent of NO.</AbstractText> |
19,440 | New-Onset Ventricular Arrhythmias in Patients with Left Ventricular Dysfunction after Coronary Surgery: Incidence, Risk Factors, and Prognosis. | The incidence, risk factors, and long-term prognosis of new-onset ventricular tachycardia (VT) and ventricular fibrillation (VF) after coronary artery bypass graft surgery (CABG) in patients with impaired left ventricular function have not been thoroughly examined. Methods: This study enrolled 612 consecutive patients with impaired left ventricular function (ejection fraction <50%) undergoing CABG at a single institution between March, 1996, and September, 2015. Outcomes were analyzed and compared, including in-hospital mortality and long-term survival. After a propensity-score, matching was performed to adjust for differences between the two cohorts. Factors significantly associated with VT/VF were also investigated using multivariate logistic regression.</AbstractText>Of the 600 patients included in the analyses, 92 (15.3%; 95% confidence interval [CI] 12.5-18.3%) had new-onset VT/VF postoperatively. Before propensity matching, patients with postoperative VT/VF were more likely to have renal failure, intra-aortic balloon pump support, lower preoperative ejection fraction (EF), and a larger left ventricle than those without VT/VF. Multivariate regression identified three preoperative risk factors and one protective factor that were independently associated with new-onset VT/VF: previous renal failure (odds ratio [OR] 4.42, P = .02), left ventricular end-diastolic dimension enlargement (OR 1.83, P = .03), ejection fraction (OR 1.88, P = .02 for EF ≥30 and <40% versus ≥40% and <50%; OR 5.46, P = .00 for EF <30% versus ≥40% and <50%), and preoperative β-blockers (OR 0.58, P = .03). The median follow-up time was 46.6 months. In the propensity-matched cohorts, survival for patients who had in-hospital VT/VF was lower than that of the non-VT/VF group (89.9% versus 97.6%; P < .05).</AbstractText>This study shows a high incidence of new-onset VT/VF after CABG in patients with impaired left ventricular function. The early and long-term survival rates were significantly lower in the VT/VF group. Preoperative renal failure, left ventricular end-systolic dimension enlargement, and the severity of left ventricular function were independently associated with the development of new-onset VT/VF after CABG surgery. Preoperative use of beta-blocker was proved to be protective in reducing both VT/VF incidence and in-hospital mortality in CABG patients with impaired left ventricular function following CABG. When considering these data, a prescription of beta-blockers is prognostically indicated to CABG patients, especially those with new-onset VT/VF postoperatively.</AbstractText> |
19,441 | Treatment of a patient with acute aortic dissection using extracorporeal cardiopulmonary resuscitation after an out-of-hospital cardiac arrest: a case report. | Circulatory support using veno-arterial extracorporeal membrane oxygenation for aortic disease is conventionally contraindicated. In this case, a 66-year-old man experienced cardiopulmonary arrest caused by acute aortic dissection. When exercising in the gym, he experienced chest discomfort, so the staff immediately called an ambulance. While in the ambulance, he experienced cardiopulmonary arrest. His initial electrocardiogram showed ventricular fibrillation. At the emergency department, we immediately performed extracorporeal cardiopulmonary resuscitation. We suspected acute coronary syndrome, so coronary angiography was carried out. Enlargement of ascending aorta was noted. Whole-body enhanced computed tomography was subsequently performed, leading to a final diagnosis of acute aortic dissection.</AbstractText>Emergency ascending aorta prosthesis implantation was performed. The patient received intensive care and was discharged on day 49 of hospitalization. His cerebral performance category score was 4 at discharge.</AbstractText>This case suggests that veno-arterial extracorporeal membrane oxygenation may be used for patients with aortic dissection presenting with cardiac arrest.</AbstractText> |
19,442 | High defibrillation threshold with a subcutaneous implantable cardiac defibrillator due to the lead having been positioned in the fat layer. | A 46-year-old female with a body mass index of 38.9 kg/m<sup>2</sup> and no organic heart disease underwent a subcutaneous implantable cardioverter-defibrillator implantation for secondary prevention of sudden cardiac death in the setting of idiopathic ventricular fibrillation. Defibrillation threshold (DFT) testing during implantation detected high shock impedance and high DFT. Fluoroscopy revealed subcoil fat between the lead and the sternum, which we suspected was the reason for the high shock impedance and high DFT. We repositioned the lead to a site just above the sternum and the shock impedance and DFT improved to within the respective normal ranges. |
19,443 | Impact of ranolazine on ventricular arrhythmias - A systematic review. | Ranolazine is a new medication for the treatment of refractory angina. However, except its anti-anginal properties, it has been found to act as an anti-arrhythmic. The aim of our systematic review is to present the existing data about the impact of ranolazine in ventricular arrhythmias. We searched MEDLINE and Cochrane databases as well clinicaltrials.gov until September 1, 2017 to find all studies (clinical trials, observational studies, case reports/series) reported data about the impact of ranolazine in ventricular arrhythmias. Our search revealed 14 studies (3 clinical trials, 2 observational studies, 8 case reports, 1 case series). These data reported a beneficial impact of ranolazine in ventricular tachycardia/fibrillation, premature ventricular beats, and ICD interventions in different clinical settings. The existing data highlight the anti-arrhythmic properties of ranolazine in ventricular arrhythmias. |
19,444 | Periprocedural Complications in Patients Undergoing Catheter Ablation of Atrial Fibrillation Without Discontinuation of a Vitamin K Antagonist and Direct Oral Anticoagulants. | Periprocedural anticoagulation is important in catheter ablation (CA) of atrial fibrillation (AF) and there is increasing evidence that uninterrupted vitamin K antagonist (VKA) therapy is superior to interrupted anticoagulation strategies. Since the emergence of direct oral anticoagulants (DOACs), numerous studies have shown promising results for their use in uninterrupted strategies. However, further studies are needed to further define the efficacy and safety of performing AF ablation with uninterrupted factor XA inhibitors or direct thrombin inhibitors.Methods and Results:We have performed CA of AF without discontinuation of either VKA or DOAC therapy since April 2014. A total of 376 patients with AF underwent CA including pulmonary vein isolation. All of the patients were divided into 2 groups (uninterrupted VKA or uninterrupted DOACs). Anticoagulation with DOACs was associated with fewer complications than uninterrupted VKA therapy (P=0.04). There were significant differences between groups in the rates of congestive heart failure, left ventricular ejection fraction, body weight, and estimated glomerular filtration rate and of the CHADS2</sub>, CHA2</sub>DS2</sub>-VASc and HAS-BLED scores. Therefore, we also analyzed the results using the propensity score-matching method. We found no significant difference in periprocedural complications between uninterrupted VKA or DOACs therapy (P=0.65).</AbstractText>CA of AF without discontinuation of DOACs is not inferior to CA without discontinuation of a VKA, with regard to ischemic or hemorrhagic complications.</AbstractText> |
19,445 | Functional selectivity of cardiac preganglionic sympathetic neurones in the rabbit heart. | Studies have shown regional and functional selectivity of cardiac postganglionic neurones indicating there might exist a similar heterogeneity in spinal segmental preganglionic neurones, which requires further investigation.</AbstractText>Right and left sympathetic chains were electrically stimulated from T6 to T1 in the innervated isolated rabbit heart preparation (n = 18). Sinus rate, left ventricular pressure, retrograde ventriculo-atrial conduction, monophasic action potential duration, effective refractory period, ventricular fibrillation threshold and electrical restitution were measured.</AbstractText>Right sympathetic stimulation had a greater influence on heart rate (T1-T2: right; 59.9 ± 6.0%, left; 41.1 ± 5.6% P < 0.001) and left stimulation had greater effects on left ventricular pressure (T1-T2: right; 20.7 ± 3.2%, left; 40.3 ± 5.4%, P < 0.01) and ventriculo-atrial conduction (T1-T2: right; -6.8 ± 1.1%, left; -15.5 ± 0.2%) at all levels, with greater effects at rostral levels (T1-T3). Left sympathetic stimulation caused shorter monophasic action potentials at the base (T4-T5: right; 119.3 ± 2.7 ms, left; 114.7 ± 2.5 ms. P < 0.05) and apex (T4-T5: right; 118.8 ± 1.2 ms, left; 114.6 ± 2.6 ms. P < 0.05), greater shortening of effective refractory period (T4-T5: right; -3.6 ± 1.3%, left; -7.7 ± 1.8%. P < 0.05), a steeper maximum slope of restitution (T4-T5 base: right; 1.3 ± 0.2, left; 1.8 ± 0.2. P < 0.01. T4-T5 apex: right; 1.0 ± 0.2, left; 1.6 ± 0.3. P < 0.05) and a greater decrease in ventricular fibrillation threshold (T4-T5: right; -22.3 ± 6.8%, left;-39.0 ± 1.7%), with dominant effects at caudal levels (T4-T6).</AbstractText>The preganglionic sympathetic efferent axons show functionally distinct pathways to the heart. The caudal segments (T4-T6) of the left sympathetic chain had a greater potential for arrhythmia generation and hence could pose a target for more focused clinical treatments for impairments in cardiac function.</AbstractText>Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
19,446 | Cardiac resynchronization therapy: How did consensus guidelines from Europe and the United States evolve in the last 15 years? | Cardiac resynchronization therapy (CRT) was proposed around 20 years ago, and its clinical use rapidly moved from pioneering experiences to randomized controlled trials (RCT). Since 2002 recommendations for CRT have been included in international consensus guidelines that even in an early phase recommended CRT as an effective treatment for improving symptoms, reducing hospitalizations and mortality in well-selected patients with wide QRS, left ventricular dysfunction and moderate to severe heart failure (NYHA classes III-IV), on optimal medical therapy. Subsequently the indications were extended to mild (NYHA class II) heart failure (associated with left ventricular dysfunction and wide QRS) and more recently also to appropriately selected patients with conventional indications for pacing having a left ventricular ejection fraction of 50% or less and NYHA class I-III. While all the guidelines strongly recommend CRT in case of LBBB with QRS duration >150 ms, lower strength of recommendations, with some heterogeneity, appears when QRS duration is 130-150 ms, especially if not associated with LBBB. Of note, according to recent guidelines, CRT is not recommended in case of QRS duration <130 ms, which is now the lower limit for candidacy to CRT, differently from the 120 ms limit used before. Despite consensus guidelines, many data indicate that CRT is still underused, with great heterogeneity in its implementation, both in North America and Europe, thus requiring a more organized patient referral. |
19,447 | The impact of the CartoSound® image directly acquired from the left atrium for integration in atrial fibrillation ablation. | Intracardiac echocardiographic (ICE) imaging might be useful for integrating three-dimensional computed tomographic (CT) images for left atrial (LA) catheter navigation during atrial fibrillation (AF) ablation. However, the optimal CT image integration method using ICE has not been established.</AbstractText>This study included 52 AF patients who underwent successful circumferential pulmonary vein isolation (CPVI). In all patients, CT image integration was performed after the CPVI with the following two methods: (1) using ICE images of the LA derived from the right atrium and right ventricular outflow tract (RA-merge) and (2) using ICE images of the LA directly derived from the LA added to the image for the RA-merge (LA-merge). The accuracy of these two methods was assessed by the distances between the integrated CT image and ICE image (ICE-to-CT distance), and between the CT image and actual ablated sites for the CPVI (CT-to-ABL distance).</AbstractText>The mean ICE-to-CT distance was comparable between the two methods (RA-merge = 1.6 ± 0.5 mm, LA-merge = 1.7 ± 0.4 mm; p = 0.33). However, the mean CT-to-ABL distance was shorter for the LA-merge (2.1 ± 0.6 mm) than RA-merge (2.5 ± 0.8 mm; p < 0.01). The LA, especially the left-sided PVs and LA roof, was more sharply delineated by direct LA imaging, and whereas the greatest CT-to-ABL distance was observed at the roof portion of the left superior PV (3.7 ± 2.8 mm) after the RA-merge, it improved to 2.6 ± 1.9 mm after the LA-merge (p < 0.01).</AbstractText>Additional ICE images of the LA directly acquired from the LA might lead to a greater accuracy of the CT image integration for the CVPI.</AbstractText> |
19,448 | Validation by Cardiac Catheterization of Noninvasive Estimation of Time Constant of Left Ventricular Pressure Decline as an Index of Relaxation by Speckle Tracking Echocardiography. | There has been no established echocardiographic parameter to accurately assess left ventricular (LV) relaxation. Impaired LV relaxation assessed by the time constant of LV pressure decline (Tau) is one of the major components of diastolic dysfunction. We sought to noninvasively estimate Tau (eTau) by speckle tracking echocardiography (STE) and to validate the eTau against Tau by catheterization. Tau was reported to be calculated using the isovolumic relaxation time (IVRT), LV end-systolic pressure, and left atrial (LA) pressure. We reported that pulmonary capillary wedge pressure (ePCWP) can be noninvasively and accurately estimated as 10.8 - 12.4 × Log (LA active emptying function/minimum LA volume index). Therefore, the eTau by STE is noninvasively calculated using the formula: eTau = IVRT / (ln 0.9 × systolic blood pressure-ln ePCWP). Echocardiographic parameters were measured just before catheterization in 110 patients with cardiac disease (age 72 ± 8). There was a good correlation between the eTau and Tau by catheterization (r = 0.69, p <0.001), whereas IVRT and the e' had a poor correlation with Tau (r = 0.33 and -0.33, respectively). The sensitivity and specificity of the eTau to predict prolonged Tau (>48 ms) was 77% and 91%, respectively, with area under curve of 0.87 using an optimal cutoff of 48 ms. Bland-Altman analysis revealed a good agreement between the eTau and Tau. In conclusion, this study demonstrated that the eTau by our noninvasive method has a good correlation with Tau obtained by cardiac catheterization. LV relaxation may be noninvasively and accurately estimated by STE. |
19,449 | Permanent pacemaker use among patients with heart failure and preserved ejection fraction: Findings from the Acute Decompensated Heart Failure National Registry (ADHERE) National Registry. | Heart failure with preserved ejection fraction may be associated with chronotropic incompetence, but little is known about the incidence and prevalence of permanent pacemaker use in this population or factors associated with its use.</AbstractText>We analyzed patients with heart failure with preserved ejection fraction (ie, left ventricular ejection fraction greater than 40%) from the ADHERE registry (2001-2006) linked with Medicare claims. We described the use of both prevalent and incident permanent pacemakers in heart failure with preserved ejection fraction and determined factors associated with pacemaker use with logistic regression models.</AbstractText>Among 13,881 patients with heart failure with preserved ejection fraction, 3136 (22.6%) had a permanent pacemaker, and of these patients, 636 had a permanent pacemaker implanted during hospitalization. Permanent pacemaker use was more common among older patients (81 vs 79 years; P < .001), men (38% vs 34%; P < .001), patients with atrial fibrillation (58% vs 36%; P < .001), and patients with wider QRS duration (140 ms vs 94 ms; P < .001). Rates of digoxin, aldosterone antagonist, and loop diuretic use were slightly higher in patients with a permanent pacemaker compared with patients with no permanent pacemaker. Factors associated with both prevalent and incident pacemaker use included age, fast or slow heart rate, atrial fibrillation, and lower body mass index.</AbstractText>Use of permanent pacemakers is relatively common among patients with heart failure with preserved ejection fraction.</AbstractText>Copyright © 2018. Published by Elsevier Inc.</CopyrightInformation> |
19,450 | Electrocardiogram abnormalities related to anti-malarials in systemic lupus erythematosus. | Cardiotoxicity with potential conduction/structural abnormalities on electrocardiogram (ECG) have been reported with anti-malarial (AM). We aimed to study whether cumulative AM is associated with ECG abnormalities.</AbstractText>A standard resting supine ECG was performed on consecutive patients attending the Lupus Clinic since 2012. ECG abnormalities were grouped into structural [left ventricular hypertrophy or atrial enlargement] and conduction abnormalities [prolonged corrected QT interval (QTc), short PR interval, left bundle branch block (LBBB), right bundle branch block (RBBB) and atrioventricular block (AVB), bradycardia, tachycardia, premature atrial complex, ectopic atrial rhythm, atrial fibrillation, premature ventricular complex and ventricular bigeminy]. Associations between cumulative AM and ECG abnormalities (structural or conduction) were assessed using logistic regression analysis (after adjusting for baseline patient characteristics) and in a nested case-control study (1:3).</AbstractText>Of 453 patients treated with AM, the median cumulative AM was 1207 grams at ECG. Conduction abnormalities were more prevalent than structural abnormalities, 71 (15.7%) vs. 58 (12.8%). AM cumulative dose did not show a statistical significant association with ECG structural abnormalities, (OR 1.82, p=0.07) while it was protective for conduction ECG abnormalities (OR 0.42, p=0.006). The nested case-control analysis also found that AM cumulative dose is protective against conduction ECG abnormalities (OR 0.36, p=0.0007). SLE duration was a risk factor for both structural and conduction ECG abnormalities.</AbstractText>This study suggests an association between cumulative AM dose above the median (1207 g) and structural ECG abnormalities. More importantly, cumulative AM decreases the odds of ECG conduction abnormalities.</AbstractText> |
19,451 | Prophylactic preoperative levosimendan for off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: Single-centered randomized prospective study. | Off-pump coronary artery bypass surgery (OPCAB) is often complicated by hemodynamic instability, especially in patients with prior left ventricular (LV) dysfunction and appropriate choice of inotrope plays a vital role in perioperative management of these patients.</AbstractText>To study hemodynamic effects and immediate outcome of prophylactic infusion of levosimendan in patients with the LV dysfunction undergoing OPCAB surgery and whether this strategy helps in successful conduct of OPCAB surgery.</AbstractText>After Institutional Ethics Committee approval, 60 patients posted for elective OPCAB surgery were randomly divided into two groups (n = 30 each). Patients with the LV ejection fraction <30% were included. Study group was started on injection levosimendan (@ 0.1 μg/kg/min) in the previous night before surgery and continued for 24 h including intraoperative period. Hemodynamic monitoring included heart rate, invasive blood pressure, cardiac index (CI), pulmonary capillary wedge pressure (PCWP), pulse oximetry, and arterial blood gases with serum lactates at as T0 (baseline), T1 (15 min after obtuse marginal and/or PDA anastomoses), T2 (at end of surgery), T3 (6 h after surgery in Intensive Care Unit [ICU]), T4 (12 h after surgery), and T5 (24 h after surgery in ICU). Vasopressor was added to maintain mean arterial pressure >60 mmHg. Chi-square/Fisher's exact/Mid P exact test and Student's t-tests were applied for categorical and continuous data.</AbstractText>CI was greater and PCWP reduced significantly in Group L during intraoperative and early postoperative period. Serum lactate concentration was lower in patients pretreated with levosimendan. Incidence of postoperative atrial fibrillation (POAF) (36.6 vs. 6.6%; P = 0.01), low cardiac output syndrome (LCOS) (30% vs. 6%; P = 0.02), and acute kidney injury (23.3% vs. 6.7%; P = 0.04) was less in Group L. Three patients (10%) in control group required conversion to cardiopulmonary bypass (CPB) as compared to none in the study group. There was no difference regarding ICU or hospital stay and mortality in both groups.</AbstractText>Preoperative levosimendan helps in successful conduct of OPCAB and reduces the incidence of LCOS, POAF, conversion to CPB, and requirement of intra-aortic balloon pump.</AbstractText> |
19,452 | Percutaneous Closure of Left Atrial Appendage significantly affects Lipidome Metabolism. | Patients with non-valvular atrial fibrillation (AF) and a high risk for oral anticoagulation can be treated by percutaneous implantation of left atrial appendage occlusion devices (LAAC) to reduce the risk of cardio-embolic stroke. This study evaluates whether LAAC may influence lipid metabolism, which has never been investigated before. Patients with successful LAAC were included consecutively. Venous peripheral blood samples of patients were collected immediately before (T0, baseline) and 6 months after (T1, mid-term) LAAC. A targeted metabolomics approach based on electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements was performed. A total of 34 lipids revealed a significant change from baseline to mid-term follow-up after successful LAAC. Subgroup analysis revealed confounding influence by gender, age, diabetes mellitus type II, body mass index, left ventricular ejection fraction, creatinine and NT-proBNP. After multivariable adjustment within logistic regression models, these 34 lipids were still significantly altered after LAAC. Successful percutaneous LAAC may affect lipid metabolism and thereby may potentially affect pro-atherogenic and cardio-toxic effects. |
19,453 | RBM20 Mutations Induce an Arrhythmogenic Dilated Cardiomyopathy Related to Disturbed Calcium Handling. | Mutations in RBM20 (RNA-binding motif protein 20) cause a clinically aggressive form of dilated cardiomyopathy, with an increased risk of malignant ventricular arrhythmias. RBM20 is a splicing factor that targets multiple pivotal cardiac genes, such as Titin (TTN) and CAMK2D (calcium/calmodulin-dependent kinase II delta). Aberrant TTN splicing is thought to be the main determinant of RBM20-induced dilated cardiomyopathy, but is not likely to explain the increased risk of arrhythmias. Here, we investigated the extent to which RBM20 mutation carriers have an increased risk of arrhythmias and explore the underlying molecular mechanism.</AbstractText>We compared clinical characteristics of RBM20 and TTN mutation carriers and used our previously generated Rbm20 knockout (KO) mice to investigate downstream effects of Rbm20-dependent splicing. Cellular electrophysiology and Ca2+</sup> measurements were performed on isolated cardiomyocytes from Rbm20 KO mice to determine the intracellular consequences of reduced Rbm20 levels.</AbstractText>Sustained ventricular arrhythmias were more frequent in human RBM20 mutation carriers than in TTN mutation carriers (44% versus 5%, respectively, P=0.006). Splicing events that affected Ca2+</sup>- and ion-handling genes were enriched in Rbm20 KO mice, most notably in the genes CamkIIδ and RyR2. Aberrant splicing of CamkIIδ in Rbm20 KO mice resulted in a remarkable shift of CamkIIδ toward the δ-A isoform that is known to activate the L-type Ca2+</sup> current ( ICa,L</sub>). In line with this, we found an increased ICa,L</sub>, intracellular Ca2+</sup> overload and increased sarcoplasmic reticulum Ca2+</sup> content in Rbm20 KO myocytes. In addition, not only complete loss of Rbm20, but also heterozygous loss of Rbm20 increased spontaneous sarcoplasmic reticulum Ca2+</sup> releases, which could be attenuated by treatment with the ICa,L</sub> antagonist verapamil.</AbstractText>We show that loss of Rbm20 disturbs Ca2+</sup> handling and leads to more proarrhythmic Ca2+</sup> releases from the sarcoplasmic reticulum. Patients that carry a pathogenic RBM20 mutation have more ventricular arrhythmias despite a similar left ventricular function, in comparison with patients with a TTN mutation. Our experimental data suggest that RBM20 mutation carriers may benefit from treatment with an ICa,L</sub> blocker to reduce their arrhythmia burden.</AbstractText> |
19,454 | Assessing the Malignant Ventricular Arrhythmic Substrate in Patients With Brugada Syndrome. | Guidelines recommend the use of implanted cardioverter-defibrillators in patients with Brugada syndrome and induced ventricular tachyarrhythmias, but there is no evidence supporting it.</AbstractText>This prospective registry study was designed to explore clinical and electrophysiological predictors of malignant ventricular tachyarrhythmia inducibility in Brugada syndrome.</AbstractText>A total of 191 consecutive selected patients with (group 1; n = 88) and without (group 2; n = 103) Brugada syndrome-related symptoms were prospectively enrolled in the registry. Patients underwent electrophysiological study and substrate mapping or ablation before and after ajmaline testing (1 mg/kg/5 min).</AbstractText>Overall, before ajmaline testing, 53.4% of patients had ventricular tachyarrhythmia inducibility, which was more frequent in group 1 (65.9%) than in group 2 (42.7%; p < 0.001). Regardless of clinical presentation, larger substrates with more fragmented long-duration ventricular potentials were found in patients with inducible arrhythmias than in patients without inducible arrhythmias (p < 0.001). One extrastimulus was used in more extensive substrates (median 13 cm2</sup>; p < 0.001), and ventricular fibrillation was the more frequently induced rhythm (p < 0.001). After ajmaline, patients without arrhythmia inducibility had arrhythmia inducibility without a difference in substrate characteristics between the 2 groups. The substrate size was the only independent predictor of inducibility (odds ratio: 4.51; 95% confidence interval: 2.51 to 8.09; p < 0.001). A substrate size of 4 cm2</sup> best identified patients with inducible arrhythmias (area under the curve: 0.98; p < 0.001). Substrate ablation prevented ventricular tachyarrhythmia reinducibility.</AbstractText>In Brugada syndrome dynamic substrate variability represents the pathophysiological basis of lethal ventricular tachyarrhythmias. Substrate size is independently associated with arrhythmia inducibility, and its determination after ajmaline identifies high-risk patients missed by clinical criteria. Substrate ablation is associated with electrocardiogram normalization and not arrhythmia reinducibility. (Epicardial Ablation in Brugada Syndrome [BRUGADA_I]; NCT02641431; Epicardial Ablation in Brugada Syndrome: An Extension Study of 200 BrS Patients; NCT03106701).</AbstractText>Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,455 | Fever-related arrhythmic events in the multicenter Survey on Arrhythmic Events in Brugada Syndrome. | The literature on fever-related arrhythmic events (AEs) in Brugada syndrome (BrS) is currently limited to few case reports and small series.</AbstractText>The present study aimed to describe the characteristics of fever-related AE in a large cohort of patients with BrS.</AbstractText>The Survey on Arrhythmic Events in Brugada Syndrome is a multicenter study on 678 patients with BrS with first AE documented at the time of aborted cardiac arrest (n = 426) or after prophylactic implantable cardioverter-defibrillator implantation (n = 252).</AbstractText>In 35 of 588 patients (6%) with available information, the AE occurred during a febrile illness. Most of the 35 patients were male (80%), Caucasian (83%), and proband (70%). The mean age at the time of AE was 29 ± 24 years (range 0.3-76 years). Most patients (80%) presented with aborted cardiac arrest and 6 (17%) with arrhythmic storm. Family history of sudden death, history of syncope, and spontaneous type 1 Brugada electrocardiogram were noted in 17%, 40%, and 71% of patients, respectively. Ventricular fibrillation was induced at electrophysiology study in 9 of 19 patients (47%). An SCN5A mutation was found in 14 of 28 patients (50%). The highest proportion of fever-related AE was observed in the pediatric population (age <16 years), with a disproportionally higher event rate in the very young (age 0-5 years) (65%). Males were involved in all age groups and females only in the pediatric and elderly groups. Fever-related AE affected 17 Caucasians aged <24 years, but no Asians aged <24 years.</AbstractText>The risk of fever-related AE in BrS markedly varies according to age group, sex, and ethnicity. Taking these factors into account could help the clinical management of patients with BrS with fever.</AbstractText>Copyright © 2018 Heart Rhythm Society. All rights reserved.</CopyrightInformation> |
19,456 | Incremental value of left atrial active function measured by speckle tracking echocardiography in patients with hypertrophic cardiomyopathy. | Hypertrophic cardiomyopathy (HCM) impairs left ventricular (LV) diastolic function leading to left atrial (LA) dilatation. Because Doppler echocardiography cannot accurately assess LV diastolic function in hearts with heterogeneous hypertrophy, assessment of LA function might be useful for risk stratification of patients with HCM. This study aimed to elucidate the impact of LA function on outcome in patients with patients.</AbstractText>Seventy-six patients with HCM who underwent echocardiographic and cardiac magnetic resonance imaging were retrospectively enrolled. Twenty-six control subjects were also included. Using speckle tracking echocardiography, LA function was divided into active and passive strain indices based on the timing of the second positive peak of LA strain rate that occurred during LV systole.</AbstractText>Left atrial strain indices of active and passive function were significantly impaired concomitantly with increased LA volume index in HCM patients compared with controls. During follow-up (2.6 ± 1.7 years), 14 patients with HCM developed cardiac events (heart failure hospitalization or atrial fibrillation). The association of LA active strain with cardiac events was independent of and incremental to clinical and echocardiographic parameters (age, gender, E/e', LV global longitudinal strain, and LA volume index) in sequential models. Cardiac events were more frequent in HCM patients with LA active strain <20.3% than with active strain ≥20.3% (P = .01).</AbstractText>Loss of LA active function was associated with increased cardiac events in patients with HCM.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
19,457 | Postnatal undernutrition in mice causes cardiac arrhythmogenesis which is exacerbated when pharmacologically stressed. | Growth restriction caused by postnatal undernutrition increases risk for cardiovascular disease in adulthood with the potential to induce arrhythmogenesis. Thus, the purpose was to determine if undernutrition during development produced arrhythmias at rest and when stressed with dobutamine in adulthood. Mouse dams were fed (CON: 20% protein), or low-protein (LP: 8%) diet before mating. A cross-fostering model was used where pups nursed by dams fed LP diet in early [EUN; postnatal day (PN) 1-10], late (LUN; PN11-21) and whole (PUN; 1-21) phases of postnatal life. Weaned pups were switched to CON diets for the remainder of the study (PN80). At PN80, body composition (magnetic resonance imaging), and quantitative electrocardiogram (ECG) measurements were obtained under 1% isoflurane anesthesia. After baseline ECG, an IP injection (1.5 µg/g body weight) of dobutamine was administered and ECG repeated. Undernutrition significantly (P<0.05) reduced body weight in LUN (22.68±0.88 g) and PUN (19.96±0.32 g) but not in CON (25.05±0.96 g) and EUN (25.28±0.9207 g). Fat mass decreased in all groups compared with controls (CON: 8.00±1.2 g, EUN: 6.32±0.65 g, LUN: 5.11±1.1 g, PUN: 3.90±0.25 g). Lean mass was only significantly reduced in PUN (CON: 17.99±0.26 g, EUN: 17.78±0.39 g, LUN: 17.34±0.33 g, PUN: 15.85±0.28 g). Absolute heart weights were significantly less from CON, with PUN having the smallest. ECG showed LUN had occurrences of atrial fibrillation; EUN had increases of 1st degree atrioventricular block upon stimulation, and PUN had increased risk for ventricular depolarization arrhythmias. CON did not display arrhythmias. Undernutrition in early life resulted in ventricular arrhythmias under stressed conditions, but undernutrition occurring in later postnatal life there is an increased incidence of atrial arrhythmias. |
19,458 | The evaluation of left ventricular diastolic dysfunction in patients with non-hemorrhagic stroke and atrial fibrillation. | Atrial fibrillation (AF) is the most common tachyarrhythmia and an important risk factor for thromboembolic stroke. CHA2DS2-VASc score was introduced for assessment of embolic events and as criteria for starting anticoagulants. This study was performed to evaluate the left ventricular diastolic dysfunction (LVDD) in patients with non-hemorrhagic stroke and AF.</AbstractText>This cross-sectional study consisted of 76 consecutive patients with suspected non-hemorrhagic stroke referred to the Cardiology Department of Alzahra and Ayatollah Kashani hospitals in Isfahan, Iran, during 2015-2016. Demographic, anthropometric and clinical characteristics were evaluated for all patients at baseline. CHA2DS2-VASc score was calculated for all. All eligible patients underwent transthoracic echocardiogram (TTE) and LVDD was measured in the patients.</AbstractText>The mean age of the patients was 64.64 ± 5.95 years and 28 subjects (36.8%) were women. The most common underlying disease in the patients was hypertension (HTN) (65.8%). Median (range) CHA2DS2-VASc score was 4 (1-7). Four patients (5.3%) had paroxysmal AF and 16 cases (21.1%) had LVDD. Analysis showed that LVDD in patients with non-hemorrhagic stroke and coexisting AF was not associated with CHA2DS2-VASc score (r = 0.151, P = 0.192).</AbstractText>LVDD is not associated with CHA2DS2-VASc score in patients with non-hemorrhagic stroke and coexisting AF.</AbstractText> |
19,459 | Regional anesthesia is safe and effective for lower limb orthopedic surgery in patient with renal tubular acidosis and hypokalemia. | Renal tubular acidosis (RTA) with hypokalemia may precipitate acute respiratory failure and potentially fatal arrhythmias like ventricular fibrillation. Though there are random reports of respiratory failure needing mechanical ventilation and sudden death in patients with RTA and hypokalemia, the anesthetic management of these patients has not been clearly elucidated. Acidosis and hypokalemia have significant interactions with both general and local anesthetics and alter their effect substantially. Proper preoperative planning and optimization are required for the safe conduct of anesthesia in this subset of patients. We describe a case of distal RTA, hypokalemia, and metabolic bone disease in whom central neuraxial anesthesia was effectively used for lower limb orthopedic surgery with no complications. |
19,460 | Safety and Efficacy of Subcutaneous Cardioverter Defibrillator in Patients at High Risk of Sudden Cardiac Death　- Primary Japanese Experience. | The entirely subcutaneous implantable cardioverter defibrillator (S-ICD) was introduced as a new alternative to conventional transvenous ICD (TV-ICD) in Japan in February 2016, but its safety and efficacy are unclear.Methods and Results:A total of 60 patients (48 men, median age, 60 years; IQR, 44-67 years; primary prevention, n=24) underwent S-ICD implantation between February 2016 and August 2017. The device pocket was formed in the intermuscular space between the serratus anterior muscle and the latissimus dorsi muscle, and the parasternal S-ICD lead was placed according to pre-implant screening. Defibrillation test was performed in 56 patients (93%). Ventricular fibrillation (VF) was induced in 55 patients and terminated by a single 65-J shock in all patients. The median time to shock therapy was 13.4 s (IQR, 12.1-14.9 s) and the median post-shock impedance of the S-ICD lead was 64 Ω (IQR, 58-77 Ω). There were no operation-related complications or subsequent infectious complications. During follow-up (median, 275 days; IQR, 107-421 days), 1 patient (1.7%) had appropriate shock for VF with successful termination, whereas 5 patients (8.3%) had inappropriate shock due to oversensing of myopotential (n=3) or T-wave (n=1), and detection of supraventricular tachycardia (n=1).</AbstractText>S-ICD is a safe and effective alternative to conventional TV-ICD. The long-term safety and efficacy of the S-ICD need further investigation.</AbstractText> |
19,461 | Association between Microvolt T-Wave Alternans and Malignant Ventricular Arrhythmias in Chagas Disease. | Sudden cardiac death is the most frequent death mechanism in Chagas disease, responsible for 55% to 65% of the deaths of patients with chronic Chagas cardiomyopathy (CCC). The most often involved electrophysiological mechanisms are ventricular tachycardia and ventricular fibrillation. The implantable cardioverter defibrillator (ICD) has a beneficial role in preventing sudden death due to malignant ventricular arrhythmias, and, thus the correct identification of patients at risk is required. The association of microvolt T-wave alternans (MTWA) with the appearance of ventricular arrhythmias has been assessed in different heart diseases. The role of MTWA is mostly unknown in patients with CCC.</AbstractText>To evaluate the association between MTWA and the occurrence of malignant ventricular arrhythmias in patients with CCC.</AbstractText>This is a case-control study including patients with CCC and ICD, with history of malignant ventricular arrhythmias (case group), and patients with CCC and no history of those arrhythmias (control group). The MTWA test results were classified as negative and non-negative (positive and indeterminate). The significance level adopted was a = 0.05.</AbstractText>We recruited 96 patients, 45 cases (46.8%) and 51 controls (53.1%). The MTWA test was non-negative in 36/45 cases (80%) and 15/51 controls (29.4%) [OR = 9.60 (95%CI: 3.41 - 27.93)]. After adjustment for known confounding factors in a logistic regression model, the non-negative result continued to be associated with malignant ventricular arrhythmias [OR = 5.17 (95%CI: 1.05 - 25.51)].</AbstractText>Patients with CCC and history of malignant ventricular arrhythmias more often have a non-negative MTWA test as compared to patients with no history of arrhythmia.</AbstractText> |
19,462 | Asymptomatic Ventricular Pre-excitation: Between Sudden Cardiac Death and Catheter Ablation. | Debate about the best clinical approach to the management of asymptomatic patients with ventricular pre-excitation and advice on whether or not to invasively stratify and ablate is on-going. Weak evidence about the real risk of sudden cardiac death and the potential benefit of catheter ablation has probably prevented the clarification of action in this not infrequent and sometimes conflicting clinical situation. After analysing all available data, real evidence-based medicine could be the alternative strategy for managing this group of patients. According to recent surveys, most electrophysiologists invasively stratify. Based on all accepted risk factors - younger age, male, associated structural heart disease, posteroseptal localisation, ability of the accessory pathway to conduct anterogradely at short intervals of ≤250 milliseconds and inducibility of sustained atrioventricular re-entrant tachycardia and/or atrial fibrillation - a shared decisionmaking process on catheter ablation is proposed. |
19,463 | Ventricular arrhythmia burden after transcatheter versus surgical pulmonary valve replacement. | Comparative ventricular arrhythmia (VA) outcomes following transcatheter (TC-PVR) or surgical pulmonary valve replacement (S-PVR) have not been evaluated. We sought to compare differences in VAs among patients with congenital heart disease (CHD) following TC-PVR or S-PVR.</AbstractText>Patients with repaired CHD who underwent TC-PVR or S-PVR at the UCLA Medical Center from 2010 to 2016 were analysed retrospectively. Patients who underwent hybrid TC-PVR or had a diagnosis of congenitally corrected transposition of the great arteries were excluded. Patients were screened for a composite of non-intraoperative VA (the primary outcome variable), defined as symptomatic/recurrent non-sustained ventricular tachycardia (VT) requiring therapy, sustained VT or ventricular fibrillation. VA epochs were classified as 0-1 month (short-term), 1-12 months (mid-term) and ≥1 year (late-term).</AbstractText>Three hundred and two patients (TC-PVR, n=172 and S-PVR, n=130) were included. TC-PVR relative to S-PVR was associated with fewer clinically significant VAs in the first 30 days after valve implant (adjusted HR 0.20, p=0.002), but similar mid-term and late-term risks (adjusted HR 0.72, p=0.62 and adjusted HR 0.47, p=0.26, respectively). In propensity-adjusted models, S-PVR, patient age at PVR and native right ventricular outflow tract (RVOT) (vs bioprosthetic/conduit outflow tract) were independent predictors of early VA after pulmonary valve implantation (p<0.05 for all).</AbstractText>Compared with S-PVR, TC-PVR was associated with reduced short-term but comparable mid-term and late-term VA burdens. Risk factors for VA after PVR included a surgical approach, valve implantation into a native RVOT and older age at PVR.</AbstractText>© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.</CopyrightInformation> |
19,464 | Axillo-iliac artery bypass for recurrent aortic coarctation to reduce cardiac afterload. | A 13-year-old girl, who had undergone interrupted aortic arch repair with an 8-mm graft as a neonate and Fontan completion in childhood, developed ventricular fibrillation due to long-QT syndrome. Cardioverter defibrillator implantation was planned. Preoperative catheterization showed a 45-mmHg aortic pressure gradient and ventricular end-diastolic pressure of 11 mmHg. This indicated that recurrent coarctation had adversely affected ventricular function. After consideration of the patient's age, symptoms and anatomical/surgical complexities, axillo-iliac bypass with cardioverter defibrillator implantation was performed. Postoperative ventricular end-diastolic pressure was 6 mmHg. Axillo-iliac bypass is a surgical option for coarctation that can reduce cardiac afterload. |
19,465 | The SAFE pathway is involved in the postconditioning mechanism of oxytocin in isolated rat heart. | Oxytocin (OT) has a postconditioning effect against the ischemia-reperfusion (I/R) injury. However, its precise cardioprotection mechanism at the early reperfusion phase remains under debate. Our previous study revealed that OT postconditioning (OTpost) is cardioprotective by activating the Reperfusion Injury Salvage Kinase (RISK) pathway. Therefore, the present study is aimed to determine the biological effects of OTpost via the OT receptor and the activation of the JAK/STAT3 signaling pathway, mitochondrial adenosine triphosphate-dependent potassium channel (mitoKATP), nitric oxide (NO) release, and its anti-apoptotic effects against I/R injury in an isolated rat heart model. Sixty-three rats were randomly allocated to one of nine groups. OT was perfused 40 min prior to the regional ischemia or 15 min at the early reperfusion phase. AG490 (a JAK/STAT3 inhibitor), 5HD (a mitoKATP blocker), atosiban (an OT receptor antagonist), L-NAME (a nonspecific nitric oxide synthase inhibitor) were applied either alone or in combination with OT during the pre-ischemia phase and/or in the early reperfusion phase. Myocardial infarct size, hemodynamic factor, ventricular arrhythmia, coronary flow, cardiac biochemical marker, and the apoptosis index were determined at the end of reperfusion. Oxytocin postconditioning reduced infarct size, lactate dehydrogenase activity, arrhythmia score, ventricular fibrillation, and apoptosis. Moreover, AG490, 5HD, atosiban, and L-NAME abrogated the cardioprotective effects of OT. Our results demonstrated that the cardioprotective effects of OT are mediated by NO release, and the activation of mitoKATP and the SAFE pathway through the JAK/STAT3 signaling cascade that finally lead to decrease in the apoptosis index during the early reperfusion phase. |
19,466 | [Are the initial pH and the lactate values after cardiopulmonary resuscitation always crucial?]. | A 52-year-old man suffered an out-of-hospital cardiac arrest (OHCA) and bystander reanimation was immediately started. The initial electrocardiogram indicated ventricular fibrillation. After repetitive defibrillations as well as intravenous administration of amiodarone, a temporary return of spontaneous circulation (ROSC) could be established. Due to unstable cardiovascular conditions with recurrence of ventricular fibrillation, mechanical resuscitation with the help of the LUCAS™ device was initiated, and the patient was admitted to our hospital for emergency coronary angiography after a cumulative period of approximately 90 min. The initial blood gas analysis displayed a significant lactate acidosis with a pH value of 6.7. Therefore, in a multidisciplinary team, the decision was made against an extracorporeal membrane oxygenation and for a coronary angiography under continuation of mechanical resuscitation. After multiple stenting of the right coronary artery and left anterior descending coronary artery, permanent ROSC could be established. The patient was admitted to our intensive care unit, where he was further treated according to the S3-guideline for infarct-related cardiogenic shock. In the course of time, the patient was quickly extubated without any neurological deficits. |
19,467 | Left atrial dilatation: A target organ damage in young to middle-age hypertensive patients. The Campania Salute Network. | Left atrial (LA) volume is a predictor of outcome in hypertension. It is unclear whether or not this effect depends on coexisting target organ damage (TOD).</AbstractText>To investigate whether LA volume predicts outcome independently of TOD [left ventricular (LV) hypertrophy (LVH) and/or carotid plaque] in a registry of hypertensive treated patients.</AbstractText>From the Campania Salute Network registry, we selected 5844 young adult hypertensive patients <65 years old (mean age 50 ± 9 years, 41% women, 8% diabetic) without prevalent CV or valvular heart disease more than mild, with normal LV ejection fraction, stage III or less CKD and available follow-up. LA volume was estimated from LA diameter applying a validated nonlinear equation, and indexed to body height in meters to the second power (eLAVI). Composite fatal and non-fatal stroke, myocardial infarction, sudden cardiac death, heart failure, TIA, myocardial revascularization, de novo angina, carotid stenting or atrial fibrillation (AF) were adjudicated as incident CV events.</AbstractText>565 (10%) patients exhibited dilated initial eLAVI. During a median follow-up of 49 months, 233 patients developed CV events. Multivariable Cox regression analysis, demonstrated that dilated eLAVI increased risk of incident composite CV events (HR 1.90, 95%CI 1.26-2.88, p = 0.002), independently of significant effect of older age, male sex, presence LVH and carotid plaque. Conclusions In middle aged, treated hypertensive patients, dilated eLAVI is associated with adverse CV risk profile and is a predictor of CV events independently of other markers of TOD. LA dilatation should be considered as a TOD.</AbstractText>Copyright © 2018 Elsevier B.V. All rights reserved.</CopyrightInformation> |
19,468 | Mitochondrial Ca<sup>2+</sup> Influx Contributes to Arrhythmic Risk in Nonischemic Cardiomyopathy. | Heart failure (HF) is associated with increased arrhythmia risk and triggered activity. Abnormal Ca2+</sup> handling is thought to underlie triggered activity, and mitochondria participate in Ca2+</sup> homeostasis.</AbstractText>A model of nonischemic HF was induced in C57BL/6 mice by hypertension. Computer simulations were performed using a mouse ventricular myocyte model of HF. Isoproterenol-induced premature ventricular contractions and ventricular fibrillation were more prevalent in nonischemic HF mice than sham controls. Isolated myopathic myocytes showed decreased cytoplasmic Ca2+</sup> transients, increased mitochondrial Ca2+</sup> transients, and increased action potential duration at 90% repolarization. The alteration of action potential duration at 90% repolarization was consistent with in vivo corrected QT prolongation and could be explained by augmented L-type Ca2+</sup> currents, increased Na+</sup>-Ca2+</sup> exchange currents, and decreased total K+</sup> currents. Of myopathic ventricular myocytes, 66% showed early afterdepolarizations (EADs) compared with 17% of sham myocytes (P</i><0.05). Intracellular application of 1 μmol/L Ru360, a mitochondrial Ca2+</sup> uniporter-specific antagonist, could reduce mitochondrial Ca2+</sup> transients, decrease action potential duration at 90% repolarization, and ameliorate EADs. Furthermore, genetic knockdown of mitochondrial Ca2+</sup> uniporters inhibited mitochondrial Ca2+</sup> uptake, reduced Na+</sup>-Ca2+</sup> exchange currents, decreased action potential duration at 90% repolarization, suppressed EADs, and reduced ventricular fibrillation in nonischemic HF mice. Computer simulations showed that EADs promoted by HF remodeling could be abolished by blocking either the mitochondrial Ca2+</sup> uniporter or the L-type Ca2+</sup> current, consistent with the experimental observations.</AbstractText>Mitochondrial Ca2+</sup> handling plays an important role in EADs seen with nonischemic cardiomyopathy and may represent a therapeutic target to reduce arrhythmic risk in this condition.</AbstractText>© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
19,469 | Ventricular arrhythmias and sudden cardiac arrest in Takotsubo cardiomyopathy: Incidence, predictive factors, and clinical implications. | Takotsubo cardiomyopathy (TTC) is a stress-related transient cardiomyopathy. Life-threatening arrhythmias (LTA) can occur and worsen prognosis.</AbstractText>The purpose of this study was to assess the incidence and outcome of LTA in TTC, as well as its predictive factors and clinical implications.</AbstractText>We studied 214 consecutive cases of TTC over 8 years. The study cohort was divided into 2 groups: those with LTA (LTA group) and those without (non-LTA group). LTA was defined as ventricular tachycardia, ventricular fibrillation, or cardiac arrest.</AbstractText>LTA occurred in 23 (10.7%) of patients mainly in the first 24 hours of hospitalization: ventricular tachycardia (n = 2), ventricular fibrillation (n = 11), cardiac arrest (n = 10: 5 asystole, 3 complete heart block, and 2 sinoatrial block). LTAs were associated with lower left ventricular ejection fraction (LVEF) and a high rate of conduction disturbances. In-hospital (39.1% vs 8.9%; P < .001) and 1-year mortality (47.8% vs 14.1%; P < .001) rates were significantly increased in the LTA group. LVEF and QRS duration >105 ms were independent predictors of LTA. In cases where a device was implanted, conduction disturbances persisted after the index event despite complete recovery of LVEF. There was no ventricular arrhythmia recurrence during follow-up.</AbstractText>LTAs occur early in patients presenting with TTC and are associated with significantly worse short- and long-term prognosis. Left ventricular impairment and QRS duration >105 ms are independent predictors of LTA. Ventricular arrhythmias occurred in the acute phase without further recurrence recorded in hospital survivors, whereas severe conduction disorders persisted during long-term follow-up. These findings may have implications on the choice of device therapy for this specific patient subgroup.</AbstractText>Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,470 | Atrial Fibrillation in the ICU. | Atrial fibrillation (AF) is the most common arrhythmia encountered in the ICU. Preexisting AF is highly prevalent among older patients with chronic conditions who are at risk for critical illness, whereas new-onset AF can be triggered by accelerated atrial remodeling and arrhythmogenic triggers encountered during critical illness. The acute loss of atrial systole and onset of rapid ventricular rates that characterize new-onset AF often lead to decreased cardiac output and hemodynamic compromise. Thus, new-onset AF is both a marker of disease severity as well as a likely contributor to poor outcomes, similar to other manifestations of organ dysfunction during critical illness. Evaluating immediate hemodynamic effects of new-onset AF during critical illness is an important component of rapid clinical assessment aimed at identifying patients in need of urgent direct current cardioversion, treatment of reversible inciting factors, and identification of patients who may benefit from pharmacologic rate or rhythm control. In addition to acute hemodynamic effects, new-onset AF during critical illness is associated with both short- and long-term increases in the risk of stroke, heart failure, and death, with AF recurrence rates of approximately 50% within 1 year following hospital discharge. In the absence of a strong evidence base, there is substantial practice variation in the choice of strategies for management of new-onset AF during critical illness. We describe acute and long-term evaluation and management strategies based on current evidence and propose future avenues of investigation to fill large knowledge gaps in the management of patients with AF during critical illness. |
19,471 | Health related quality of life after extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest. | Recent data identifies extracorporeal cardio-pulmonary resuscitation (eCPR) as a potential addendum of conventional cardiopulmonary-resuscitation (cCPR) in highly specified circumstances and selected patients. However, consented criteria indicating eCPR are lacking. Therefore we provide first insights into the health-related quality of life (HRQoL) outcomes of patients treated with eCPR in a real world setting.</AbstractText>Retrospective single-center experience of 60 consecutive patients treated with eCPR between 01/2014 and 06/2016 providing 1-year survival- and HRQoL data obtained through the Short-Form 36 Survey (SF-36) after refractory out-of-hospital- (OHCA) and in-hospital cardiac arrest (IHCA) of presumed cardiac etiology.</AbstractText>Resuscitation efforts until initiation of eCPR averaged 66 ± 35 min and 63.3% of the patients suffered from OHCA. Fifty-five (91.7%) of the overall events were witnessed and bystander-CPR was performed in 73.3% (n = 44) of cases. Cause of arrest was dominated by acute myocardial infarction (AMI, 66.7%) and initial rhythm slightly outbalanced by ventricular fibrillation/tachycardia (VF/VT 53.3%). 12-month survival was 31%. Survivors experienced more often bystander-CPR (p = .001) and a shorter duration of cCPR (p = .002). While mid-term survivors' perceived HRQoL was compromised compared to controls (p ≦ .0001 for PF, RP, RE and BP; p = .007 for GH; p = .016 for SF; p = .030 for MH; p = .108 for VT), scores however resembled HRQoL of subjects on hemodialysis, following cardiogenic shock or pulmonary failure treated with extracorporeal membrane oxygenation (ECMO).</AbstractText>While HRQoL scores of our survivors ranged markedly below controls, compared to patients on chronic hemodialysis, following ECMO for cardiogenic shock or pulmonary failure most of the discrepancies ameliorated. Thus, successfull eCPR in properly selected patients does translate into an encouraging HRQoL approximating chronic renal failure.</AbstractText>Copyright © 2018 Elsevier B.V. All rights reserved.</CopyrightInformation> |
19,472 | Clinical Course and Quality of Life in High-Risk Patients With Hypertrophic Cardiomyopathy and Implantable Cardioverter-Defibrillators. | High-risk patients with hypertrophic cardiomyopathy (HCM) are identified by contemporary risk stratification and effectively treated with implantable cardioverter-defibrillators (ICDs). However, long-term HCM clinical course after ICD therapy for ventricular tachyarrhythmias is incompletely understood.</AbstractText>Cohort of 486 high-risk HCM patients with ICDs was assembled from 8 international centers. Clinical course and device interventions were addressed, and survey questionnaires assessed patient anxiety level and psychological well-being related to ICD therapy. Of 486 patients, 94 (19%) experienced appropriate ICD interventions terminating ventricular tachycardia/ventricular fibrillation, 3.7% per year for primary prevention, over 6.4±4.7 years. Of 94 patients, 87 were asymptomatic or only mildly symptomatic at the time of appropriate ICD interventions; 74 of these 87 (85%) remained in classes I/II without significant change in clinical status over the subsequent 5.9±4.9 years (up to 22). Among the 94 patients, there was one sudden death (caused by device failure; 1.1%); 3 patients died from other HCM-related processes unrelated to arrhythmic risk (eg, end-stage heart failure). Post-ICD intervention, freedom from HCM mortality was 100%, 97%, and 92% at 1, 5, and 10 years, distinctly lower than in ischemic or nonischemic cardiomyopathy ICD trials. HCM patients with ICD interventions reported heightened anxiety in expectation of future shocks, but with intact general psychological well-being and quality of life.</AbstractText>In HCM, unlike ischemic heart disease, prevention of sudden death with ICD therapy is unassociated with significant increase in cardiovascular morbidity or mortality, or transformation to heart failure deterioration. ICD therapy does not substantially impair overall psychological and physical well-being.</AbstractText>© 2018 American Heart Association, Inc.</CopyrightInformation> |
19,473 | Loss of p21-activated kinase 1 (Pak1) promotes atrial arrhythmic activity. | Atrial fibrillation (AF) is initiated through arrhythmic atrial excitation from outside the sinus node or remodeling of atrial tissue that allows reentry of excitation. Angiotensin II (AngII) has been implicated in the initiation and maintenance of AF through changes in Ca2+</sup> handling and production of reactive oxygen species (ROS).</AbstractText>We aimed to determine the role of p21-activated kinase 1 (Pak1), a downstream target in the AngII signaling cascade, in atrial electrophysiology and arrhythmia.</AbstractText>Wild-type and Pak1-/-</sup> mice were used to determine atrial function in vivo on the organ and cellular level by quantification of electrophysiological and Ca2+</sup> handling properties.</AbstractText>We demonstrate that reduced Pak1 activity increases the inducibility of atrial arrhythmia in vivo and in vitro. On the cellular level, Pak1-/-</sup> atrial myocytes (AMs) exhibit increased basal and AngII (1 μM)-induced ROS production, sensitivity to the NADPH oxidase-2 (NOX2) inhibitors gp91ds-tat and apocynin (1 μM), and enhanced membrane translocation of Ras-related C3 substrate 1 (Rac1) that is part of the multimolecular NOX2 complex. Upon stimulation with AngII, Pak1-/-</sup> AMs exhibit an exaggerated increase in the intracellular Calcium concentration ([Ca2+</sup>]i</sub>) and arrhythmic events that were sensitive to sodium-calcium exchanger (NCX) inhibitors (KB-R7943 and SEA0400; 1 μM) and suppressed in AMs from NOX2-deficient (gp91phox-/-</sup>) mice. Pak1 stimulation (FTY720; 200 nM) in wild-type AMs and AMs from a canine model of ventricular tachypacing-induced AF prevented AngII-induced arrhythmic Ca2+</sup> overload by attenuating NCX activity in a NOX2-dependent manner.</AbstractText>The experimental results support that Pak1 stimulation can attenuate NCX-dependent Ca2+</sup> overload and prevent triggered arrhythmic activity by suppressing NOX2-dependent ROS production.</AbstractText>Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,474 | Hyponatremia is associated with occurrence of atrial fibrillation in outpatients with heart failure and reduced ejection fraction. | Hyponatremia and atrial fibrillation (AF) have been established as strong predictors for worse clinical outcomes in patients with heart failure (HF). However, little is known about hyponatremia in relation to the occurrence of AF. This study aims to investigate the possible relationship between hyponatremia and AF in patients with chronic HF and reduced ejection fraction (HFrEF).</AbstractText>Turkish research team-HF (TREAT-HF) is a network that has been undertaking multicenter, observational cohort studies on HF. A total of 880 patients who had plasma sodium measurement in TREAT-HF data set were included in this study. Hyponatremia was defined as a plasma sodium level of ≤135 mmol/L. The patients were classified into hyponatremia (n=213) or normonatremia (n=667) based on the sodium level.</AbstractText>The rate of AF was found to be 33.3% in patients with hyponatremia and 18.8% in patients with normonatremia (p<0.001). Univariate analysis demonstrated an association between hyponatremia and AF. Furthermore, in multivariate logistic regression model, hyponatremia was also found to be significantly and independently associated with the occurrence of AF (odds ratio [OR]=2.457, 95% confidence interval [CI]=1.586-3.806, p<0.001) in addition to other well-known risk factors for AF.</AbstractText>The results of this study showed that AF was more prevalent in outpatients with HFrEF and hyponatremia than in those with HFrEF and normonatremia. These results also suggest that hyponatremia is independently associated with the occurrence of AF.</AbstractText>Copyright © 2018 Hellenic Society of Cardiology. All rights reserved.</CopyrightInformation> |
19,475 | Why we prefer levetiracetam over phenytoin for treatment of status epilepticus. | Over last fifty years, intravenous (iv) phenytoin (PHT) loading dose has been the treatment of choice for patients with benzodiazepine-resistant convulsive status epilepticus and several guidelines recommended this treatment regimen with simultaneous iv diazepam. Clinical studies have never shown a better efficacy of PHT over other antiepileptic drugs. In addition, iv PHT loading dose is a complex and time-consuming procedure which may expose patients to several risks, such as local cutaneous reactions (purple glove syndrome), severe hypotension and cardiac arrhythmias up to ventricular fibrillation and death, and increased risk of severe allergic reactions. A further disadvantage of PHT is that it is a strong enzymatic inducer and it may make ineffective several drugs that need to be used simultaneously with antiepileptic treatment. In patients with a benzodiazepine-resistant status epilepticus, we suggest iv administration of levetiracetam as soon as possible. If levetiracetam would be ineffective, a further antiepileptic drug among those currently available for iv use (valproate, lacosamide, or phenytoin) can be added before starting third line treatment. |
19,476 | No effect of season on the electrocardiogram of long-eared bats (Nyctophilus gouldi) during torpor. | Heterothermic animals regularly undergo profound alterations of cardiac function associated with torpor. These animals have specialised tissues capable of withstanding fluctuations in body temperature > 30 °C without adverse effects. In particular, the hearts of heterotherms are able to resist fibrillation and discontinuity of the cardiac conduction system common in homeotherms during hypothermia. To investigate the patterns of cardiac conduction in small insectivorous bats which enter torpor year round, I simultaneously measured ECG and subcutaneous temperature (T<sub>sub</sub>) of 21 Nyctophilus gouldi (11 g) during torpor at a range of ambient temperatures (T<sub>a</sub> 1-28 °C). During torpor cardiac conduction slowed in a temperature dependent manner, primarily via prolongation along the atrioventricular pathway (PR interval). A close coupling of depolarisation and repolarisation was retained in torpid bats, with no isoelectric ST segment visible until animals reached T<sub>sub</sub> <6 °C. There was little change in ventricular repolarisation (JT interval) with decreasing T<sub>sub</sub>, or between rest and torpor at mild T<sub>a</sub>. Bats retained a more rapid rate of ventricular conduction and repolarisation during torpor relative to other hibernators. Throughout all recordings across seasons (> 2500 h), there was no difference in ECG morphology or heart rate during torpor, and no manifestations of significant conduction blocks or ventricular tachyarrhythmias were observed. My results demonstrate the capacity of bat hearts to withstand extreme fluctuations in rate and temperature throughout the year without detrimental arrhythmogenesis. I suggest that this conduction reserve may be related to flight and the daily extremes in metabolism experienced by these animals, and warrants further investigation of cardiac electrophysiology in other flying hibernators. |
19,477 | Echocardiographic predictors of atrial fibrillation after mitral valve replacement. | Detection of the echocardiographic predictors of post-operative atrial fibrillation in patients with rheumatic mitral valve disease undergoing mitral valve replacement.</AbstractText>The study included 50 patients with rheumatic mitral valve disease undergoing mitral valve replacement. Preoperative assessment included standard two-dimensional echocardiography to assess LA diameter, volume, and emptying fraction, LV volume and ejection fraction. TDI derived velocity, strain of the left atrium and speckle tracking to assess left ventricular function then postoperative follow up for 1 month for occurrence of atrial fibrillation.</AbstractText>The incidence of postoperative AF was 44%; these patients were significantly older (P</i> = 0.001) and show higher prevalence of DM (P</i> = 0.001) and HTN (P</i> = 0.001). Also, LA diameters (antero-posterior, transverse and longitudinal) and LA volumes (maximal and minimal) were increased (P</i> < 0.001), but no difference in LA emptying fraction (P</i> > 0.05). Systolic LA strain and left ventricular global longitudinal strain were significantly reduced in those patients (P</i> value <0.001). Echocardiographic predictors of AF were LA systolic strain (P</i> value <0.001) and LV global longitudinal strain (P</i> value = 0.003). Cutoff value for systolic LA strain ≤23 had sensitivity 90.91% and specificity 93.33% in predicting POAF. While, left ventricular global longitudinal strain ≤-14.9% had sensitivity 63.6% and specificity 100.0% in predicting AF.</AbstractText>LA systolic strain and LV global longitudinal strain were significant predictors of POAF. Echocardiographic parameters can identify patients at greater risk of developing POAF who can benefit from preventive measure and guide the selection of prosthesis.</AbstractText> |
19,478 | Upgrade to his bundle pacing in pacing-dependent patients referred for pulse generator change: Feasibility and intermediate term follow up. | Right ventricular pacing (RVP) is associated with an increased incidence of heart failure and may impair cardiac function. Permanent His bundle pacing (HBP) has the potential to physiologically preserve and prevent cardiac dysfunction. This study was to evaluate the feasibility and intermediate follow-up results of upgrade to HBP implantation in patients referred for pulse generator change with long term RVP.</AbstractText>Twelve of 14 pacing dependent patients who were referred for pulse generator exchange underwent upgrade into HBP successfully in our center. QRS duration, New York Heart Association (NYHA) functional class, echocardiography, use of diuretics and lead parameters were measured at baseline and during the follow-up.</AbstractText>Among the 12 patients attempted (mean age, 70.8 ± 8.9 years, 75% males) successfully, the average ejection fraction (EF) was 52.2 ± 11.2%. Nine of 12 patients underwent upgrade to HBP, and three patients with EF < 40% underwent HBP and biventricular pacing (BVP) as well. A significant reduction in mean QRS duration was observed compared with pre-implantation, from 157.8 ± 13.3 ms to 109.3 ± 16.9 ms (p < 0.001). After 6 months follow-up period, median NYHA functional class was improved from 2.7 ± 0.6 to 1.8 ± 0.6 (p = 0.007) and left ventricular internal diastolic diameter (LVIDd) was reduced from 5.5 ± 0.4 cm to 5.3 ± 0.3 cm (p = 0.03).</AbstractText>HBP improves heart failure symptoms with preserved EF by long term RVP. Permanent HBP is feasible and safe for upgrade in patients with long term RVP irrespective of LVEF.</AbstractText>Copyright © 2018. Published by Elsevier B.V.</CopyrightInformation> |
19,479 | Mahaim fiber-mediated tachycardia. | We present the case of a previously healthy 42-year-old man who attended the emergency department due to a sudden onset of rapid and regular palpitations. The ECG showed 190 bpm, wide QRS with left bundle branch block tachycardia. He was started on amiodarone with progression to 230 bpm, wide QRS tachycardia with multiple morphologies, followed by spontaneous conversion to sinus rhythm, normal PR interval and rS pattern in LIII. The echocardiogram was negative for structural heart disease. The electrophysiological study demonstrated the presence of an accessory pathway with anterograde decremental conduction and no retrograde conduction. Both episodes of clinical tachycardia were induced. A diagnosis of Mahaim fiber-mediated antidromic atrioventricular reentrant tachycardia and pre-excited atrial fibrillation was made. Mapping was performed with detection of an M potential (His-like) at the lateral region of the tricuspid ring followed by radiofrequency ablation with immediate success criteria. Post-ablation there was a change to a qR pattern in LIII. At 12-months follow-up there was no recurrence of the tachycardia. |
19,480 | Comparison of Prognostic Usefulness of Serum Insulin-Like Growth Factor-Binding Protein 7 in Patients With Heart Failure and Preserved Versus Reduced Left Ventricular Ejection Fraction. | We aimed to characterize of the role of insulin-like growth factor-binding protein 7 (IGFBP-7) in heart failure (HF) pathophysiology. IGFBP-7 has been associated with cardiac hypertrophy and diastolic dysfunction in HF. In 86 patients with HF with a preserved ejection fraction (HFpEF) (ejection fraction [EF] ≥45%) and 79 with HF with a reduced ejection fraction (HFrEF), we assessed concentrations of serum IGFBP-7, correlations between serum IGFBP-7 and clinical data, diastolic function, and associations with outcome. IGFBP-7 was lower in HFpEF than HFrEF (102 vs 152 µg/L, p <0.001) and correlated with New York Heart Association class (HFpEF: r = 0.25, p = 0.020; HFrEF: r = 0.26, p = 0.022), N-terminal pro-brain natriuretic peptide (NT-proBNP) (HFpEF: r = 0.53, p <0.001; HFrEF: r = 0.50, p <0.001), and estimated glomerular filtration rate (eGFR) (HFpEF: r = -0.47, p <0.001; HFrEF: r = -0.45, p <0.001). In HFpEF, IGFBP-7 correlated with E/e' (r = 0.31, p = 0.012) and E/A ratio (r = 0.31, p = 0.011). In HFrEF, but not HFpEF, IGFBP-7 correlated with age (r = 0.29, p = 0.009) and atrial fibrillation (r = 0.34, p = 0.002). IGFBP-7 predicted the outcome in HFpEF (hazard ratio 4.19 [1.01 to 17.35], p = 0.048]) but not in HFrEF (0.72 [0.24 to 2.14], p = 0.554). In conclusion in HFrEF, IGFBP-7 was elevated and associated with HF severity but not prognostic, suggesting a marker of risk. In HFpEF, IGFBP-7 was less elevated but associated with markers of diastolic dysfunction, HF severity, and prognosis. IGFBP-7 may contribute to the progression of HFpEF possibly through inflammation and oxidative stress. |
19,481 | Size as an Important Determinant of Chest Blow-induced Commotio Cordis. | Commotio cordis is sudden cardiac death caused by a relatively innocent blow to the left chest wall. Adolescents account for the majority of the cases; whether this is due to the higher frequency of adolescents playing ball sports or whether there is some maturational reduction of risk is not known.</AbstractText>In a swine model of commotio cordis, the effect of body weight/size (directly related to age) to the susceptibility of chest impact-induced ventricular fibrillation (VF) is examined.</AbstractText>Ball impacts were delivered at escalating velocities from 48.3 to 96.9 km·h (30-60 mph) to 128 swine ranging in weight from 5 to 54 kg.</AbstractText>VF occurred in 29% of impacts to the smallest animals compared with 34% in the 14- to 239-kg group, 27% in the 24- to 33.9-kg group, 30% in 34- to 43-kg group, and 15% in the 44- to 54-kg animals. The highest-weight group was associated with a significantly lower incidence of VF compared with other weights (P = 0.002). In a multivariate logistic regression analysis, controlling for repeated measures, four variables predicted VF: body weight (P = 0.0008), velocity (P < 0.0001), distance from the center of the heart, (P < 0.0001), and peak left ventricular pressure induced by the blow (P = 0.0007).</AbstractText>In this experimental model, animals weighing <44 kg seem to have a similar susceptibility to commotio cordis, whereas animals weighing ≥44 kg have a lower susceptibility. An increase in size of the individual, rather than reduced play of ball sports, is the likely reason for the decreased commotio cordis incidence in older individuals.</AbstractText> |
19,482 | Cardiac Aspergilloma: A Rare Case of a Cardiac Mass Involving the Native Tricuspid Valve, Right Atrium, and Right Ventricle in an Immunocompromised Patient. | <i>Aspergillus</i> can cause devastating opportunistic infections in immunocompromised patients. Rarely does this fungus invade the heart, and when it does, survival is especially poor despite optimal medical and surgical treatment. We report a case of cardiac aspergilloma with involvement of the tricuspid valve and both the right atrium and ventricle found on a transthoracic echocardiogram in an immunocompromised patient after developing atrial fibrillation with rapid ventricular rate. The findings from this case suggest that early clinical suspicion is critical in early diagnosis and thus early treatment. |
19,483 | Synaptic Plasticity in Cardiac Innervation and Its Potential Role in Atrial Fibrillation. | Synaptic plasticity is defined as the ability of synapses to change their strength of transmission. Plasticity of synaptic connections in the brain is a major focus of neuroscience research, as it is the primary mechanism underpinning learning and memory. Beyond the brain however, plasticity in peripheral neurons is less well understood, particularly in the neurons innervating the heart. The atria receive rich innervation from the autonomic branch of the peripheral nervous system. Sympathetic neurons are clustered in stellate and cervical ganglia alongside the spinal cord and extend fibers to the heart directly innervating the myocardium. These neurons are major drivers of hyperactive sympathetic activity observed in heart disease, ventricular arrhythmias, and sudden cardiac death. Both pre- and postsynaptic changes have been observed to occur at synapses formed by sympathetic ganglion neurons, suggesting that plasticity at sympathetic neuro-cardiac synapses is a major contributor to arrhythmias. Less is known about the plasticity in parasympathetic neurons located in clusters on the heart surface. These neuronal clusters, termed ganglionated plexi, or "little brains," can independently modulate neural control of the heart and stimulation that enhances their excitability can induce arrhythmia such as atrial fibrillation. The ability of these neurons to alter parasympathetic activity suggests that plasticity may indeed occur at the synapses formed on and by ganglionated plexi neurons. Such changes may not only fine-tune autonomic innervation of the heart, but could also be a source of maladaptive plasticity during atrial fibrillation. |
19,484 | The novel CaMKII inhibitor GS-680 reduces diastolic SR Ca leak and prevents CaMKII-dependent pro-arrhythmic activity. | Ca/calmodulin-dependent protein kinase II (CaMKII) was shown to increase diastolic sarcoplasmic reticulum (SR) Ca leak, which can result in delayed afterdepolarizations and triggered arrhythmias. Since increased CaMKII expression and activity has been mechanistically linked to arrhythmias in human heart failure (HF) and atrial fibrillation (AF), specific strategies aimed at CaMKII inhibition may have therapeutic potential.</AbstractText>We tested the antiarrhythmic and inotropic effects of a novel selective and ATP-competitive CaMKII inhibitor (GS-680).</AbstractText>Trabeculae were isolated from right atrial appendage biopsies of patients undergoing cardiac surgery. Premature atrial contractions (PACs) were induced by stimulation with isoproterenol (ISO, 100 nM) at increased [Ca]o</sub> (3.5 mM). Interestingly, compared to vehicle, PACs were significantly inhibited by exposure to GS-680 (at 100 and 300 nM). GS-680 also significantly decreased early and delayed afterdepolarizations in isolated human atrial myocytes. Moreover, GS-680 (at 100 or 300 nM) significantly inhibited diastolic SR Ca leak, measured as frequency of spontaneous SR Ca release events (Ca sparks) in isolated human atrial myocytes (Fluo-4 loaded) similar to the well-established peptide CaMKII inhibitor AIP. In accordance, GS-680 significantly reduced CaMKII autophosphorylation (Western blot) but enhanced developed tension after 10 or 30 s pause of electrical stimulation (post-rest behavior). Surprisingly, we found a strong negative inotropic effect of GS-680 in atrial trabeculae at 1 Hz stimulation rate, which was not observed at 4 Hz and abolished by beta-adrenergic stimulation. In contrast, GS-680 did not impair systolic force of isolated ventricular trabeculae from explanted hearts of heart transplant recipients at 1 Hz, blunted the negative force-frequency relationship (1-3 Hz) and significantly increased the Ca transient amplitude.</AbstractText>The novel ATP-competitive and selective CaMKII inhibitor GS-680 inhibits pro-arrhythmic activity in human atrium and improves contractility in failing human ventricle, which may have therapeutic implications.</AbstractText>Copyright © 2018 Elsevier Ltd. All rights reserved.</CopyrightInformation> |
19,485 | Left ventricular compressions improve return of spontaneous circulation and hemodynamics in a swine model of traumatic cardiopulmonary arrest. | Prehospital cardiopulmonary resuscitation, including closed chest compressions, has commonly been considered ineffective in traumatic cardiopulmonary arrest (TCPA) because traditional chest compressions do not produce substantial cardiac output. However, recent evidence suggests that chest compressions located over the left ventricle (LV) produce greater hemodynamics when compared to traditional compressions. We hypothesized that chest compressions located directly over the LV would improve return of spontaneous circulation (ROSC) and hemodynamics when compared with traditional chest compressions, in a swine model of TCPA.</AbstractText>Transthoracic echocardiography was used to mark the location of the aortic root (traditional compressions), and the center of the LV on animals (n = 26) which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation was induced. After 10 minutes of ventricular fibrillation, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 minutes followed by advanced life support (ALS) for an additional 10 minutes. During BLS, the area of maximal compression was verified using transesophageal echocardiography. Hemodynamic variables were averaged over the final 2 minutes of the BLS and ALS periods.</AbstractText>Five (38%) of the LV group achieved ROSC compared with zero of the aortic root group (p = 0.04). Additionally, there was an increase in aortic systolic blood pressure (SBP), aortic diastolic blood pressure (DBP) and coronary perfusion pressure (CPP) at the end of both the BLS (95% confidence interval, SBP, -49 to -21; DBP, -14 to -5.6; and CPP, -15 to -7.4) and ALS (95% confidence interval: SBP, -66 to -21; DBP, -49 to -6.8; and CPP, -51 to -7.5) resuscitation periods among the LV group.</AbstractText>In our swine model of TCPA, chest compressions performed directly over the LV improved ROSC and hemodynamics when compared with traditional chest compressions.</AbstractText> |
19,486 | Initial experience with the subcutaneous implantable cardioverter-defibrillator with the real costs of hospitalization analysis in a single Polish center. | The recent introduction of an entirely subcutaneous implantable cardioverter-defibril-lator (S-ICD) represents an important progress in the defibrillation technology towards a less invasive approach. This is a single-center observational study of S-ICD implantations in Poland.</AbstractText>The S-ICD was implanted in 11 patients with standard indications for an ICD. Patients in whom the device was implanted were evaluated for adverse events and device function at hospital discharge. All hospitalization costs were calculated and summed up for all patients. Costs were divided into following categories: medical materials, pharmaceuticals, operating theatre staff, cardiology depart-ment staff, laboratory tests, non-laboratory tests and additional non-medical costs.</AbstractText>The mean age of patients was 51.6 ± 16.4 years, 9 were men and 2 were women. Four pa-tients had atrial fibrillation as the basal rhythm, 1 patient had atrial flutter and 6 patients had sinus rhythm. All patients had at least one condition that precluded the use of a traditional ICD system or the S-ICD was preferred due to other conditions, i.e. a history complicated transvenous ICD therapy (18%), anticipated higher risk of infection (27%), lack or difficult vascular access (18%), young age and anticipated high cumulated risk of lifetime device therapy (36%). The mean duration of the im-plantation procedure was 2 h. One patient developed a postoperative pocket hematoma. Mean total time of hospitalization was 28 (6-92) days. Average cost of hospitalization per patient was 21,014.29 EUR (minimal = 19,332.71 EUR and maximal = 24,824.14 EUR).</AbstractText>S-ICD implantation appears to provide a viable alternative to transvenous ICD, espe-cially for patients without pacing requirements.</AbstractText> |
19,487 | Feasibility of zero or near zero fluoroscopy during catheter ablation procedures. | Awareness of risks associated with radiation exposure to patients and medical staff has significantly increased. It has been reported before that the use of advanced three-dimensional electroanatomical mapping (EAM) system significantly reduces fluoroscopy time, however this study aimed for zero or near zero fluoroscopy ablation to assess its feasibility and safety in ablation of atrial fibrillation (AF) and other tachyarrhythmias in a "real world" experience of a single tertiary care center.</AbstractText>This was a single-center study where ablation procedures were attempted without fluoroscopy in 34 consecutive patients with different tachyarrhythmias under the support of EAM system. When transseptal puncture (TSP) was needed, it was attempted under the guidance of intracardiac echocardiography (ICE).</AbstractText>Among 34 patients consecutively enrolled in this study, 28 (82.4%) patients were referred for radiofrequency ablation (RFA) of AF, 3 (8.8%) patients for ablation of right ventricular outflow tract (RVOT) ventricular extrasystole (VES), 1 (2.9%) patient for ablation of atrioventricular nodal reentry tachycardia (AVNRT), 2 (5.9%) patients for typical atrial flutter ablation. In 21 (62%) patients the en- tire procedure was carried out without the use of fluoroscopy. Among 28 AF patients, 15 (54%) patients underwent ablation without the use of fluoroscopy and among these 15 patients, 10 (67%) patients required TSP under ICE guidance while 5 (33%) patients the catheters were introduced to left atrium through a patent foramen ovale. In 13 AF patients, fluoroscopy was only required for double TSP. The total procedure time of AF ablation was 130 ± 50 min. All patients referred for atrial flutter, AVNRT, and VES of the RVOT ablation did not require any fluoroscopy.</AbstractText>This study demonstrates the feasibility of zero or near zero fluoroscopy procedure including TSP with the support of EAM and ICE guidance in a "real world" experience of a single tertiary care center. When fluoroscopy was required, it was limited to TSP hence keeping the radiation dose very low.</AbstractText> |
19,488 | Real-Time Pathophysiologic Correlates of Left Atrial Appendage Thrombus in Patients Who Underwent Transesophageal-Guided Electrical Cardioversion for Atrial Fibrillation. | Although current guidelines advocate using the CHA<sub>2</sub>DS<sub>2</sub>-VASc score to assess the risk of stroke in patients with atrial fibrillation (AF), compared with transesophageal echocardiography (TEE), its ability to predict left atrial appendage thrombus (LAAT) is limited. We studied 3,324 consecutive patients with sustained AF from our prospective registry of patients who underwent first-time TEE-guided electrical cardioversion (ECV) from May 2000 through March 2012. The association of CHA<sub>2</sub>DS<sub>2</sub>-VASc score or TEE risk factors with the occurrence of LAAT was analyzed. The mean (SD) age was 69 (12.5) years and 67% were men. LAAT was identified in 49 (1.5%) during pre-ECV TEE. Compared with patients without LAAT, those with LAAT had lower peak left atrial appendage emptying velocity (LAAEV) (17.2 ± 8.5 vs 36.6 ± 20.8; p <0.001) and left ventricular ejection fraction (LVEF) (39.9 ± 17.6 vs 51.4 ± 13.7; p <0.001); their CHA<sub>2</sub>DS<sub>2</sub>-VASc score also was higher, but the difference was not statistically significant (3.6 ± 1.4 vs 3.2 ± 1.6; p = 0.06). Multivariate logistic regression analysis identified an LVEF ≤40% (adjusted odds ratio 2.48, 95% confidence interval 1.38 to 4.46), LAAEV 20.3 to 33.9 cm/s (odds ratio 12.19, 95% confidence interval 1.53 to 96.86), and LAAEV ≤20.2 cm/s as independent predictors of LAAT. An LAAEV cut-point of 20 cm/s and an LVEF ≤40% were optimal for detecting LAAT (sensitivity 75% and 62%; specificity 77% and 75%; area under the curve 0.822 and 0.776, respectively). On follow-up, LAAT was an independent risk factor of subsequent ischemic stroke but did not influence survival. In conclusion, reduced LVEF and reduced LAAEV are important pathophysiologic correlates of left atrial appendage thrombogenesis and subsequent ischemic stroke in patients who underwent TEE-guided ECV for AF. |
19,489 | Impact of catheter ablation of atrial fibrillation on long-term clinical outcomes in patients with heart failure. | Heart failure (HF) promotes atrial fibrillation (AF) and AF worsens HF. This study aimed to investigate the long-term clinical outcomes after AF ablation in patients with HF.</AbstractText>A total of 106 consecutive HF patients, including 51 (48.1%) with a reduced left ventricular ejection fraction (LVEF) (HFrEF) and 55 (51.9%) with a preserved LVEF (HFpEF), underwent AF ablation. All patients underwent successful pulmonary vein antrum isolation, and substrate modification was added in 38 (35.8%). The mean follow-up period was 32.4±18.6 months, and mean number of procedures was 1.4±0.5 per patient. Low-dose antiarrhythmic drugs were combined in 29 (27.3%) patients. Freedom from recurrent atrial arrhythmias (ATa), HF-related hospitalizations, and the composite endpoint (all-cause death, stroke, HF-related hospitalizations) at 3 years was 88.7%, 97.6%, and 97.6% in HFrEF patients, and 79.3%, 96.2%, and 91.8% in HFpEF patients, respectively. LVEF normalization (≥50%) was observed in 37 (72.5%) HFrEF patients post-ablation, and a smaller LV diastolic diameter (LVDd) was the sole predictor [odds ratio (OR)=0.863; 95% confidence interval (CI)=0.779-0.955, p=0.005]. Shortening of the LVDd (≥5mm) was observed in 16 (29.1%) HFpEF patients post-ablation, and no recurrence after the initial procedure was the sole predictor (OR=6.229; 95% CI=1.524-25.469, p=0.011).</AbstractText>Catheter ablation of AF could be one of the important therapeutic options in the management of patients with HF combined with AF regardless of the type of HF.</AbstractText>Copyright © 2018 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.</CopyrightInformation> |
19,490 | Medical Management of Rheumatic Heart Disease: A Systematic Review of the Evidence. | Rheumatic heart disease (RHD) is an important cause of heart disease globally. Its management can encompass medical and procedural (catheter and surgical) interventions. Literature pertaining to the medical management of RHD from PubMed 1990-2016 and via selected article reference lists was reviewed. Areas included symptom management, left ventricular dysfunction, rate control in mitral stenosis, atrial fibrillation, anticoagulation, infective endocarditis prophylaxis, and management in pregnancy. Diuretics, angiotensin blockade and beta-blockers for left ventricular dysfunction, and beta-blockers and If inhibitors for rate control in mitral stenosis reduced symptoms and improved left ventricular function, but did not alter disease progression. Rhythm control for atrial fibrillation was preferred, and where this was not possible, rate control with beta-blockers was recommended. Anticoagulation was indicated where there was a history of cardioembolism, atrial fibrillation, spontaneous left atrial contrast, and mechanical prosthetic valves. While warfarin remained the agent of choice for mechanical valve implantation, non-vitamin K antagonist oral anticoagulants may have a role in RHD-related AF, particularly with valvular regurgitation. Evidence for anticoagulation after bioprosthetic valve implantation or mitral valve repair was limited. RHD patients are at increased risk of endocarditis, but the evidence supporting antibiotic prophylaxis before procedures that may induce bacteremia is limited and recommendations vary. The management of RHD in pregnancy presents particular challenges, especially regarding decompensation of previously stable disease, the choice of anticoagulation, and the safety of medications in both pregnancy and breast feeding. |
19,491 | Timing of Postdischarge Follow-Up and Medication Adherence Among Patients With Heart Failure. | Medication adherence improves outcomes for patients with heart failure, but adherence rates remain low. We examined the association between earlier postdischarge follow-up and medication adherence.</AbstractText>We performed a retrospective cohort study of patients ≥65 years who were hospitalized for heart failure, covered by Medicare Part D, and discharged alive from April 2006 to October 2012 using the Get With The Guidelines-Heart Failure Registry linked to Medicare claims. Patients were categorized into 4 groups by timing of first postdischarge follow-up visit: ≤1, 1 to 2, 2 to 6, and >6 weeks. Medication adherence was defined by proportion of days covered of >80% at 90 days and 1-year posthospital discharge to 5 guideline-directed medical therapies (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, evidence-based β-blocker, aldosterone antagonist, hydralazine/isosorbide dinitrate, and anticoagulation for atrial fibrillation). Among 9878 patients with heart failure, 73% had left ventricular ejection fraction ≤40%, median age was 78 years (25th-75th percentile, 71-84), and 48% were male. Overall, 30% had a follow-up appointment within 1-week postdischarge and 25% >6 weeks. At 1 year, medication adherence was 53% for evidence-based β-blockers, 48% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 8% for hydralazine/isosorbide dinitrate. We found no significant association between timing of first follow-up visit and medication adherence at 1 year (1.04, 0.92-1.17) when comparing follow-up visits >6 weeks to the earliest ones.</AbstractText>Posthospital heart failure discharge, overall adherence to medical therapies in Medicare beneficiaries was low. Early follow-up was not associated with increased medication adherence to guideline-directed medical therapy in the short or long term.</AbstractText>© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
19,492 | Electrocardiographic left ventricular hypertrophy predicts recurrence of atrial arrhythmias after catheter ablation of paroxysmal atrial fibrillation. | Left ventricular hypertrophy (LVH) is an independent predictor of new-onset atrial fibrillation. Whether LVH can predict the recurrence of arrhythmia after radiofrequency catheter ablation (RFCA) in patients with paroxysmal atrial fibrillation (PAF) remains unclear.</AbstractText>PAF patients with baseline-electrocardiographic LVH has a higher recurrence rate after RFCA procedure compared with those without LVH.</AbstractText>A total of 436 patients with PAF undergoing first RFCA were consecutively enrolled and clustered into 2 groups based on electrocardiogram (ECG) findings: non-ECG LVH (218 patients) and ECG LVH (218 patients). LVH was characterized by the Romhilt-Estes point score system; the score ≥5points were defined as LVH.</AbstractText>At 42 months' (interquartile range, 18.0-60.0 months) follow-up after RFCA, 151 (69.3%) patients in the non-ECG LVH group and 108 (49.5%) patients in the ECG LVH group maintained sinus rhythm without using antiarrhythmic drugs (P < 0.001). Patients with ECG LVH tended to experience a much higher prevalence of stroke and recurrence of atrial arrhythmia episodes compared with those without ECG LVH (log-rank P < 0.001). Multivariate analysis found the presence of ECG LVH and left atrial diameter to be independent risk factors for recurrence after adjusting for confounding factors.</AbstractText>The presence of ECG LVH was a strong and independent predictor of recurrence in patients with PAF following RFCA.</AbstractText>© 2018 Wiley Periodicals, Inc.</CopyrightInformation> |
19,493 | Methylene Blue Counteracts H<sub>2</sub>S-Induced Cardiac Ion Channel Dysfunction and ATP Reduction. | We have previously demonstrated that methylene blue (MB) counteracts the effects of hydrogen sulfide (H<sub>2</sub>S) cardiotoxicity by improving cardiomyocyte contractility and intracellular Ca<sup>2+</sup> homeostasis disrupted by H<sub>2</sub>S poisoning. In vivo, MB restores cardiac contractility severely depressed by sulfide and protects against arrhythmias, ranging from bundle branch block to ventricular tachycardia or fibrillation. To dissect the cellular mechanisms by which MB reduces arrhythmogenesis and improves bioenergetics in myocytes intoxicated with H<sub>2</sub>S, we evaluated the effects of H<sub>2</sub>S on resting membrane potential (E<sub>m</sub>), action potential (AP), Na<sup>+</sup>/Ca<sup>2+</sup> exchange current (I<sub>NaCa</sub>), depolarization-activated K<sup>+</sup> currents and ATP levels in adult mouse cardiac myocytes and determined whether MB could counteract the toxic effects of H<sub>2</sub>S on myocyte electrophysiology and ATP. Exposure to toxic concentrations of H<sub>2</sub>S (100 µM) significantly depolarized E<sub>m</sub>, reduced AP amplitude, prolonged AP duration at 90% repolarization (APD<sub>90</sub>), suppressed I<sub>NaCa</sub> and depolarization-activated K<sup>+</sup> currents, and reduced ATP levels in adult mouse cardiac myocytes. Treating cardiomyocytes with MB (20 µg/ml) 3 min after H<sub>2</sub>S exposure restored E<sub>m</sub>, APD<sub>90</sub>, I<sub>NaCa</sub>, depolarization-activated K<sup>+</sup> currents, and ATP levels toward normal. MB improved mitochondrial membrane potential (∆ψ<sub>m</sub>) and oxygen consumption rate in myocytes in which Complex I was blocked by rotenone. We conclude that MB ameliorated H<sub>2</sub>S-induced cardiomyocyte toxicity at multiple levels: (1) reversing excitation-contraction coupling defects (Ca<sup>2+</sup> homeostasis and L-type Ca<sup>2+</sup> channels); (2) reducing risks of arrhythmias (E<sub>m</sub>, APD, I<sub>NaCa</sub> and depolarization-activated K<sup>+</sup> currents); and (3) improving cellular bioenergetics (ATP, ∆ψ<sub>m</sub>). |
19,494 | Association of Left Atrial Function Index with Atrial Fibrillation and Cardiovascular Disease: The Framingham Offspring Study. | Left atrial (LA) size, a marker of atrial structural remodeling, is associated with increased risk for atrial fibrillation (AF) and cardiovascular disease (CVD). LA function may also relate to AF and CVD, irrespective of LA structure. We tested the hypothesis that LA function index (LAFI), an echocardiographic index of LA structure and function, may better characterize adverse LA remodeling and predict incident AF and CVD than existing measures.</AbstractText>In 1786 Framingham Offspring Study eighth examination participants (mean age, 66±9 years; 53% women), we related LA diameter and LAFI (derived from the LA emptying fraction, left ventricular outflow tract velocity time integral, and indexed maximal LA volume) to incidence of AF and CVD on follow-up. Over a median follow-up of 8.3 years (range, 7.5-9.1 years), 145 participants developed AF and 139 developed CVD. Mean LAFI was 34.5±12.7. In adjusted Cox regression models, lower LAFI was associated with higher risk of incident AF (hazard ratio=3.83, 95% confidence interval=2.23-6.59, lowest [Q1] compared with highest [Q4] LAFI quartile) and over 2-fold higher risk of incident CVD (hazard ratio=2.20, 95% confidence interval=1.32-3.68, Q1 versus Q4). Addition of LAFI, indexed maximum LA volume, or LA diameter to prediction models for AF or CVD did not significantly improve model discrimination for either outcome.</AbstractText>In our prospective investigation of a moderate-sized community-based sample, LAFI, a composite measure of LA size and function, was associated with incident AF and CVD. Addition of LAFI to the risk prediction models for AF or CVD, however, did not significantly improve their performance.</AbstractText>© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
19,495 | Ventricular fibrillation induced by radiofrequency energy delivery for premature ventricular contractions arising from the right ventricular outflow tract: is implantablecardioverterdefibrillator indicated? | INTRODUCTION    Inadvertently induced ventricular fibrillation (VF) by radiofrequency (RF) energy delivery for premature ventricular complexes (PVCs) is a rare phenomenon; nevertheless, it is crucial to assess long‑term risk of sudden cardiac death in these patients. OBJECTIVES    The aim of our study was to define the long‑term prognosis in patients with normal ejection fraction (EF), in whom VF was inadvertently induced by RF energy application during ablation of symptomatic idiopathic PVCs originating from the right ventricular outflow tract (RVOT). PATIENTS AND METHODS    Among over 20 000 RF catheter ablations performed at 5 tertiary centers (2008-2016), 6 patients (5 men) had VF induced by RF application to the RVOT. The mean (SD) age of patients was 35.2 (16.8) years. All patients had normal EF (≥60%). We analyzed the risk of malignant ventricular arrhythmias and assessed heart function during follow‑up. RESULTS    After ablation, baseline contrast‑enhanced magnetic resonance imaging was performed in 4 of the 6 patients; no area of late gadolinium enhancement was observed. One patient received an implantable cardioverter‑defibrillator (ICD). Exercise tests revealed only rare PVCs. All patients completedthe follow‑up (mean [SD] duration of follow‑up, 64.0 [34.9] months). All patients were alive, with no cases of syncope, documented ventricular tachycardia, or VF. The patient with an ICD received 2 inappropriate high‑voltage therapies. CONCLUSIONS    Patients with inadvertently induced VF via RF energy application during ablation of PVCs from the RVOT, who have normal left ventricular function and no electrocardiography abnormalities have good prognosis and low VF risk during long‑term follow‑up. Therefore, ICD placement seems to be not indicated for these patients. |
19,496 | Biatrial Electrical and Structural Atrial Changes in Heart Failure: Electroanatomic Mapping in Persistent Atrial Fibrillation in Humans. | This study sought to characterize the biatrial substrate in heart failure (HF) and persistent atrial fibrillation (PeAF).</AbstractText>Atrial fibrillation (AF) and HF frequently coexist; however, the contribution of HF to the biatrial substrate in PeAF is unclear.</AbstractText>Consecutive patients with PeAF and normal left ventricular (NLV) systolic function (left ventricular ejection fraction [LVEF] >55%) or idiopathic cardiomyopathy (LVEF ≤45%) undergoing AF ablation were enrolled. In AF, pulmonary vein (PV) cycle length (PVCL) was recorded via a multipolar catheter in each PV and in the left atrial appendage for 100 consecutive cycles. After electrical cardioversion, biatrial electroanatomic mapping was performed. Complex electrograms, voltage, scarring, and conduction velocity were assessed.</AbstractText>Forty patients, 20 patients with HF (mean age: 62 ± 8.9 years; AF duration: 15 ± 11 months; LVEF: 33 ± 8.4%) and 20 with NLV (mean age: 59 ± 6.7 years; AF duration: 14 ± 9.1 months; p = 0.69; mean LVEF: 61 ± 3.6%; p < 0.001), were enrolled. HF reduced biatrial tissue voltage (p < 0.001) with greater voltage heterogeneity (p < 0.001). HF was associated with significantly more biatrial fractionation (left atrium [LA]: 30% vs. 9%; p < 0.001; right atrium [RA]: 28% vs. 11%; p < 0.001), low voltage (<0.5 mV) (LA: 23% vs. 6%; p = 0.002; RA: 20% vs 11%; p = 0.006), and scarring (<0.05 mV) in the LA (p = 0.005). HF was associated with a slower average PVCL (185 vs. 164 ms; p = 0.016), which correlated significantly with PV antral bipolar voltage (R = -0.62; p < 0.001) and fractionation (R = 0.46; p = 0.001).</AbstractText>HF is associated with significantly reduced biatrial tissue voltage, fractionation, and prolongation of PVCL. Advanced biatrial remodeling may have implications for invasive and noninvasive rhythm control strategies in patients with AF and HF.</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,497 | The J-waves of hypothermia. | Prominent J-waves are observed in several clinical conditions many of which are highly arrhythmogenic and may lead to ventricular fibrillation (VF) and/or sudden cardiac death. We present the case of a 34-year-old male patient with hypothermia. Prominent J-waves (Osborn waves) and prolonged QT interval was evident in nearly every lead. Early recognition of these arrhythmogenic electrocardiogram (ECG) findings and treatment of hypothermia is important to minimize the risk of arrhythmic events. |
19,498 | Cardiorenal syndrome as predictor of in-hospital mortality in ST-segment elevation myocardial infarction. | Cardiorenal syndrome includes numerous conditions affecting the heart and kidney, and is a strong predictor of cardiovascular mortality.</AbstractText>An analysis was performed on 157 consecutive patients admitted to the Coronary Care Unit of the Camilo Cienfuegos Hospital due to an ST-segment elevation myocardial infarction and heart failure, from January 2013 to December 2016. An analysis was made of the presence of cardiorenal syndrome and its relationship with epidemiological, clinical, and analytical variables, as well as complementary explorations. The relationship between cardiorenal syndrome and in-hospital mortality was assessed using binary logistical regression.</AbstractText>A total of 52 (33.1%) patients had a cardiorenal syndrome. The haemoglobin level was lower in the group of patients with cardiorenal syndrome (117.2 ± 15.3 vs. 123.3 ± 15.1, P = .019), and in left ventricular ejection fraction (34.8 ± 8 vs. 43.2 ± 10.8). A positive correlation was found between the Killip class and the increase in serum creatinine after 48 h. The serum creatinine was associated with left ventricular ejection fraction (r = 0.166; P = .038). The multivariate analysis showed that cardiorenal syndrome was an independent predictor of in-hospital mortality when adjusted for a history of ischaemic heart disease, diabetes mellitus status, atrial fibrillation, ventricular arrhythmias, left ventricular ejection fraction, age and systolic blood pressure.</AbstractText>The presence of cardiorenal syndrome has an influence on the prognosis of patients who suffer a cardiorenal syndrome. Its detection could be useful in the risk stratification.</AbstractText>Copyright © 2018 Sociedad Española de Arteriosclerosis. Publicado por Elsevier España, S.L.U. All rights reserved.</CopyrightInformation> |
19,499 | Indications for Cardiac Resynchronization Therapy: A Comparison of the Major International Guidelines. | This study compares and contrasts the recommended indications for cardiac resynchronization therapy (CRT) according to the most recent guidelines from international cardiology societies.</AbstractText>CRT has been shown to reduce morbidity and mortality in selected patients with systolic heart failure. Cardiology societies provide guidelines regarding the indications for CRT. As evidence evolves, it is challenging for the guideline committees to review the impact of newer evidence in a timely fashion.</AbstractText>Six of the most recent international guidelines providing recommendation concerning CRT implantation ranging from 2011 to 2017 were reviewed. These included guidelines from 2 European, 1 North American, 1 Canadian, and 1 Australian/New Zealand societies and the National Institute for Health and Care Excellence guidelines, specific to the United Kingdom.</AbstractText>Although international societies provide consistent recommendations for most CRT indications, differences are found in recommendations for several important patient populations. Specifically, divergent recommendations exist regarding QRS duration, bundle branch morphology, patients in atrial fibrillation, choice of device type (CRT pacemakers vs. CRT defibrillators), and selected patients who are likely to be dependent on right ventricular pacing. The timing of publication of specific guidelines appears to play an essential role in explaining these disparities.</AbstractText>Despite general consistency in international guideline recommendations, there remain certain patient populations for whom there are variations in recommendations concerning eligibility for CRT and selection of the most appropriate device in the individual patient.</AbstractText>Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
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