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19,900 | Incidence of drug-induced torsades de pointes with intravenous amiodarone. | To define the incidence, presentation, and outcomes of drug-induced Torsades de Pointes (TdP) with intravenous (IV) amiodarone.</AbstractText>From January 2014 to August 2016 a total of 268 patients received IV amiodarone, 142 for ventricular tachycardia, 104 for atrial flutter/fibrillation, and 22 for incessant atrial tachycardia. A uniform dosing of amiodarone to yield 1gm/day was used in all patients.</AbstractText>Four of the 268 patients (M:F 1:3) with mean age of 51.25+9.17years developed pause dependent TdP degenerating to VF, after a mean dose of 690+176.63mg, infused over 12+5.88h. The QTc that was 505+9.02ms at the time of TdP normalized to 433.75+6.13ms 48-72h after stopping amiodarone. There was no immediate or late mortality, and patients are well at 5-10 months of follow-up. None of the patients tested positive for LQTS genes.</AbstractText>The incidence of drug-induced TdP with IV amiodarone is about 1.5%. Risk factors include female sex, left ventricular dysfunction, electrolyte abnormalities, baseline prolonged QTc, concomitant beta-blocker, and digoxin therapy. Amiodarone induced TdP has favorable prognosis if recognized and treated promptly, and these patients should not receive amiodarone by any route in future.</AbstractText>Copyright © 2017 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
19,901 | Effects of propofol on ventricular repolarization and incidence of malignant arrhythmias in adults. | Propofol is commonly used for procedural sedation in interventional electrophysiology. However, ventricular arrhythmias under Propofol have been reported. Our aim was to investigate ventricular repolarization and incidence of ventricular arrhythmias under Propofol infusion in adults with cardiac arrhythmias.</AbstractText>QRS, QTcB (Bazett), QTcFri (Fridericia), JTc, measurement of T peak to Tend time (Tp-e</sub>) at baseline and under Propofol infusion was performed in 235 patients. Screening for unexpected ventricular arrhythmias was performed in 1165 patients undergoing EP procedures under Propofol.</AbstractText>A significant prolongation of Tp-e</sub> under Propofol infusion (79.7±17.3 vs. 86.4±22.5ms, p<0.001) and of QTcFri (429.3±35.8 vs. 435.5±36.5, p=0.033) was detected. No significant change of the QTcB interval, JTc interval or QRS duration was observed. One case (0.09%) of ventricular fibrillation during rapid ventricular pacing under Propofol occurred.</AbstractText>Although transmural dispersion of ventricular repolarisation is increased under Propofol, incidence of malignant ventricular arrhythmias is low. For evaluation of QT interval under Propofol, Fridericia's correction formula should be used rather than Bazett's formula.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,902 | Ventricular Arrhythmias. | Ventricular tachycardia (VT) is the most common form of wide complex tachycardia and is associated with a high mortality rate. Electrocardiographic analysis remains paramount in diagnosis and helps to direct therapy. Antiarrhythmic agents, although effective in reducing arrhythmia burden, have never demonstrated a mortality benefit. The implantable cardioverter-defibrillator aids not only in the acute termination of ventricular arrhythmia, but provides a wealth of information for the long-term management of patients with VT. Contemporary treatment options such as catheter ablation are increasingly used and effective, but often remain imperfect, with recurrent VT being not uncommon. |
19,903 | The Subcutaneous Defibrillator. | The transvenous implantable cardioverter-defibrillator (ICD) has been shown in multiple studies to be effective in the prevention of sudden cardiac death in select populations. The Achilles heel of traditional ICD technology has been the transvenous lead. The subcutaneous ICD provides effective sudden death protection while avoiding lead-related complications of traditional transvenous systems. The subcutaneous ICD is a reasonable option for patients with an ICD indication who do not need bradycardia pacing or cardiac resynchronization therapy. |
19,904 | Sudden Cardiac Death in Acute Coronary Syndromes. | Sudden cardiac death in acute coronary syndromes mostly results from complex ventricular arrhythmias. Although the incidence has fallen with contemporary management, they still pose a threat for many patients. Treatment consists of immediate termination by electrical cardioversion and prompt coronary revascularization for relief of ischemia. Beta-blockers administered prophylactically have a protective effect. For recurrent episodes, pharmacologic treatment consists of beta-blockers and amiodarone, or, in nonresponsive patients, lidocaine. Other antiarrhythmic drugs play only a marginal role. Catheter ablation performed in qualified centers can be effective in recurrent episodes of ventricular tachycardia or ventricular fibrillation triggered by premature ventricular contractions. |
19,905 | Heart Failure and Sudden Cardiac Death. | The Centers for Diseases Control and Prevention estimates that 5.7 million adults in the United States suffer from heart failure and 1 in 9 deaths in 2009 cited heart failure as a contributing cause. Almost 50% of patients who are diagnosed with heart failure die within 5 years of diagnosis. Cardiovascular disease is a public health burden. The prognosis of patients with heart failure has improved significantly. However, the risk for death remains high. Managing sudden death risk and intervening appropriately with primary or secondary prevention strategies are of paramount importance. |
19,906 | Ventricular Arrhythmias and Sudden Cardiac Death. | Ventricular arrhythmias remain a significant cause of sudden cardiac death (SCD), and knowledge of their cause and high-risk features is important. SCD occurs when the interaction between vulnerable substrates and acute triggers results in sustained ventricular tachycardia progressing to ventricular fibrillation. Here, the authors aim to review the role of ventricular arrhythmias in SCD, first by approaching the substrates that support ventricular arrhythmias, and then by exploring features of these substrates and the acute triggers that may lead to SCD. |
19,907 | Cardiac Innervation and the Autonomic Nervous System in Sudden Cardiac Death. | Neural remodeling in the autonomic nervous system contributes to sudden cardiac death. The fabric of cardiac excitability and propagation is controlled by autonomic innervation. Heart disease predisposes to malignant ventricular arrhythmias by causing neural remodeling at the level of the myocardium, the intrinsic cardiac ganglia, extracardiac intrathoracic sympathetic ganglia, extrathoracic ganglia, spinal cord, and the brainstem, as well as the higher centers and the cortex. Therapeutic strategies at each of these levels aim to restore the balance between the sympathetic and parasympathetic branches. Understanding this complex neural network will provide important therapeutic insights into the treatment of sudden cardiac death. |
19,908 | Role of Cardiac Imaging in Evaluating Risk for Sudden Cardiac Death. | Sudden cardiac death (SCD) is a major cause of death from cardiovascular disease. Our ability to predict patients at the highest risk of developing lethal ventricular arrhythmias remains limited. Despite recent studies evaluating risk stratification tools, there is no optimal strategy. Cardiac imaging provides the opportunity to assess left ventricular ejection fraction, strain, fibrosis, and sympathetic innervation, all of which are pathophysiologically related to SCD risk. These modalities may play a role in the identification of vulnerable anatomic substrates that provide the pathophysiologic basis for SCD. Further studies are required to identify optimal imaging platform for risk assessment. |
19,909 | Basic Electrophysiologic Mechanisms of Sudden Cardiac Death Caused by Acute Myocardial Ischemia and Infarction. | Sudden cardiac death caused by acute ischemia results from electrophysiologic changes in myocardium deprived of its blood supply. These changes include a reduction in resting potential and phase 0 depolarization and an increase in intercellular resistivity that slow conduction, cause conduction block, and lead to reentrant excitation and ventricular fibrillation. Reperfusion of a coronary artery after a short period of occlusion leads to similar changes. |
19,910 | Sex-specific cardiovascular susceptibility to ischaemic myocardial injury following exposure to prenatal hypoxia. | Cardiovascular diseases (CVDs) are the leading cause of mortality and hypertension contributes substantially to the incidence of stroke, coronary artery disease, heart failure, atrial fibrillation and peripheral vascular disease. The origin of hypertension is clearly multifactorial, and a complex and multifaceted approach is necessary to decrease its incidence. The most recognizable factors involved in reducing the incidence of hypertension are prevention, early diagnosis and treatment; however, the importance of the foetal environment and early postnatal development has recently been considered. In clinical practice, these factors are still frequently overlooked, probably because of a lack of knowledge about the underlying mechanisms and effective treatment or prevention. Pathophysiological mechanisms underlying the prenatal programming of CVDs were investigated in the study by Shah et al. published recently in <i>Clinical Science</i> (2017) 131(17), 2303-2317. The study explored cardiac susceptibility of adult male and female rat offspring to ischaemic myocardial injury due to prenatal exposure to hypoxia. The results demonstrated significant changes in global cardiac function and left ventricular dilatation following myocardial infarction in rat offspring prenatally exposed to hypoxia. The effects were gender specific and occurred only in males, whereas females were protected. These findings are important from several perspectives. First, they point to the fact that an inadequate foetal environment can increase susceptibility to death from myocardial infarction. Second, during their reproductive life, females are better protected from cardiovascular insult than males, but it is not known if they lose this advantage after menopause, and can be equally at risk as males. |
19,911 | Muscle fasciculation detected by ECG. | A 79-year-old man presented to hospital with scald burns to the perineum after a syncopal episode while in a hot bathtub. Admission ECG was misdiagnosed as possible ventricular fibrillation with high-frequency irregular waveforms in lead V2 at a rate exceeding 1000 cycles per minute, corresponding to intervening skeletal muscle contractions unrelated to the heart. Follow-up ECG showed full resolution of the irregular waveforms. Muscle fasciculations are a benign cause of ECG artefact and can easily be mistaken for serious cardiac arrhythmias. While most muscle fasciculations detected on ECG are benign, in the correct clinical circumstance these waveforms indicate an underlying neuromuscular disorder. The patient underwent surgical skin grafting with no perioperative cardiac complications and no further syncope in hospital. |
19,912 | Coexistence of tachyarrhythmias in patients with tetralogy of Fallot. | The expanding population of adult patients with tetralogy of Fallot (ToF) requires knowledge of its long-term sequelae.</AbstractText>The purpose of this study was to examine the coexistence and order of appearance of atrial fibrillation (AF), other supraventricular tachycardias (SVTs), ventricular tachycardia (VT), and ventricular fibrillation (VF), and their impact on survival during long-term follow-up.</AbstractText>Adult, corrected ToF patients [N = 225; 128 male; mean ± SD (minimum-maximum) age 41 ± 12 (19-79) years] were included in the study. Medical correspondence, ECGs, and Holter recordings were reviewed for documented AF, other SVTs, VT, and VF.</AbstractText>During follow-up of 35 ± 9 (16-64) years, sustained tachyarrhythmias, including SVT (n=50, 22%), AF (n=29, 13%), VT (n=20, 9%), and VF (n=9, 4%), were observed in 71 patients (32%), of whom 27 (38%) had coexistence of different tachyarrhythmias. In 18 patients with coexisting SVT and AF, SVT most often preceded AF in 13 (72%). Age at SVT onset was similar between those with and those without subsequent AF development (40 ± 17 years vs 35 ± 16 years; P = .283). However, age at SVT and AF onset were positively correlated (rho 0.585; P = .011). Prevalence of SVT/AF was associated with VT/VF prevalence (odds ratio [OR] 4.59; P < .001). Although 11% of patients with SVT/AF subsequently develop VT/VF, onset of SVT/AF could not predict future VT/VF development (OR 1.81; P = .233). Adult ToF patients are initially at risk for SVT development, followed by AF, VT, and VF at 46 (43-50), 56 (53-59), 57 (54-61), and 62 (61-63) years after ToF correction (P < .001), respectively. Survival time decreased when sustained tachyarrhythmias developed (P = .024). Age at onset of SVT, AF, and VT was positively correlated with age at death (SVT: rho 0.734; P = .004; AF: rho 0.783; P = .007, VT: rho 0.755; P = .050).</AbstractText>Coexistence of different (supra)ventricular tachyarrhythmias is frequently observed in adult ToF patients. In these patients, a specific order of these tachyarrhythmias was observed. Tachyarrhythmias are associated with decreased survival time, and, more importantly, age at tachyarrhythmia development positively correlates with age at death.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,913 | Mitral valve pressure gradient after percutaneous mitral valve repair: every beat counts. | A patient presented with symptoms of decompensated heart failure 2 months after percutaneous mitral valve (MV) repair. Echocardiography demonstrated impaired left ventricular function with elevated MV pressure gradients and pulmonary pressures during rapid atrial fibrillation. Heart rate control was achieved by implantation of a biventricular pacemaker with subsequent His-bundle ablation because atrial fibrillation was refractory to medical treatment. During biventricular pacing at different rates (50-110 b.p.m.), heart rate correlated positively with both MV mean pressure gradient and global longitudinal strain and negatively with stroke volume. MV pressure gradients directly translated into elevated pulmonary pressures. Thus, rate control and biventricular pacing improved cardiac haemodynamics. |
19,914 | Early and medium-term outcomes of Alfieri mitral valve repair in the management of systolic anterior motion during septal myectomy. | This report studies the early and medium-term clinical and echocardiographic outcomes of the Alfieri edge-to-edge mitral valve repair, as adjunctive therapy, to prevent and treat systolic anterior motion (SAM) at the time of septal myectomy (SM) for left ventricular outflow tract obstruction in hypertrophic cardiomyopathy.</AbstractText>From 2009-2015, 11 consecutive patients had a trans-atrial Alfieri repair, to prevent (n = 7) or treat (n = 4) SAM at the time of SM.</AbstractText>No patients were lost to follow-up. There were no perioperative or late deaths. Pre-bypass, the mean left ventricular outflow tract gradient, measured directly by simultaneous needle insertion, was 40.7 ± 19.9 mmHg at rest and 115.8 ± 30.4 mmHg on provocation with Isoproterenol, which reduced after SM and Alfieri repair and discontinuation of bypass, to a mean gradient of 8.3 ± 9.8 mmHg at rest and 25.8 ± 9.2 mmHg on provocation. One patient who required mitral valve replacement on day 4, was hospitalized at 2.7 years with heart failure requiring diuresis and remains well at 6 years. One patient developed postoperative atrial fibrillation. There were no other early or late complications. At a median follow-up of 6.6 years (international quartile range 1.2-7.4), clinical and echocardiographic data demonstrated maintained improvement in mean New York Heart Association class from 2.6 ± 0.9 preoperatively to 1.7 ± 0.4 and reduction in mean grade of mitral regurgitation from 2.7 ± 0.8 preoperatively to 0.7 ± 0.6.</AbstractText>The Alfieri repair, as adjunctive therapy, for the prevention or treatment of SAM at the time of SM demonstrates satisfactory early and medium-term clinical and echocardiographic outcomes supporting the ongoing utility of this approach.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
19,915 | Loss-of-activity-mutation in the cardiac chloride-bicarbonate exchanger AE3 causes short QT syndrome. | Patients with short QT syndrome (SQTS) may present with syncope, ventricular fibrillation or sudden cardiac death. Six SQTS susceptibility genes, encoding cation channels, explain <25% of SQTS cases. Here we identify a missense mutation in the anion exchanger (AE3)-encoding SLC4A3 gene in two unrelated families with SQTS. The mutation causes reduced surface expression of AE3 and reduced membrane bicarbonate transport. Slc4a3 knockdown in zebrafish causes increased cardiac pH<sub>i</sub>, short QTc, and reduced systolic duration, which is rescued by wildtype but not mutated SLC4A3. Mechanistic analyses suggest that an increase in pH<sub>i</sub> and decrease in [Cl<sup>-</sup>]<sub>i</sub> shortened the action potential duration. However, other mechanisms may also play a role. Altered anion transport represents a mechanism for development of arrhythmia and may provide new therapeutic possibilities. |
19,916 | <i>In Silico</i> Assessment of Efficacy and Safety of I<sub>Kur</sub> Inhibitors in Chronic Atrial Fibrillation: Role of Kinetics and State-Dependence of Drug Binding. | Current pharmacological therapy against atrial fibrillation (AF), the most common cardiac arrhythmia, is limited by moderate efficacy and adverse side effects including ventricular proarrhythmia and organ toxicity. One way to circumvent the former is to target ion channels that are predominantly expressed in atria vs. ventricles, such as K<sub>V</sub>1.5, carrying the ultra-rapid delayed-rectifier K<sup>+</sup> current (I<sub>Kur</sub>). Recently, we used an <i>in silico</i> strategy to define optimal K<sub>V</sub>1.5-targeting drug characteristics, including kinetics and state-dependent binding, that maximize AF-selectivity in human atrial cardiomyocytes in normal sinus rhythm (nSR). However, because of evidence for I<sub>Kur</sub> being strongly diminished in long-standing persistent (chronic) AF (cAF), the therapeutic potential of drugs targeting I<sub>Kur</sub> may be limited in cAF patients. Here, we sought to simulate the efficacy (and safety) of I<sub>Kur</sub> inhibitors in cAF conditions. To this end, we utilized sensitivity analysis of our human atrial cardiomyocyte model to assess the importance of I<sub>Kur</sub> for atrial cardiomyocyte electrophysiological properties, simulated hundreds of theoretical drugs to reveal those exhibiting anti-AF selectivity, and compared the results obtained in cAF with those in nSR. We found that despite being downregulated, I<sub>Kur</sub> contributes more prominently to action potential (AP) and effective refractory period (ERP) duration in cAF vs. nSR, with ideal drugs improving atrial electrophysiology (e.g., ERP prolongation) more in cAF than in nSR. Notably, the trajectory of the AP during cAF is such that more I<sub>Kur</sub> is available during the more depolarized plateau potential. Furthermore, I<sub>Kur</sub> block in cAF has less cardiotoxic effects (e.g., AP duration not exceeding nSR values) and can increase Ca<sup>2+</sup> transient amplitude thereby enhancing atrial contractility. We propose that <i>in silico</i> strategies such as that presented here should be combined with <i>in vitro</i> and <i>in vivo</i> assays to validate model predictions and facilitate the ongoing search for novel agents against AF. |
19,917 | An increasing electromechanical window is a predictive marker of ventricular fibrillation in anesthetized rabbit with ischemic heart. | The QTc interval is widely used in Safety Pharmacological studies to predict arrhythmia risk, and the electromechanical window (EMW) and short-term variability of QT intervals (STV<sub>QT</sub>) have been studied as new biomarkers for drug-induced Torsades de Pointes (TdP). However, the use of EMW and STV<sub>QT</sub> to predict ventricular fibrillation (VF) has not been elucidated. This study aimed to evaluate EMW and STV<sub>QT</sub> to predict VF in anesthetized rabbit model of VF. VF was induced by ligation of the left anterior descending and a descending branch of the left circumflex coronary arteries in a sample population of rabbits (n=18). VF was developed 55.6% (10/18). In rabbit with VF, the EMW was significantly higher than in rabbits without VF (96.3 ± 15.6 ms and 49.5 ± 5.6 ms, respectively, P<0.05). STV<sub>QT</sub> had significantly increased before the onset of VF in rabbits that experienced VF, but not in rabbits that did not experience VF (11.7 ± 1.8 ms and 3.7 ± 0.4 ms, respectively, P<0.05). The EMW and STV<sub>QT</sub> had better predictive power for VF with higher sensitivity and specificity than the QTc measure. The result suggested that the increasing of EMW, as well as the elevation of STV<sub>QT</sub>, can potentially be used as biomarkers for predicting of VF. |
19,918 | Association of common genetic variants related to atrial fibrillation and the risk of ventricular fibrillation in the setting of first ST-elevation myocardial infarction. | Cohort studies have revealed an increased risk for ventricular fibrillation (VF) and sudden cardiac death (SCD) in patients with atrial fibrillation (AF). In this study, we hypothesized that single nucleotide polymorphisms (SNP) previously associated with AF may be associated with the risk of VF caused by first ST-segment elevation myocardial infarction (STEMI).</AbstractText>We investigated association of 24 AF-associated SNPs with VF in the prospectively assembled case-control study among first STEMI-patients of Danish ancestry.</AbstractText>We included 257 cases (STEMI with VF) and 537 controls (STEMI without VF). The median age at index infarction was 60 years for the cases and 61 years for the controls (p = 0.100). Compared to the control group, the case group was more likely to be male (86% vs. 75%, p = 0.001), have a history of AF (7% vs. 2%, p = 0.006) or hypercholesterolemia (39% vs. 31%, p = 0.023), and a family history of sudden death (40% vs. 25%, p < 0.001). All 24 selected SNPs have previously been associated with AF. None of the 24 SNPs were associated with the risk of VF after adjustment for age and sex under additive genetic model of inheritance in the logistic regression model.</AbstractText>In this study, we found that the 24 AF-associated SNPs may not be involved in increasing the risk of VF. Larger VF cohorts and use of new next generation sequencing and epigenetic may in future identify additional AF and VF risk loci and improve our understanding of genetic pathways behind the two arrhythmias.</AbstractText> |
19,919 | Dronedarone produces early regression of myocardial remodelling in structural heart disease. | Left ventricular hypertrophy (LVH) in hypertension is associated with a greater risk of sustained supraventricular/atrial arrhythmias. Dronedarone is an antiarrhythmic agent that was recently approved for the treatment of atrial fibrillation. However, its effect on early regression of LVH has not been reported. We tested the hypothesis that short-term administration of dronedarone induces early regression of LVH in spontaneously hypertensive rats (SHRs).</AbstractText>Ten-month-old male SHRs were randomly assigned to an intervention group (SHR-D), where animals received dronedarone treatment (100 mg/kg) for a period of 14 days, or to a control group (SHR) where rats were given vehicle. A third group with normotensive control rats (WKY) was also added. At the end of the treatment with dronedarone we studied the cardiac anatomy and function in all the rats using transthoracic echocardiogram, cardiac metabolism using the PET/CT study (2-deoxy-2[18F]fluoro-D-glucose) and cardiac structure by histological analysis of myocyte size and collagen content.</AbstractText>The hypertensive vehicle treated SHR rats developed the classic cardiac pattern of hypertensive cardiomyopathy as expected for the experimental model, with increases in left ventricular wall thickness, a metabolic shift towards an increase in glucose use and increases in myocyte and collagen content. However, the SHR-D rats showed statistically significant lower values in comparison to SHR group for septal wall thickness, posterior wall thickness, ventricular mass, glucose myocardial uptake, size of left ventricular cardiomyocytes and collagen content. All these values obtained in SHR-D rats were similar to the values measured in the normotensive WKY control group.</AbstractText>The results suggest by three alternative and complementary ways (analysis of anatomy and cardiac function, metabolism and histological structure) that dronedarone has the potential to reverse the LVH induced by arterial hypertension in the SHR model of compensated ventricular hypertrophy.</AbstractText> |
19,920 | Effects of combined helium pre/post-conditioning on the brain and heart in a rat resuscitation model. | The noble gas helium induces cardio- and neuroprotection by pre- and post-conditioning. We investigated the effects of helium pre- and post-conditioning on the brain and heart in a rat resuscitation model.</AbstractText>After approval by the Animal Care Committee, 96 Wistar rats underwent cardiac arrest for 6 min induced by ventricular fibrillation. Animals received 70% helium and 30% oxygen for 5 min before cardiac arrest and for 30 min after restoration of spontaneous circulation (ROSC). Control animals received 70% nitrogen and 30% oxygen. Hearts and brains were excised after 2, 4 h or 7 days. Neurological degeneration was evaluated using TUNEL and Nissl staining in the hippocampal CA-1 sector. Cognitive function after 7 days was detected with the tape removal test. Molecular targets were measured by infrared western blot. Data are shown as median [Interquartile range].</AbstractText>Helium treatment resulted in significantly less apoptosis (TUNEL positive cells/100 pixel 73.5 [60.3-78.6] vs.78.2 [70.4-92.9] P = 0.023). Changes in Caveolin-3 expression in the membrane fraction and Hexokinase-II in the mitochondrial fraction were observed in the heart. Caveolin-1 expression of treated animals significantly differed from control animals in the membrane fraction of the heart and brain after ROSC.</AbstractText>Treatment with helium reduced apoptosis in our resuscitation model. Differential expression levels of Caveolin-1, Caveolin-3 and Hexokinase II in the heart were found after helium pre- and post-conditioning. No beneficial effects were seen on neurofunctional outcome.</AbstractText>© 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.</CopyrightInformation> |
19,921 | Vitamin D and new-onset atrial fibrillation: A meta-analysis of randomized controlled trials. | Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, which affects 1.5% to 2% of the general population. More than six million Europeans suffer from AF. To research vitamin D levels in the prevention of new-onset atrial fibrillation (AF), we conducted a systematic review of randomized controlled trials (RCTs). We focused on the vitamin D levels in the prevention of new-onset AF. The outcomes assessed were vitamin D levels, left ventricular ejection fraction (LVEF), and left atrium diameter. Six RCTs ultimately met the inclusion criteria in the meta-analysis. The outcomes of Vitamin D levels (MD = -4.27, 95% CI = -5.20 to-3.34, P = 0.30) in the new-onset AF showed no significant difference. The left atrium diameter (MD = 1.96, 95% CI = 1.48 to 2.60, P < 0.01) between new-onset AF and LVEF (MD = -0.92, 95% CI = -1.59 to -0.26, P < 0.01) showed significant difference. Our study shows that circulating vitamin D levels may not play a major role in the development of new-onset AF. |
19,922 | Spectrum and Outcome of Patients Who Have Undergone Implantation of an Implantable Cardioverter Defibrillator After Aborted-Sudden Cardiac Arrest. | Most of implantable cardioverter defibrillator (ICD) secondary prevention studies have been published 2 decades ago. We aimed to describe a contemporary cohort of patients who have undergone implantation of an ICD after an aborted-sudden cardiac arrest (SCA). We retrospectively evaluated consecutive patients referred to our centers between 2005 and 2013. Predictors of overall mortality or heart transplant were analyzed using Cox proportional hazards models. A total of 250 patients (76.4% male, 48.7 ± 16.7 years) were included (mean follow-up = 49.6 ± 35 months). The presence of a structural heart disease (SHD) was considered as the primary cause of the aborted-SCA in 160 patients (64%). In 90 patients (36%), no SHD was observed, with patients much younger (40.9 ± 16.2 years vs 53.0 ± 15.5 years in the SHD group, p < 0.0001). The 5-year estimated rates of death or heart transplant were 14.3% and 5.2% in the group with and without SHD, respectively (hazard ratio = 4.65, 95% confidence interval 1.40 to 15.6, p = 0.014). The 5-year estimated rates of appropriate ICD therapy in the ventricular fibrillation zone were 16.7% and 25.1% in patients without and with SHD (p = 0.24), respectively. Only left ventricular ejection fraction remained independently associated with mortality or heart transplant (hazard ratio = 0.94, 95% confidence interval 0.90 to 0.97, p = 0.0004). Overall, 69 patients (27.6%) experienced at least 1 ICD-related complication. In conclusion, compared with secondary prevention pivotal studies, the current patients who have undergone implantation of an ICD after aborted-SCA are younger, with a high proportion of structurally normal hearts. Compared with patients without SHD, who depicted a relatively favorable outcome, patients with SHD present a fourfold higher risk of death during follow-up. Reduced left ventricular ejection fraction remains the major influencing factor. |
19,923 | Outcome of Patients With In-Hospital Ventricular Tachycardia and Ventricular Fibrillation Arrest While Using a Wearable Cardioverter Defibrillator. | In-hospital sudden cardiac arrests occurring during nighttime and weekend hours or within unmonitored hospital areas have been reported to have a poorer outcomes than monitored cardiac arrest. This study sought to assess the outcome of in-hospital ventricular tachycardia (VT) and ventricular fibrillation (VF) arrest by time of day, day of week, and within-hospital location when using a wearable cardioverter defibrillator (WCD). We retrospectively identified and reviewed consecutive in-hospital VT/VF arrests from January 2011 to May 2015 experienced by patients wearing a WCD using the manufacturer's postmarket registry. An index shockable sudden cardiac arrest event was defined as the first arrest caused by VT/VF. Event location and clinical outcome were extracted from patient call logs. Survival analysis was performed using the Kaplan-Meier method. A total of 234 in-hospital VT/VF arrests were included (mean age = 65 ± 12 years, male = 74%); 50% had a history of congestive heart failure. The median follow-up time was 6 days (interquartile range 1-4). In the 128 (55%) daytime events (7:00 a.m. to 7:00 p.m.), 24-hour survival was 91%. The 106 (45%) nighttime events (7:01 p.m. to 6:59 a.m.) had 89% 24-hour survival (p = 0.54). Survival outcome by monitored or unmonitored hospital locations were similar. Kaplan-Meir analyses showed no difference in 30-day survival either between weekend and weekday events (72% vs 65%, p = 0.79), or between daytime and nighttime events (64% vs 69%, p = 0.37). In conclusion, WCD use during in-hospital VT/VF arrest correlated with high survival rates regardless of event time or location inside a hospital. Use of a WCD appears to mitigate some of the risks associated with in-hospital VT/VF arrest. |
19,924 | Usefulness of the American Heart Association's Life Simple 7 to Predict the Risk of Atrial Fibrillation (from the REasons for Geographic And Racial Differences in Stroke [REGARDS] Study). | The American Heart Association has identified metrics of ideal cardiovascular (CV) health known as Life's Simple 7 (LS7). We determined the prospective relationship between the LS7 and the incident atrial fibrillation (AF) in a biracial cohort. The REasons for Geographic And Racial Differences in Stroke (REGARDS) study enrolled non-Hispanic black and white adults 45 years or older. This analysis included 9,576 REGARDS participants (mean age 63 ± 8.4 years; 57% women; 30% black) who were free of AF at baseline and completed a follow-up examination 9.4 years later. An overall LS7 score was calculated at baseline as the sum of the LS7 component scores and classified as inadequate (0 to 4), average (5 to 9), or optimal (10 to 14) CV health. The primary outcome was incident AF, identified at follow-up by either electrocardiogram or a self-reported medical history of a physician diagnosis. A total of 725 incident AF cases were detected. Compared with the inadequate category (n = 534), participants in the optimal category (n = 1,953) had a 32% lower odds of developing AF (odds ratio 0.68; 95% confidence interval 0.47, 0.99) in a logistic regression model adjusted for demographic characteristics, alcohol use, left ventricular hypertrophy, coronary heart disease, and stroke. A 1-point higher LS7 score was associated with a 5% lower odds of incident AF (odds ratio  = 0.95; 95% confidence interval 0.91, 0.99). In conclusion, better CV health, as defined by the LS7 score, is associated with a reduction in development of AF. |
19,925 | Interictal cardiac autonomic nervous system disturbances in dogs with idiopathic epilepsy. | Autonomic nervous system (ANS) activity in the interictal period (InIp) in dogs with presumed idiopathic epilepsy (pIE) was assessed using heart rate variability (HRV) analysis. The HRVs obtained from 28 pIE dogs with interictal epileptic discharges (InIEd; 11 with treatment and 17 without treatment) detected on electroencephalography (EEG) were compared with those obtained from 13 healthy dogs. On electrocardiographic (ECG) study, the P wave dispersion (PWD; P<0.001), P max (P=0.004) and corrected QT interval (QTc; P=0.025) were significantly increased in the pIE group. On the basis of HRV analysis, the pIE dogs had an increased activity of the parasympathetic component of the ANS, including the percentage of R-R interval (pNN50%) that differs more than 50ms (P=0.011) and high frequency band (HF; P=0.041). Administration of phenobarbitone had no influence on the ANS pattern when pIE subgroups were compared (P>0.05). In InIp, dogs elicited specific conductibility delays of the electrical impulses (increased PWD and QTc interval); these delays are considered to be risk factors for developing severe arrhythmias, such as atrial fibrillation and ventricular tachycardia. When compared with human beings, a different ANS pattern characterised by increased parasympathetic activity was observed, which may influence the therapeutic approach of IE in dogs. |
19,926 | Role of epinephrine and extracorporeal membrane oxygenation in the management of ischemic refractory ventricular fibrillation: a randomized trial in pigs. | xtracorporeal membrane oxygenation (ECMO) is used in cardiopulmonary resuscitation (CPR) of refractory cardiac arrest. We used a 2×2 study design to compare ECMO versus CPR and epinephrine versus placebo in a porcine model of ischemic refractory ventricular fibrillation (VF). Pigs underwent 5 minutes of untreated VF, 10 minutes of CPR, and were randomized to receive epinephrine versus placebo for another 35 minutes. Animals were further randomized to LAD reperfusion at minute 45 with ongoing CPR versus veno-arterial ECMO cannulation at minute 45 of CPR and subsequent LAD reperfusion. Four-hour survival was improved with ECMO while epinephrine showed no effect. |
19,927 | Cost-Effectiveness Analysis of Cardiovascular Disease Treatment in Japan. | The quality-adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER) are important concepts in cost-effectiveness analysis, which is becoming increasingly important in Japan. QALY is used to estimate quality of life (QOL) and life years, and can be used to compare the efficacies of cancer and cardiovascular treatments. ICER is defined as the difference in cost between treatments divided by the difference in their effects, with a smaller ICER indicating better cost-effectiveness. Here, we present a review of cost-effectiveness analyses in Japan as well other countries. A number of treatments were shown to be cost-effective, e.g., statin for secondary prevention of cardiovascular disease, aspirin for primary prevention of cardiovascular disease, DOAC for high-risk atrial fibrillation, beta blockers, ACE inhibitors, and ARB for heart failure, sildenafil and bosentan for pulmonary hypertension, CABG for multi-vessel coronary disease, ICD for ventricular tachycardia, and CRT for heart failure with low ejection fraction, while others were not cost-effective, e.g., epoprostenol for pulmonary hypertension and LVAD for end-stage heart failure. Further investigations are required regarding some treatments, e.g., PCSK-9 inhibitors for familial hypercholesterolemia, PCI for multi-vessel coronary disease, catheter ablation for atrial fibrillation, and TAVI for severe aortic stenosis. Ethical aspects should be taken into consideration when utilizing the results of cost-effectiveness analysis in medical policy. |
19,928 | Diastolic Dysfunction Is a Risk of Perioperative Myocardial Injury Assessed by High-Sensitivity Cardiac Troponin T in Elderly Patients Undergoing Non-Cardiac Surgery. | High-sensitivity cardiac troponin T (hs-cTnT) is useful for detecting myocardial injury and is expected to become a prognostic marker in patients undergoing non-cardiac surgery. The aim of this pilot study evaluating the efficacy of β-blocker therapy in a perioperative setting (MAMACARI study) was to assess perioperative myocardial injury (PMI) in elderly patients with preserved ejection fraction (EF) undergoing non-cardiac surgery.Methods and Results:In this prospective observational cohort study of 151 consecutive patients with preserved EF and aged >60 years who underwent non-cardiac surgery, serum levels of hs-cTnT were measured before and on postoperative days 1 and 3 after surgery. PMI was defined as postoperative hs-cTnT >0.014 ng/mL and relative hs-cTnT change ≥20%. A total of 36 (23.8%) of the patients were diagnosed as having PMI. The incidence of a composite of cardiovascular events within 30 days after surgery, including myocardial infarction, stroke, worsening heart failure, atrial fibrillation and pulmonary embolism, was significantly higher in patients with PMI than in patients without PMI (odds ratio (OR) 9.25, P<0.001, 95% confidence interval (CI) 2.65-32.3). Multivariate analysis revealed that left ventricular diastolic dysfunction defined by echocardiography was independently associated with PMI (OR: 3.029, 95% CI: 1.341-6.84, P=0.008).</AbstractText>PMI is frequently observed in elderly patients undergoing non-cardiac surgery. Diastolic dysfunction is an independent predictor of PMI.</AbstractText> |
19,929 | Management of arrhythmia in sepsis and septic shock. | The occurrence of supraventricular arrhythmias is associated with an unfavourable prognosis in septic shock. Available trials are difficult to apply in sepsis and septic shock patients due to included cohorts, control groups and because "one size does not fit all". The priorities in the critically ill are maintenance of the sinus rhythm and diastolic ventricular filling. The rate control modality should be reserved for chronic AF and in situations when the sinus rhythm is difficult to maintain due to extreme stress conditions resulting from a high dosage of vasoactive agents. Electric cardioversion is indicated in unstable patients with an absence of contraindications and is more feasible in combination with an antiarrhythmic agent. Besides amiodarone being preferred for its lower cardiodepressant side effect compared to other agents, drugs with a different degree of betablocking activity are very useful in supraventricular arrhythmias and septic shock, providing echocardiography is routinely used to support their indications within the current summary of product characteristics. A typical patient benefiting from propafenone is without significant structural heart disease, i.e. typically with normal to moderately reduced left ventricular systolic function. Future research should be channelled towards echocardiography-guided prospective controlled trials on antiarrhythmic therapy which may clarify the issue of rhythm versus rate control, the effects of various antiarrhythmic drugs, and a place for electric cardioversion in critically ill patients in septic shock. |
19,930 | Hypothermia Modulates Arrhythmia Substrates During Different Phases of Resuscitation From Ischemic Cardiac Arrest. | We designed an innovative porcine model of ischemia-induced arrest to determine dynamic arrhythmia substrates during focal infarct, global ischemia from ventricular tachycardia or fibrillation (VT/VF) and then reperfusion to determine the effect of therapeutic hypothermia (TH) on dynamic arrhythmia substrates and resuscitation outcomes.</AbstractText>Anesthetized adult pigs underwent thoracotomy and regional plunge electrode placement in the left ventricle. Subjects were then maintained at either control (CT; 37°C, n=9) or TH (33°C, n=8). The left anterior descending artery (LAD) was occluded and ventricular fibrillation occurred spontaneously or was induced after 30 minutes. Advanced cardiac life support was started after 8 minutes, and LAD reperfusion occurred 60 minutes after occlusion. Incidences of VF/VT and survival were compared with ventricular ectopy, cardiac alternans, global dispersion of repolarization during LAD occlusion, and LAD reperfusion. There was no difference in incidence of VT/VF between groups during LAD occlusion (44% in CT versus 50% in TH; P</i>=1s). During LAD occlusion, ectopy was increased in CT and suppressed in TH (33±11 ventricular ectopic beats/min versus 4±6 ventricular ectopic beats/min; P</i>=0.009). Global dispersion of repolarization and cardiac alternans were similar between groups. During LAD reperfusion, TH doubled the incidence of cardiac alternans compared with CT, with a marked increase in VF/VT (100% in TH versus 17% in CT; P</i>=0.004). Ectopy and global dispersion of repolarization were similar between groups during LAD reperfusion.</AbstractText>TH alters arrhythmia substrates in a porcine translational model of resuscitation from ischemic cardiac arrest during the complex phases of resuscitation. TH worsens cardiac alternans, which was associated with an increase in spontaneous VT/VF during reperfusion.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
19,931 | Long-term outcomes for different surgical strategies to treat left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. | Surgical intervention is used to treat dynamic left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy. This study assesses the effect of different surgical strategies on long-term mortality and morbidity.</AbstractText>In total, 347 patients underwent surgical intervention for LVOTO (1988-2015). Group A (n = 272) underwent septal myectomy; Group B (n = 33), septal myectomy and mitral valve (MV) repair; Group C (n = 22), myectomy and MV replacement; and Group D (n = 20), MV replacement alone. Median follow-up was 5.2 years (interquartile range 1.9-7.9). The mean resting LVOT gradient improved post-operatively from 71.9 ± 39.6 mmHg to 13.4 ± 18.5 mmHg (P < 0.05). Overall, 72.4% of patients improved by >1 New York Heart Association (NYHA) class; 58.9% of patients undergoing MV replacement alone did not improve their NYHA class. There were 5 perioperative deaths and 20 late deaths (>30 days). Survival rates at 1, 5 and 10 years respectively were 98.4, 96.9, 91.9% in Group A; 97.0, 92.4, 61.6% in Group B; 100.0, 100.0, 55.6% in Group C; and 94.7, 85.3, 85.3% in Group D (log-rank, P < 0.05). Long-term (>30 days) complications included atrial fibrillation (29.6%), transient ischaemic attack/stroke (2.4%) and heart failure hospitalisation (3.2%). There were 16 repeat surgical interventions at 3.0 years.</AbstractText>Septal myectomy is a safe procedure resulting in symptomatic improvement in the majority of patients. The annual incidence of non-fatal disease-related complications after surgical treatment of LVOTO is relatively high. Patients who underwent MV replacements had poorer outcomes with less symptomatic benefit in spite of a similar reduction in LVOT gradients.</AbstractText>© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.</CopyrightInformation> |
19,932 | A lower eicosapentaenoic acid/arachidonic acid ratio is associated with in-hospital fatal arrhythmic events in patients with acute myocardial infarction: a J-MINUET substudy. | The ratio of serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) is significantly associated with long-term clinical outcomes in patients with acute myocardial infarction (AMI). However, it has not been conclusively demonstrated that higher serum EPA/AA ratio fares better clinical outcomes in the early phase of AMI. The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry conducted in 28 Japanese medical institutions between July 2012 and March 2014. We enrolled 3,283 consecutive AMI patients who were admitted to participating institutions within 48 h of symptom onset. A serum EPA/AA ratio was available for 629 of these patients. The endpoints were in-hospital mortality and major adverse cardiac events (MACE), defined as a composite of all cause death, cardiac failure, ventricular tachycardia (VT) and/or ventricular fibrillation (VF) and bleeding during hospitalization. Although similar rates of in-hospital mortality, cardiac failure, bleeding, and MACE were found in the lower serum EPA/AA group and higher serum EPA/AA group, the incidence of VT/VF during hospitalization was significantly higher in the low ratio group (p = 0.008). Receiver operating characteristic curve analysis showed that an EPA/AA ratio < 0.35 could predict the incidence of VT/VF with 100% sensitivity and 64.0% specificity. A lower serum EPA/AA ratio was associated with a higher frequency of fatal arrhythmic events in the early phase of AMI. |
19,933 | Impaired Left Atrial Strain as a Predictor of New-onset Atrial Fibrillation After Aortic Valve Replacement Independently of Left Atrial Size. | Left atrial dysfunction in aortic stenosis may precede atrial enlargement and predict the occurrence of atrial fibrillation (AF). To test this hypothesis, we assessed left atrial function and determined its impact on the incidence of AF after aortic valve replacement.</AbstractText>A total of 149 severe aortic stenosis patients (74±8.6 years, 51% men) with no prior AF were assessed using speckle-tracking echocardiography. Left atrial function was evaluated using peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and phasic left atrial volumes. The occurrence of AF was monitored in 114 patients from surgery until hospital discharge.</AbstractText>In multiple linear regression, PALS and PACS were inversely correlated with left atrial dilation, left ventricular hypertrophy, and diastolic function. Atrial fibrillation occurred in 36 patients within a median time of 3 days [interquartile range, 1-4] after aortic valve replacement. In multiple Cox regression, PALS and PACS were independently associated with the incidence of AF (HR, 0.946; 95%CI, 0.910-0.983; P=.005 and HR, 0.932; 95%CI, 0.883-0.984; P=.011, respectively), even after further adjustment for left atrial dimensions. Both reduced PALS and PACS were associated with the incidence of AF in patients with nondilated left atria (P value for the interaction of PALS with left atrial dimensions=.013).</AbstractText>In severe aortic stenosis, left atrial dysfunction predicted the incidence of postoperative AF independently of left atrial dilation, suggesting that speckle-tracking echocardiography before surgery may help in risk stratification, particularly in patients with nondilated left atria.</AbstractText>Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.</CopyrightInformation> |
19,934 | Association between percutaneous hemodynamic support device and survival from cardiac arrest in the state of Michigan. | The role of circulatory support in the post-cardiac arrest period remains controversial. Our objective was to investigate the association between treatment with a percutaneous hemodynamic support device and outcome after admission for cardiac arrest.</AbstractText>We performed a retrospective study of adult patients with admission diagnosis of cardiac arrest or ventricular fibrillation (VF) from the Michigan Inpatient Database, treated between July 1, 2010, and June 30, 2013. Patient demographics, clinical characteristics, treatments, and disposition were electronically abstracted based on ICD-9 codes at the hospital level. Mixed-effects logistic regression models were fit to test the effect of percutaneous hemodynamic support device defined as either percutaneous left ventricular assist device (pLVAD) or intra-aortic balloon pump (IABP) on survival. These models controlled for age, sex, VF, myocardial infarction (MI), and cardiogenic shock with hospital modeled as a random effect.</AbstractText>A total of 103 hospitals contributed 4393 patients for analysis, predominately male (58.8%) with a mean age of 64.1years (SD 15.5). On univariate analysis, younger age, male sex, VF as the initial rhythm, acute MI, percutaneous coronary intervention, percutaneous hemodynamic support device, and absence of cardiogenic shock were associated with survival to discharge (each p<0.001). Mixed-effects logistic regressions revealed use of percutaneous hemodynamic support device was significantly associated with survival among all patients (OR 1.8 (1.28-2.54)), and especially in those with acute MI (OR 1.95 (1.31-2.93)) or cardiogenic shock (OR 1.96 (1.29-2.98)).</AbstractText>Treatment with percutaneous hemodynamic support device in the post-arrest period may provide left ventricular support and improve outcome.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,935 | Type of Atrial Fibrillation and Outcomes in Patients With Heart Failure and Reduced Ejection Fraction. | Atrial fibrillation (AF) is common in heart failure (HF), but the outcome by type of AF is largely unknown.</AbstractText>This study investigated outcomes related to type of AF (paroxysmal, persistent or permanent, or new onset) in 2 recent large trials in patients with HF with reduced ejection fraction.</AbstractText>The study analyzed patients in the PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) and ATMOSPHERE (Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure) trials. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for outcomes related to AF type.</AbstractText>Of 15,415 patients, 5,481 (35.6%) had a history of AF at randomization, and of these, 1,645 (30.0%) had paroxysmal AF. Compared with patients without AF, patients with paroxysmal AF at randomization had a higher risk of the primary composite endpoint of cardiovascular death or HF hospitalization (HR: 1.20; 95% confidence interval [CI]: 1.09 to 1.32; p < 0.001), HF hospitalization (HR: 1.34; 95% CI: 1.19 to 1.51; p < 0.001), and stroke (HR: 1.34; 95% CI: 1.02 to 1.76; p = 0.037), whereas the corresponding risks in patients with persistent or permanent AF were not elevated. Neither type of AF was associated with higher mortality. New onset AF was associated with the greatest risk of adverse outcomes: primary endpoint (HR: 2.21; 95% CI: 1.80 to 2.71), HF hospitalization (HR: 2.11; 95% CI: 1.58 to 2.81), stroke (HR: 2.20; 95% CI: 1.25 to 3.88), and all-cause mortality (HR: 2.26; 95% CI: 1.86 to 2.74), all p values < 0.001, compared with patients without AF. Anticoagulants were used less often in patients with paroxysmal (53%) and new onset (16%) AF than in patients with persistent or permanent AF (71%).</AbstractText>Among HF patients with a history of AF, those with paroxysmal AF were at greater risk of HF hospitalization and stroke than were patients with persistent or permanent AF, underlining the importance of anticoagulant therapy. New onset AF was associated with increased risk of all outcomes. (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF]; NCT01035255) (Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure [ATMOSPHERE]; NCT00853658).</AbstractText>Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,936 | Out-of-hospital cardiac arrests in Switzerland: Predictors for emergency department mortality in patients with ROSC or on-going CPR on admission to the emergency department. | One of the leading causes of death is out-of-hospital cardiac arrest (OHCA) with an in-hospital mortality of about 70%. To identify predictors for the high mortality of OHCA patients and especially for women, that are considered at high risk for in-hospital mortality, we evaluated one specific setting of in-hospital treatment after OHCA: the emergency department (ED).</AbstractText>Retrospective analysis of consecutive ED admissions with OHCA at the Inselspital Bern, Switzerland from 1st June 2012 to 31th Mai 2015. Demographic, preclinical and ED medical data were compared for patient groups with return of circulation (ROSC) and on-going resuscitation (CPR) on admission, as well as for subgroups with and without ED mortality. Predictors for ED mortality were investigated using univariate analysis with logistic regression.</AbstractText>In 354 patients (228 (64.4%) with ROSC; 126 (35.6%) with on-going CPR) we found an overall ED mortality of 28.5% (5.7% ROSC group; 69.8% on-going CPR group). Female gender (OR 7.053 (CI 95% 2.085; 24.853), p = 0.002) and greater age (OR 1.052 (95% CI 1.006-1.101), p = 0.029) were associated with ED mortality in the ROSC but not in the on-going CPR group. Ventricular fibrillation as initially monitored rhythm (OR 0.126 (95% CI 0.027-0.582), p = 0.008) and shorter CPR duration (OR 1.055 (95% CI 1.024;1.088), p = 0.001) were associated with ED survival in patients with ROSC but not in patients with on-going CPR on admission. In ROSC patients a higher lactate and lower pH were associated with mortality (pH: OR 0.009 (CI95% 0.000;0.420), p = 0.016; lactate: OR 1.183 (95% CI 1.037; 1.349), p = 0.013); similar in on-going CPR patients (pH 0.061 (95% CI 0.007, 0.558), p = 0.013, lactate: 1.146 (95% CI 1.041;1.261), p = 0.005).</AbstractText>Patients with ROSC who died during ED care were predominantly women and older patients, as well as patients with non-shockable initial heart rhythm and long CPR durations. In patients with on-going CPR on admission, no clinical or demographic predictors for ED mortality were found. Higher lactate and lower pH were predictors in both OHCA groups.</AbstractText> |
19,937 | Estimating the probabilities of rare arrhythmic events in multiscale computational models of cardiac cells and tissue. | Ectopic heartbeats can trigger reentrant arrhythmias, leading to ventricular fibrillation and sudden cardiac death. Such events have been attributed to perturbed Ca2+ handling in cardiac myocytes leading to spontaneous Ca2+ release and delayed afterdepolarizations (DADs). However, the ways in which perturbation of specific molecular mechanisms alters the probability of ectopic beats is not understood. We present a multiscale model of cardiac tissue incorporating a biophysically detailed three-dimensional model of the ventricular myocyte. This model reproduces realistic Ca2+ waves and DADs driven by stochastic Ca2+ release channel (RyR) gating and is used to study mechanisms of DAD variability. In agreement with previous experimental and modeling studies, key factors influencing the distribution of DAD amplitude and timing include cytosolic and sarcoplasmic reticulum Ca2+ concentrations, inwardly rectifying potassium current (IK1) density, and gap junction conductance. The cardiac tissue model is used to investigate how random RyR gating gives rise to probabilistic triggered activity in a one-dimensional myocyte tissue model. A novel spatial-average filtering method for estimating the probability of extreme (i.e. rare, high-amplitude) stochastic events from a limited set of spontaneous Ca2+ release profiles is presented. These events occur when randomly organized clusters of cells exhibit synchronized, high amplitude Ca2+ release flux. It is shown how reduced IK1 density and gap junction coupling, as observed in heart failure, increase the probability of extreme DADs by multiple orders of magnitude. This method enables prediction of arrhythmia likelihood and its modulation by alterations of other cellular mechanisms. |
19,938 | Epicardial radiofrequency catheter ablation of Brugada syndrome with electrical storm during ventricular fibrillation: A case report. | Brugada syndrome (BrS) is characterized by ST segment elevation at the J point ≥2 mm in the right precordial electrocardiogram (ECG) leads, in the absence of structural heart disease, electrolyte disturbances, or ischemia. It is a well-described cause of sudden death in young patients, especially in the age of between 30 and 40 years old. Here, we reported an unusual case of electrical storm (ES) of ventricular fibrillation (VF) caused by BrS with complete right bundle-branch block (CRBBB) in a 75-year-old male patient.</AbstractText>A 75-year-old male patient survived sudden cardiac death caused by a ventricular ES. He presented with the cove-shaped ST elevation of 2 mm in lead V1 with typical CRBBB and lacked structural cardiomyopathy and coronary heart disease. The patient suffered ventricular ES again, although the implantable cardioverter defibrillator(ICD) had implanted.</AbstractText>Brugada syndrome with complete right bundle-branch block.</AbstractText>Implantable cardioverter defibrillator (ICD) implantation was performed. But this therapy could not prevent the recurrence of malignant arrhythmia. Finally, the ES was treated successfully using radiofrequency catheter ablation (RFCA) at the area of the free wall of the right ventricular outflow tract (RVOT) epicardium.</AbstractText>During 7 months of follow-up, the patient was asymptomatic and free of arrhythmic events.</AbstractText>As far as we know, the patient is the oldest patient reported to have BrS. RFCA offers an alternative therapy for patients with BrS, especially when ICD shocks are encountered.</AbstractText> |
19,939 | Predictors of heart rhythm disturbances in hypertensive obese patients with obstructive sleep apnea. | To assess the incidence and predictors of heart rhythm and conduction disturbances in hypertensive obese patients with and without obstructive sleep apnea (OSA).</AbstractText>This is an open, cohort, prospective study. Out of 493 screened patients, we selected 279 hypertensive, obese individuals without severe concomitant diseases: 75 patients without sleep-disordered breathing (non-SDB group), and 204 patients with OSA (OSA group). At baseline, all patients underwent examination, including ECG, Holter ECG monitoring, and sleep study. During follow-up (on 3, 5, 7 and 10th</sup> years; phone calls once per 6 months), information about new events, changes in therapy and life style was collected, diagnostic procedures were performed. As the endpoints, we registered significant heart rhythm and conduction disorders as following: atrial fibrillation (AF), ventricular tachycardia, atrioventricular block (AV) 2-3 degree, sinoatrial block, significant sinus pauses (> 2000 ms), and the required pacemaker implantation.</AbstractText>The median follow-up was 108 (67.5-120) months. The frequency of heart rhythm disorders was higher in OSA patients (29 cases, χ</i>2</sup> = 5.5; Р</i> = 0.019) compared to the non-SDB patients (three cases; OR: 3.92, 95% CI: 1.16-13.29). AF was registered in 15 patients (n</i> = 12 in OSA group; Р</i> = 0.77). Heart conduction disturbance developed in 16 patients, without an association with the rate of coronary artery disease onset. Regression analysis showed that only hypertension duration was an independent predictor of AF (OR: 1.10, 95% CI: 1.04-1.16; Р</i> = 0.001). In case of heart conduction disturbances, apnea duration was the strongest predictor (Р</i> = 0.002).</AbstractText>Hypertensive obese patients with OSA demonstrate 4-fold higher incidence of heart rhythm and conduction disturbances than subjects without SDB. Hypertension duration is an independent predictor for AF development, while sleep apnea/hypopnea duration is the main factor for heart conduction disorders onset in hypertensive obese patients with OSA.</AbstractText> |
19,940 | Unilateral Pulmonary Edema in a Patient with Worsening Tricuspid Valve Regurgitation: A Secret Inside Pulmonary Veins. | We present the case of a 69-year-old patient who was referred to the Department of Echocardiography for surgical treatment of severe tricuspid valve regurgitation (TVR) with advanced congestive heart failure. In 2013 the patient underwent unsuccessful percutaneous ablation for permanent atrial fibrillation. In 2015, following numerous episodes of atrial fibrillation and congestive heart failure with left pleural effusion, the patient was admitted to another center. A transthoracic echocardiogram showed severe TVR and moderate precapillary pulmonary hypertension, confirmed at right cardiac catheterization. He showed bilateral ankle swelling, mild systolic cardiac murmur and localized leftmost decreased breath sounds. Chest X-ray revealed left-sided pulmonary edema and ipsilateral large pleural effusion. Following percutaneous drainage of the left pulmonary effusion, the patient underwent transthoracic and transesophageal echocardiography (TEE), confirming severe TVR due to annular dilation, severe pulmonary hypertension (60 mmHg) and right ventricular overload. At TEE, we found a narrowed single left pulmonary vein. Coronary artery angiography showed no critical stenosis. The patient underwent cardiac magnetic resonance and Angiography that confirmed ostial stenosis of a single left pulmonary vein. We performed successful bare-metal stent implantation. After the procedure, we observed progressive improvement in the patient's clinical condition, concomitant with reverse pulmonary hypertension, significant TVR reduction and chest X-ray normalization. This is a rare case of unilateral pulmonary edema following percutaneous ablation of atrial fibrillation. |
19,941 | Case report: electrical storm during induced hypothermia in a patient with early repolarization. | Population based studies showed an association of early repolarization in the electrocardiogram (ECG) and a higher rate of sudden cardiac death presumably due to ventricular fibrillation. The triggers for ventricular fibrillation in patients with early repolarization are not fully understood.</AbstractText>We describe the case of a young patient with a survived ventricular fibrillation arrest while asleep followed by multiple episodes of recurrent ventricular fibrillation. The admission ECG showed an early repolarization pattern with substantial J-point elevation in most of the ECG-leads. After initiation of a hypothermia protocol, the patient developed an electrical storm with multiple ventricular fibrillation episodes requiring multiple cardioversions. Intravenous isoproterenol infusion successfully suppressed the malignant arrhythmia.</AbstractText>Hypothermia appears proarrhythmic in patients with early repolarization and may trigger ventricular fibrillation. This knowledge is particularly important when initiating temperature management protocols in patients after a survived cardiac arrest. During the acute phase of an early repolarization associated electrical storm, isoproterenol is the most effective treatment suppressing the ventricular fibrillation-inducing premature ventricular complexes at higher heart rates.</AbstractText> |
19,942 | WITHDRAWN: Pharmacological cardioversion for atrial fibrillation and flutter. | Atrial fibrillation is the commonest cardiac dysrhythmia. It is associated with significant morbidity and mortality. There are two approaches to the management of atrial fibrillation: controlling the ventricular rate or converting to sinus rhythm in the expectation that this would abolish its adverse effects.</AbstractText>To assess the effects of pharmacological cardioversion of atrial fibrillation in adults on the annual risk of stroke, peripheral embolism, and mortality.</AbstractText>We searched the Cochrane Controlled Trials Register (Issue 3, 2002), MEDLINE (2000 to 2002), EMBASE (1998 to 2002), CINAHL (1982 to 2002), Web of Science (1981 to 2002). We hand searched the following journals: Circulation (1997 to 2002), Heart (1997 to 2002), European Heart Journal (1997-2002), Journal of the American College of Cardiology (1997-2002) and selected abstracts published on the web site of the North American Society of Pacing and Electrophysiology (2001, 2002).</AbstractText>Randomised controlled trials or controlled clinical trials of pharmacological cardioversion versus rate control in adults (>18 years) with acute, paroxysmal or sustained atrial fibrillation or atrial flutter, of any duration and of any aetiology.</AbstractText>One reviewer applied the inclusion criteria and extracted the data. Trial quality was assessed and the data were entered into RevMan.</AbstractText>We identified two completed studies AFFIRM (n=4060) and PIAF (n=252). We found no difference in mortality between rhythm control and rate control relative risk 1.14 (95% confidence interval 1.00 to 1.31).Both studies show significantly higher rates of hospitalisation and adverse events in the rhythm control group and no difference in quality of life between the two treatment groups.In AFFIRM there was a similar incidence of ischaemic stroke, bleeding and systemic embolism in the two groups. Certain malignant dysrhythmias were significantly more likely to occur in the rhythm control group. There were similar scores of cognitive assessment.In PIAF, cardioverted patients enjoyed an improved exercise tolerance but there was no overall benefit in terms of symptom control or quality of life.</AbstractText><AbstractText Label="AUTHORS' CONCLUSIONS">There is no evidence that pharmacological cardioversion of atrial fibrillation to sinus rhythm is superior to rate control. Rhythm control is associated with more adverse effects and increased hospitalisation. It does not reduce the risk of stroke. The conclusions cannot be generalised to all people with atrial fibrillation. Most of the patients included in these studies were relatively older (>60 years) with significant cardiovascular risk factors.</AbstractText> |
19,943 | In vivo Analysis of the Anti-atrial Fibrillatory, Proarrhythmic and Cardiodepressive Profiles of Dronedarone as a Guide for Safety Pharmacological Evaluation of Antiarrhythmic Drugs. | Anti-atrial fibrillatory, proarrhythmic and cardiodepressive profiles of dronedarone were analyzed using the halothane-anesthetized beagle dogs (n = 4) to create a standard protocol for clarifying both efficacy and adverse effects of anti-atrial fibrillatory drugs. Intravenous administration of dronedarone hydrochloride in doses of 0.3 and 3 mg/kg over 30 s attained the peak plasma concentrations of 61 and 1248 ng/mL, respectively, reflecting sub- to supra-therapeutic ones. The low dose decreased the left ventricular contraction and mean blood pressure, which were enhanced at the high dose. The high dose also decreased the heart rate and cardiac output, but increased the total peripheral resistance and left ventricular end-diastolic pressure, showing its potent cardiodepressive profile. Moreover, the high dose delayed the atrioventricular nodal and intraventricular conductions in addition to the ventricular repolarization, suggesting its inhibitory action on the Ca<sup>2+</sup>, Na<sup>+</sup> and K<sup>+</sup> channels in the in situ heart, respectively. The high dose also prolonged the effective refractory period 1.9 times greater in the atrium than in the ventricle, explaining its clinically demonstrated efficacy against the atrial arrhythmias. Dronedarone significantly prolonged the T<sub>peak</sub>-T<sub>end</sub> in a dose-related manner with a tendency to prolong the terminal repolarization period and J-T<sub>peak</sub>c, indicating considerable risk to induce torsade de pointes. No significant change was detected in the P-wave duration by either dose, indicating the lack of effect on the atrial Na<sup>+</sup> channel in vivo. The current experimental protocol and the results of dronedarone can be used as a guide for safety pharmacological evaluation of new anti-atrial fibrillatory drugs. |
19,944 | [Hypothermia-induced ECG changes: characteristic, but not specific]. | Hypothermia-induced J‑ or so-called Osborn waves can be detected under therapeutic hypothermia in approximately 20-40% of cases. The occurrence of J‑waves in the context of the targeted temperature management after cardiopulmonary resuscitation is characteristic, but not pathognomonic for hypothermia. An electrocardiographic diagnosis under hypothermia after cardiac arrest should always be done with caution due to the various hypothermia-associated electromechanical changes of the myocardium. |
19,945 | Prognostic Factors in Patients with an Implanted Pacemaker after 80 Years of Age in a 4-Year Follow-Up. | The controversy over electrotherapy for patients aged >80 years occurs already at the stage of qualification for this treatment type and concerns optimal device selection, the implantation strategy, and the overall benefit from pacemaker therapy. The group also has a considerable number of cardiovascular risk factors, and the data from the literature on the impact of the pacing mode on the remote prognosis of this group are ambiguous.</AbstractText>Assessment of the risk factors for death among patients with implanted pacemakers >80 years of age in a 4-year follow-up.</AbstractText>The study group consisted of 140 consecutive patients (79 women) aged 84.48 ± 3.65 years with single- or dual-chamber pacemakers implanted >80 years of age because of symptomatic bradycardia. In univariate and multivariate Cox regression analyses, demographic, echocardiographic, and laboratory parameters, pharmacotherapy, and factors related to the implanted device - i.e., indications, pacemaker type, and the implantation position of the tip of the right ventricular lead - were included. The endpoint was death for any reason in a 4-year follow-up.</AbstractText>During follow-up, 68 patients (48.6%) died. Although atrial fibrillation with a slow ventricular response constituted 20% of the indications for implantation, 60.8% of the patients received a single-chamber system (VVI/VVIR). In the whole group, the multivariate Cox regression analysis showed both a favourable prognostic significance of DDD pacing system implantation (HR = 0.507; 95% CI: 0.294-0.876) and coexisting hypertension (HR = 0.520; 95% CI: 0.299-0.902). The risk factors were fasting glycaemia (HR = 1.180; 95% CI: 1.038-1.342) and, potentially, female sex (HR = 1.672; 95% CI: 0.988-2.830; p = 0.056). In the female subgroup a more favourable prognosis was related to the use of angiotensin-converting enzyme inhibitors (HR = 0.435; 95% CI: 0.202-0.933) and DDD pacemaker implantation (HR = 0.381; 95% CI: 0.180-0.806). In the male subgroup a more favourable prognosis was related to concerned patients with coexisting hypertension (HR = 0.349; 95% CI: 0.079-0.689).</AbstractText>DDD mode pacing seems to serve as a factor which decreases mortality among patients aged >80 years in long-term follow-up. The potentially poorer prognosis for the female patients in this group may result from a combination of the dominant VVI pacing mode, potential propagation of atrial fibrillation, a low proportion of antithrombotic therapy, and sex-related predispositions to thromboembolic complications.</AbstractText>© 2017 S. Karger AG, Basel.</CopyrightInformation> |
19,946 | A novel algorithm increases the delivery of effective cardiac resynchronization therapy during atrial fibrillation: The CRTee randomized crossover trial. | Cardiac resynchronization therapy (CRT) requires a high percentage of ventricular pacing (%Vp) to maximize its clinical benefits. Atrial fibrillation (AF) has been shown to reduce %Vp in CRT due to competition with irregular intrinsic atrioventricular (AV) conduction. We report the results of a prospective randomized crossover trial evaluating the amount of effective CRT delivered during AF with a novel algorithm (eCRTAF).</AbstractText>The purpose of this study was to determine whether eCRTAF increases the amount of effective CRT delivered during AF compared to a currently available rate regularization algorithm.</AbstractText>Patients previously implanted with a cardiac resynchronization therapy-defibrillator and with a history of AF and intact AV conduction received up to 4 weeks of control (Conducted AF Response) and up to 4 weeks of eCRTAF in a randomized sequence. The percent effective CRT (%eCRT) pacing, which excludes beats without left ventricular capture, %Vp, and mean heart rate (HR) were recorded during AF and sinus rhythm.</AbstractText>The eCRTAF algorithm resulted in a significantly higher %eCRT during AF than control (87.8% ± 7.8% vs 80.8% ± 14.3%; P <.001) and %Vp during AF than control (90.0% ± 5.9% vs 83.2% ± 11.9%; P <.001), with a small but statistically significant increase in mean HR of 2.5 bpm (79.5 ± 9.7 bpm vs 77.0 ± 9.9 bpm; P <.001).</AbstractText>In a cohort of CRT patients with a history of AF, eCRTAF significantly increased %eCRT pacing and %Vp during AF with a small increase in mean HR. This algorithm may represent a novel noninvasive method of significantly increasing effective CRT delivery during AF, potentially improving CRT response.</AbstractText>Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,947 | Diastolic Dysfunction is Common in Survivors of Pediatric Differentiated Thyroid Carcinoma. | Whether pediatric patients with differentiated thyroid carcinoma (DTC) are at risk of developing treatment-related adverse effects on cardiac function is unknown. We therefore studied in long-term survivors of pediatric DTC the prevalence of cardiac dysfunction and atrial fibrillation in relation to treatment variables, and the association between cardiac dysfunction and plasma biomarkers.</AbstractText>In this nationwide prospective multicenter study, cardiac assessments were performed in 66 adult survivors of pediatric DTC (age at diagnosis ≤18 years and follow-up ≥5 years after diagnosis) treated in the Netherlands between 1970 and 2009. Assessment included echocardiography, plasma biomarkers (N-terminal pro-brain natriuretic peptide, high-sensitive troponin-T, galectin-3), and 24-hour Holter electrocardiography. Echocardiographic measurements were compared with retrospective data of 66 sex- and age-matched unaffected Dutch controls. Diastolic dysfunction was defined as an early diastolic septal and/or lateral tissue velocity (e') less than 2 SD of mean age-adjusted reference data.</AbstractText>The survivors (86.4% women) had at DTC diagnosis a median age of 16 years. Median follow-up was 17 years. Left ventricular ejection fraction <50% was found in one survivor, and median global longitudinal systolic strain was near normal. Diastolic dysfunction was present in 14 asymptomatic survivors (21.2%). Overall, diastolic function of survivors was lower compared with controls (e'mean 14.5 versus 15.8 cm/s, P = 0.006). Older attained age and higher waist circumference were associated with decreased diastolic function, whereas thyrotropin levels and cumulative administered radioiodine dose were not. In survivors, biomarkers were not associated with diastolic dysfunction; atrial fibrillation was not observed.</AbstractText>While systolic function is unaffected, diastolic dysfunction is frequently observed in asymptomatic long-term survivors of pediatric DTC, which may suggest early cardiac aging.</AbstractText> |
19,948 | The intracardiac concentrations of the N-terminal-pro B-type natriuretic peptide (NT-proBNP) and the determinants of its secretion in patients with atrial fibrillation. | N-terminal-pro B-type natriuretic peptide (NT-proBNP) is elevated not only in heart failure (HF) but also in atrial fibrillation (AF). The role and secretion pattern of NT-proBNP in AF is still undetermined.</AbstractText>The study aimed to assess NT-proBNP concentrations in patients with and without preserved left ventricular ejection fraction (LVEF) depending on the type of AF. It was also intended to define the main source of NT-proBNP production within the heart. In addition, it aimed to study the relation of NT-proBNP with some echocardiographic parameters reflecting the stretch of heart chambers as well as with the chosen parameters of physical capacity.</AbstractText>Blood samples were collected from the right atrium (RA), left atrium (LA), and femoral artery (FA) in 53 patients referred for occlusion of the LA appendage. Thirty patients were assigned into Group I (LVEF ≥ 50%, no HF symptoms) and the remaining 23 patients to Group II (LVEF < 50%, HF symptoms). NT-proBNP concentrations were determined using the ELISA test.</AbstractText>In Group I, the lowest NT-proBNP level was found in RA (460.47 ± 723.15 pg/mL and 1097.72 ± 851.42 pg/mL for paroxysmal and permanent AF, respectively), higher in LA (481.5 ± 724.56 pg/mL and 1188.06 ± 851.42 pg/mL for paroxysmal and permanent AF), and the highest values in FA (537.77 ± 808.49 pg/mL and 1188.04 ± 798.28 pg/mL for paroxysmal and permanent AF). In Group II the NT-proBNP values were significantly higher compared to Group I (p < 0.01), but similarly values in RA were the lowest (183.47 ± 1826.08 pg/mL and 2141.68 ± 1801.69 pg/mL for paroxysmal and permanent AF), intermediate values were observed in LA (1857.57 ± 2221.39 pg/mL and 2386.81 ± 2067.2 pg/mL for paroxysmal and permanent AF), and the highest were seen in FA (1936.27 ± 2149.85 and 2437.33 ± 1999.37 pg/mL for paroxysmal and permanent AF, respectively). In Group I, NT-proBNP from LA best correlated with LA area (r = 0.56) and RA area (r = 0.56). In Group II, the strongest correlations were found between NT-proBNP from LA and left ventricular end-systolic dimension (r = 0.57) and volume (r = 0.6).</AbstractText>NT-proBNP is markedly elevated in the majority of patients with AF even in the absence of HF. LA secretion of NT-proBNP is an important contributor to the overall increase of NT-proBNP also in HF patients. In AF patients, the concentration of NT-proBNP correlates with the remodelling of heart chambers, but not with physical capacity.</AbstractText> |
19,949 | Clinical, echocardiographic, and pacing parameters affecting atrial fibrillation burden in patients with tachycardia-bradycardia syndrome. | The influence of various factors on atrial fibrillation (AF) development in the population of tachycardia-bradycardia syndrome (TBS) patients remains unclear. There are no data on the impact of different right ventricular pacing percentage (RVp%) profiles.</AbstractText>The purpose of the study was to evaluate the relationship between the AF burden (AFB) and various clinical, echocardiographic, and pacing parameters in TBS patients.</AbstractText>We performed a prospective, one-year registry of TBS patients with documented AF referred for dual-chamber pacemaker (DDD) implantation.</AbstractText>The data of 65 patients were analysed. The median 12-month RVp% and AFB was 9.4% and 1.0%, respectively. During the follow-up 14% of patients had no AF (p = 0.003), and the withdrawal of AF symptoms was observed in 49% of patients (p < 0.0001). The AFB was related to the left atrium diameter (r = 0.31, p = 0.02), especially in the subjects with left ventricular ejection fraction < 60% (r = 0.44, p = 0.04). Based on the relative change of RVp%, three groups of various RVp% profile were established: stable, decreasing, and increasing RVp%. In the stable RVp% group (n = 21) there was a quadratic correlation between the 12-month RVp% and AFB (r = 0.71, p = 0.0003). In the stable RVp% > 20% subgroup there was a significant increase of AFB in comparison to the RVp% ≤ 20% subgroup (ΔAFB 1.8% vs. 0.0%, p = 0.03, respectively). In the increasing RVp% group (n = 28) the AFB increased whereas in the decreasing RVp% (n = 16) it remained stable (ΔAFB 0.67% vs. 0.0%, p = 0.034, respectively).</AbstractText>DDD implantation in TBS patients is related to a significant reduction in AF symptoms, and left atrial diameter correlates with cumulative AFB in the mid-term observation. Stable RVp% > 20% is associated with AF progression whereas lower stable RVp% may stabilise AF development. Increasing RVp% may be associated with the AFB increase in comparison to the decreasing RVp% subgroup in which AFB remains stable.</AbstractText> |
19,950 | The Electrophysiological Substrate of Early Repolarization Syndrome: Noninvasive Mapping in Patients. | The early repolarization (ER) pattern is a common ECG finding. Recent studies established a definitive clinical association between ER and fatal ventricular arrhythmias. However, the arrhythmogenic substrate of ER in the intact human heart has not been characterized.</AbstractText>To map the epicardial electrophysiological (EP) substrate in ER syndrome patients using noninvasive Electrocardiographic Imaging (ECGI), and to characterize substrate properties that support arrhythmogenicity.</AbstractText>Twenty-nine ER syndrome patients were enrolled, 17 of which had a malignant syndrome. Characteristics of the abnormal EP substrate were analyzed using data recorded during sinus rhythm. The EP mapping data were analyzed for electrogram morphology, conduction and repolarization. Seven normal subjects provided control data.</AbstractText>The abnormal EP substrate in ER syndrome patients has the following properties: (1) Abnormal epicardial electrograms characterized by presence of J-waves in localized regions; (2) Absence of conduction abnormalities, including delayed activation, conduction block, or fractionated electrograms; (3) Marked abbreviation of ventricular repolarization in areas with J-waves. The action potential duration (APD) was significantly shorter than normal (196±19 vs. 235±21 ms, p<0.05). Shortening of APD occurred heterogeneously, leading to steep repolarization gradients compared to normal control (45±17 vs.7±5 ms/cm, p<0.05). Premature ventricular contractions (PVCs) were recorded in 2 patients. The PVC sites of origin were closely related to the abnormal EP substrate with J-waves and steep repolarization gradients.</AbstractText>Early Repolarization is associated with steep repolarization gradients caused by localized shortening of APD. Results suggest association of PVC initiation sites with areas of repolarization abnormalities. Conduction abnormalities were not observed.</AbstractText> |
19,951 | Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis. | There is conflicting evidence, relying on heterogeneous studies, as to whether aldosterone excess is responsible for an increased risk of cardiovascular and cerebrovascular complications in patients with primary aldosteronism. We aimed to assess the association between primary aldosteronism and adverse cardiac and cerebrovascular events, target organ damage, diabetes, and metabolic syndrome, compared with the association of essential hypertension and these cardiovascular and end organ events, by integrating results of previous studies.</AbstractText>We did a meta-analysis of prospective and retrospective observational studies that compared patients with primary aldosteronism and essential hypertension, to analyse the association between primary aldosteronism and stroke, coronary artery disease (as co-primary endpoints), atrial fibrillation and heart failure, target organ damage, metabolic syndrome, and diabetes (as secondary endpoints). We searched MEDLINE and Cochrane Library for articles published up to Feb 28, 2017, with no start date restriction. Eligible studies compared patients with primary aldosteronism with patients with essential hypertension (as a control group) and reported on the clinical events or endpoints of interest. We also compared primary aldosteronism subtypes, aldosterone-producing adenoma, and bilateral adrenal hyperplasia.</AbstractText>We identified 31 studies including 3838 patients with primary aldosteronism and 9284 patients with essential hypertension. After a median of 8·8 years (IQR 6·2-10·7) from the diagnosis of hypertension, compared with patients with essential hypertension, patients with primary aldosteronism had an increased risk of stroke (odds ratio [OR] 2·58, 95% CI 1·93-3·45), coronary artery disease (1·77, 1·10-2·83), atrial fibrillation (3·52, 2·06-5·99), and heart failure (2·05, 1·11-3·78). These results were consistent for patients with aldosterone-producing adenoma and bilateral adrenal hyperplasia, with no difference between these subgroups. Similarly, primary aldosteronism increased the risk of diabetes (OR 1·33, 95% CI 1·01-1·74), metabolic syndrome (1·53, 1·22-1·91), and left ventricular hypertrophy (2·29, 1·65-3·17).</AbstractText>Diagnosing primary aldosteronism in the early stages of disease, with early initiation of specific treatment, is important because affected patients display an increased cardiovascular risk compared with patients with essential hypertension.</AbstractText>None.</AbstractText>Copyright © 2018 Elsevier Ltd. All rights reserved.</CopyrightInformation> |
19,952 | Comparison of prevalence and management of left atrial appendage thrombi under old and new anticoagulants prior to left atrial catheter ablation. | The prevalence and management of left atrial appendage (LAA) thrombi associated with new anticoagulants remain to be elucidated, especially prior to atrial fibrillation (AFib) ablation. This study sought to (1) compare the prevalence of LAA thrombi and/or severe LAA contrast under vitamin K antagonist (VKA) agents and novel oral anticoagulants (NOACs), (2) evaluate the rate of LAA thrombus resolution after anticoagulation modification, and (3) determine the predictive factors of LAA thrombi and severe LAA contrast in patients prior to LA AFib ablation.</AbstractText>Between January 2013 and March 2016, 576 consecutive patients referred for AFib ablation were included, and the prevalence of transesophageal echocardiography-detected thrombi was similar under NOACs (2.1%) and VKA agents (2.6%).</AbstractText>Thrombus resolution was obtained in 50% of cases following anticoagulation modification. Through multivariate exact logistic regression analysis with relevant clinical and echocardiographic features, age (P<.001), LAA hypocontractility (P<.001), and left ventricular ejection fraction (P=.007) were found to be independently associated with the occurrence of LAA thrombus. The relevant factors independently associated with LAA thrombus or severe contrast were LAA hypocontractility (P<.001) and age (P<.001).</AbstractText>The prevalence of transesophageal echocardiography-detected thrombi in patients referred for AFib ablation is similar under NOACs (2.1%) and VKA agents (2.6%). Under VKA therapy with 3-4 international normalized ratio, 50% of thrombi dissolved. Independent predictive factors of procedure contraindication included age, LAA hypocontractility, and left ventricular ejection fraction.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,953 | Hypertension and cardiovascular risk: General aspects. | Hypertension is the strongest or one of the strongest risk factors for almost all different cardiovascular diseases acquired during life, including coronary disease, left ventricular hypertrophy and valvular heart diseases, cardiac arrhythmias including atrial fibrillation, cerebral stroke and renal failure. The continuous relationship between blood pressure and cardiovascular and renal events makes the distinction between high normal blood pressure and hypertension based on arbitrary cut-off values for blood pressures. Overall the prevalence of hypertension in different European countries appears to be around 30-45% of the general population, with a steep increase with ageing. The prevention of cardiovascular disease and treatment recommendations should be related to quantification of total cardiovascular risk which could be estimated from several different models. However the impact of age on risk is so strong that young adults (particularly women) are unlikely to reach high-risk levels even when they have more than one major risk factor and a clear increase in relative risk. Therefore age-adjusted models, models assessing relative risks compared to others of same age and models including thorough assessments of target organ damage and ambulatory 24h blood pressure are needed together with national models because of the large variations between countries. |
19,954 | Cardiac arrest caused by sibutramine obtained over the Internet: a case of a young woman without pre-existing cardiovascular disease successfully resuscitated using extracorporeal membrane oxygenation. | Sibutramine is a weight loss agent that was withdrawn from the market in the USA and European Union because it increases adverse events in patients with cardiovascular diseases. However, non-prescription weight loss pills containing sibutramine can be still easily purchased over the Internet.</AbstractText>A 21-year-old woman without history of cardiovascular diseases developed cardiac arrest. She was a user of a weight loss pills, containing sibutramine and hypokalemia-inducing agents, imported from Thailand over the Internet.</AbstractText>She was successfully resuscitated without any neurological deficits by using extracorporeal membrane oxygenation for refractory ventricular fibrillation.</AbstractText>This case indicates that sibutramine can cause cardiac arrest even in subjects without pre-existing cardiovascular disease when combined with agents that promote QT prolongation.</AbstractText> |
19,955 | Cardiocerebral and cardiopulmonary resuscitation - 2017 update. | Sudden cardiac arrest is a major public health problem in the industrialized nations of the world. Yet, in spite of recurrent updates of the guidelines for cardiopulmonary resuscitation and emergency cardiac care, many areas have suboptimal survival rates. Cardiocerebral resuscitation, a non-guidelines approach to therapy of primary cardiac arrest based on our animal research, was instituted in Tucson (AZ, USA) in 2002 and subsequently adopted in other areas of the USA. Survival rates of patients with primary cardiac arrest and a shockable rhythm significantly improved wherever it was adopted. Cardiocerebral resuscitation has three components: the community, the pre-hospital, and the hospital. The community component emphasizes bystander recognition and chest compression only resuscitation. Its pre-hospital or emergency medical services component emphasizes: (i) urgent initiation of 200 uninterrupted chest compressions before and after each indicated single defibrillation shock, (ii) delayed endotracheal intubation in favor of passive delivery of oxygen by a non-rebreather mask, (iii) early adrenaline administration. The hospital component was added later. The national and international guidelines for cardiopulmonary resuscitation and emergency medical services are still not optimal, for several reasons, including the fact that they continue to recommend the same approach for two entirely different etiologies of cardiac arrest: primary cardiac arrest, often caused by ventricular fibrillation, where the arterial blood oxygenation is little changed at the time of the arrest, and secondary cardiac arrest from severe respiratory insufficiency, where the arterial blood is severely desaturated at the time of cardiac arrest. These different etiologies need different approaches to therapy. |
19,956 | An automatic system for the comprehensive retrospective analysis of cardiac rhythms in resuscitation episodes. | An automatic resuscitation rhythm annotator (ARA) would facilitate and enhance retrospective analysis of resuscitation data, contributing to a better understanding of the interplay between therapy and patient response. The objective of this study was to define, implement, and demonstrate an ARA architecture for complete resuscitation episodes, including chest compression pauses (CC-pauses) and chest compression intervals (CC-intervals).</AbstractText>We analyzed 126.5h of ECG and accelerometer-based chest-compression depth data from 281 out-of-hospital cardiac arrest (OHCA) patients. Data were annotated by expert reviewers into asystole (AS), pulseless electrical activity (PEA), pulse-generating rhythm (PR), ventricular fibrillation (VF), and ventricular tachycardia (VT). Clinical pulse annotations were based on patient-charts and impedance measurements. An ARA was developed for CC-pauses, and was used in combination with a chest compression artefact removal filter during CC-intervals. The performance of the ARA was assessed in terms of the unweighted mean of sensitivities (UMS).</AbstractText>The UMS of the ARA were 75.0% during CC-pauses and 52.5% during CC-intervals, 55-points and 32.5-points over a random guess (20% for five categories). Filtering increased the UMS during CC-intervals by 5.2-points. Sensitivities for AS, PEA, PR, VF, and VT were 66.8%, 55.8%, 86.5%, 82.1% and 83.8% during CC-pauses; and 51.1%, 34.1%, 58.7%, 86.4%, and 32.1% during CC-intervals.</AbstractText>A general ARA architecture was defined and demonstrated on a comprehensive OHCA dataset. Results showed that semi-automatic resuscitation rhythm annotation, which may involve further revision/correction by clinicians for quality assurance, is feasible. The performance (UMS) dropped significantly during CC-intervals and sensitivity was lowest for PEA.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
19,957 | Correlation Between Concentration of Air Pollutants and Occurrence of Cardiac Arrhythmias in a Region with Humid Continental Climate. | In this study, we investigated the correlation of air temperature, pressure and concentration of air pollutants with the rate of admissions for cardiac arrhythmias at two clinical centers in the area with a humid continental climate. This retrospective study included 3749 patients with arrhythmias admitted to emergency department (ED). They were classified into four groups: supraventricular tachycardia (SVT), ventricular tachycardia (VT), atrial fibrillation/undulation (Afib/Aund), and palpitations (with no ECG changes, or with sinus tachycardia and extrasystoles). The number of patients, values of meteorological parameters (average daily values of air temperature, pressure and relative humidity) and concentrations of air pollutants (particles of dimensions ~10 micrometers or less (PM(10)), ozone (O(3)) and nitrogen dioxide (NO(2))) were collected during a two-year period ( July 2008-June 2010). There were 1650 (44.0%), 1525 (40.7%), 451 (12.0%) and 123 (3.3%) patients with palpitations, Afib/Aund, SVT and VT, respectively. Spearman’s correlation yielded positive correlation between the occurrence of arrhythmias and air humidity on the day (r=0.07), and 1 (r=0.08), 2 (r=0.09) and 3 days before (r=0.09), and NO(2) particles on the day (r=0.08) of ED admission; palpitations and air humidity on the day (r=0.11), and 1 (r=0.09), 2 (r=0.07) and 3 days before (r=0.10), and PM(10) (r=0.11) and NO(2) (r=0.08) particles on the day of ED admission; and Afi b/Aund and air humidity 2 days before (r=0.08) ED admission (p<0.05 all). In conclusion, there was a very weak positive correlation of the occurrence of cardiac arrhythmias with air humidity and concentration of air pollutants in the region with a humid continental climate. |
19,958 | Lower cardiac index levels relate to lower cerebral blood flow in older adults. | To assess cross-sectionally whether lower cardiac index relates to lower resting cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) among older adults.</AbstractText>Vanderbilt Memory & Aging Project participants free of stroke, dementia, and heart failure were studied (n = 314, age 73 ± 7 years, 59% male, 39% with mild cognitive impairment). Cardiac index (liters per minute per meter squared) was quantified from echocardiography. Resting CBF (milliliters per 100 grams per minute) and hypercapnia-induced CVR were quantified from pseudo-continuous arterial spin-labeling MRI. Linear regressions with ordinary least-square estimates related cardiac index to regional CBF, with adjustment for age, education, race/ethnicity, Framingham Stroke Risk Profile score (systolic blood pressure, antihypertensive medication use, diabetes mellitus, current cigarette smoking, left ventricular hypertrophy, prevalent cardiovascular disease [CVD], atrial fibrillation), APOE</i> ε4 status, cognitive diagnosis, and regional tissue volume.</AbstractText>Lower cardiac index corresponded to lower resting CBF in the left (β = 2.4, p</i> = 0.001) and right (β = 2.5, p</i> = 0.001) temporal lobes. Results were similar when participants with prevalent CVD and atrial fibrillation were excluded (left temporal lobe β = 2.3, p</i> = 0.003; right temporal lobe β = 2.5, p</i> = 0.003). Cardiac index was unrelated to CBF in other regions assessed (p</i> > 0.25) and CVR in all regions (p</i> > 0.05). In secondary cardiac index × cognitive diagnosis interaction models, cardiac index and CBF associations were present only in cognitively normal participants and affected a majority of regions assessed with effects strongest in the left (p</i> < 0.0001) and right (p</i> < 0.0001) temporal lobes.</AbstractText>Among older adults without stroke, dementia, or heart failure, systemic blood flow correlates with cerebral CBF in the temporal lobe, independently of prevalent CVD, but not CVR.</AbstractText>© 2017 American Academy of Neurology.</CopyrightInformation> |
19,959 | Predictors of sudden cardiac death in atrial fibrillation: The Atherosclerosis Risk in Communities (ARIC) study. | We previously reported that incident atrial fibrillation (AF) is associated with an increased risk of sudden cardiac death (SCD) in the general population. We now aimed to identify predictors of SCD in persons with AF from the Atherosclerosis Risk in Communities (ARIC) study, a community-based cohort study. We included all participants who attended visit 1 (1987-89) and had no prior AF (n = 14,836). Incident AF was identified from study electrocardiograms and hospitalization discharge codes through 2012. SCD was physician-adjudicated. We used cause-specific Cox proportional hazards models, followed by stepwise selection (backwards elimination, removing all variables with p>0.10) to identify predictors of SCD in participants with AF. AF occurred in 2321 (15.6%) participants (age 45-64 years, 58% male, 18% black). Over a median of 3.3 years, SCD occurred in 110 of those with AF (4.7%). Predictors of SCD in AF included higher age, body mass index (BMI), coronary heart disease, hypertension, diabetes, current smoker, left ventricular hypertrophy, increased heart rate, and decreased albumin. Predictors associated only with SCD and not other cardiovascular (CV) death included increased BMI (HR per 5-unit increase, 1.15, 95% CI, 0.97-1.36, p = 0.10), increased heart rate (HR per SD increase, 1.18, 95% CI 0.99-1.41, p = 0.07), and low albumin (HR per SD decrease 1.23, 95% CI 1.02-1.48, p = 0.03). In the ARIC study, predictors of SCD in AF that are not associated with non-sudden CV death included increased BMI, increased heart rate, and low albumin. Further research to confirm these findings in larger community-based cohorts and to elucidate the underlying mechanisms to facilitate prevention is warranted. |
19,960 | Pulmonary hypertension in stiff left atrial syndrome: pathogenesis and treatment in one. | We present the rare case of a patient with pulmonary hypertension in the context of the stiff left atrial syndrome after extensive catheter ablation, a unique constellation characterized by high pulmonary artery and pulmonary artery wedge pressures due to left atrial dysfunction but normal left ventricular end-diastolic pressure, normal mitral valve, and absence pulmonary vein stenosis. This patient was surprisingly oligosymptomatic, however, which may have been due to a persistent post-puncture atrial septal defect, which may have allowed for controlled left atrial decompression, which is in line with the novel concept of the catheter-based creation of an intracardiac shunt as a treatment for heart failure. |
19,961 | Left ventricular ejection fraction and left atrium diameter related to new-onset atrial fibrillation following acute myocardial infarction: a systematic review and meta-analysis. | New-onset atrial fibrillation (NOAF) occurs frequently in patients with acute myocardial infarction (AMI), and is associated with increased subsequent cardiovascular mortality. However, only a few studies directly evaluated the relationship of left ventricular ejection fraction (LVEF) or left atrium diameter (LAD) and NOAF following AMI.</AbstractText>MEDLINE®</sup>, EMBASE®</sup> and the Cochrane Library were carried out to find studies until January 2017. Pooled mean difference (MD) and 95% confidence interval (CI) were calculated to evaluate the value of LVEF and LAD in the prediction of NOAF after AMI. We performed sensitivity analyses to explore the potential sources of heterogeneity. Statistical analyses were carried out using the Revman 5.3.</AbstractText>We included 10 qualifying studies comprising a total of 708 patients with NOAF and 6785 controls. Overall, decreased LVEF and increased LAD levels had a significant positive association with NOAF in patients with AMI. The MD in the LVEF levels between the patients with and those without NOAF was -4.91 units (95% Cl: -5.70 to -4.12), test for overall effect z-score = 12.18 (p</i> < 0.00001, I2</sup> = 35%). Moreover, in a subgroup analysis, the MD for LAD and NOAF was 2.55 units (95% Cl: 1.91 to 3.19), test for overall effect z-score = 7.80 (p</i> < 0.00001, I2</sup> = 57%).</AbstractText>Our meta-analysis demonstrated that both decreased LVEF and increased LAD levels were associated with greater risk of NOAF following AMI.</AbstractText> |
19,962 | Atrial ectopy as a mediator of the association between race and atrial fibrillation. | Blacks have a lower risk of atrial fibrillation (AF) despite having more AF risk factors, but the mechanism remains unknown. Premature atrial contraction (PAC) burden is a recently identified risk factor for AF.</AbstractText>The purpose of this study was to determine whether the burden of PACs explains racial differences in AF risk.</AbstractText>PAC burden (number per hour) was assessed by 24-hour ambulatory electrocardiographic (ECG) monitoring in a randomly selected subset of patients in the Cardiovascular Health Study. Participants were followed prospectively for the development of AF, diagnosed by study ECG and hospital admission records.</AbstractText>Among 938 participants (median age 73 years; 34% black; 58% female), 206 (22%) developed AF over a median follow-up of 11.0 years (interquartile range 6.1-13.4). After adjusting for age, sex, body mass index, coronary disease, congestive heart failure, diabetes, hypertension, alcohol consumption, smoking status, and study site, black race was associated with a 42% lower risk of AF (hazard ratio 0.58, 95% confidence interval [CI] 0.40-0.85; P = .005). The baseline PAC burden was 2.10 times (95% CI 1.57-2.83; P <.001) higher in whites than blacks. There was no detectable difference in premature ventricular contraction (PVC) burden by race. PAC burden mediated 19.5% (95% CI 6.3-52.5) of the adjusted association between race and AF.</AbstractText>On average, whites exhibited more PACs than blacks, and this difference statistically explains a modest proportion of the differential risk of AF by race. The differential PAC burden, without differences in PVCs, by race suggests that identifiable common exposures or genetic influences might be important to atrial pathophysiology.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,963 | Palytoxin congeners. | Palytoxin, isolated from a zoanthid of the genus Palythoa, is the most potent marine toxin known. Intoxication by palytoxin leads to vasoconstriction, hemorrhage, ataxia, muscle weakness, ventricular fibrillation, pulmonary hypertension, ischemia and death. Palytoxin and its numerous derivatives (congeners) may enter the food chain and accumulate mainly in fishes and crabs, causing severe human intoxication and death following ingestion of contaminated products. Furthermore, toxic effects in individuals exposed via inhalation or skin contact to marine aerosol in coincidence with Ostreopsis blooms, have been reported. Blooms of the benthic dinoflagellate Ostreopsis cf. ovata are a concern in the Mediterranean Sea, since this species produces a wide range of palytoxin-like compounds listed among the most potent marine toxins. Thus, the formerly unsuspected broad distribution of the benthic dinoflagellate Ostreopsis spp. has recently posed a problem of risk assessment for human health. Palytoxin has a strong potential for toxicity in humans and animals, and currently this toxin is of great concern worldwide. This review summarized and discussed the pharmacology and toxicology data of palytoxin and its congeners, including their cytotoxicity, human and animal toxicities. Moreover, the risk assessment and their control strategies including prevention and treatment assays were evaluated. |
19,964 | [Sudden cardiac death and coronary thrombus]. | Out-of-hospital cardiac arrest is most often due to an acute coronary artery occlusion. The cause of coronary thrombosis in cardiac arrest is debated. Plaque erosion could be a trigger leading to immediate thrombus formation followed by ventricular fibrillation or rapid ventricular tachycardia. Coronary artery spasm is frequent: spasm provocation tests should be performed in survivors with normal coronary arteries. Use of drugs such as cocaine can lead to sudden death and blood sampling at arrival is recommended in survivors of out-of-hospital cardiac arrest. Delivery of immediate and effective basic life support remains the most important predictive factor for survival in out-of-hospital cardiac arrest. |
19,965 | Cardiac magnetic resonance imaging: Which information is useful for the arrhythmologist? | Cardiac magnetic resonance (CMR) is a non-invasive, non-ionizing, diagnostic technique that uses magnetic fields, radio waves and field gradients to generate images with high spatial and temporal resolution. After administration of contrast media (<i>e.g</i>., gadolinium chelate), it is also possible to acquire late images, which make possible the identification and quantification of myocardial areas with scar/fibrosis (late gadolinium enhancement, LGE). CMR is currently a useful instrument in clinical cardiovascular practice for the assessment of several pathological conditions, including ischemic and non-ischemic cardiomyopathies and congenital heart disease. In recent years, its field of application has also extended to arrhythmology, both in diagnostic and prognostic evaluation of arrhythmic risk and in therapeutic decision-making. In this review, we discuss the possible useful applications of CMR for the arrhythmologist. It is possible to identify three main fields of application of CMR in this context: (1) arrhythmic and sudden cardiac death risk stratification in different heart diseases; (2) decision-making in cardiac resynchronization therapy device implantation, presence and extent of myocardial fibrosis for left ventricular lead placement and cardiac venous anatomy; and (3) substrate identification for guiding ablation of complex arrhythmias (atrial fibrillation and ventricular tachycardias). |
19,966 | [Surgical Treatment for Myocardial Rerupture after Repair of Post Infarction Left Ventricular Free Wall Rupture]. | A 73-year-old man was admitted for cardiac tamponade by oozing type left ventricular free wall rupture associated with acute myocardial infarction. Transthoracic echocardiography demonstrated moderate pericardial effusion and the presence of pseudoaneurysm within posterior wall. He went into shock with a systolic blood pressure of 60 mmHg. After introducing percutaneous cardiopulmonary support and intraaortic balloon pump, the sutureless repair was performed immediately. After having rehabilitation for right-sided hemiparesis, an elective pseudoaneurysm repair was planned. While a waiting an operation, 7 weeks later, he went into shock again with chest pain. Echocardiography and computed tomography demonstrated much amount of pericardial bloody effusion on the posterior aspect and 1.5 cm defect on the pseudoaneurysm wall. Emergently a patch closure with a bovine pericardium was performed using cardiopulmonary bypass under ventricular fibrillation through a left thoracotomy. Postoperative course was uneventful. |
19,967 | Real-Time Ventricular Fibrillation Amplitude-Spectral Area Analysis to Guide Timing of Shock Delivery Improves Defibrillation Efficacy During Cardiopulmonary Resuscitation in Swine. | The ventricular fibrillation amplitude spectral area (AMSA) predicts whether an electrical shock could terminate ventricular fibrillation and prompt return of spontaneous circulation. We hypothesized that AMSA can guide more precise timing for effective shock delivery during cardiopulmonary resuscitation.</AbstractText>Three shock delivery protocols were compared in 12 pigs each after electrically induced ventricular fibrillation, with the duration of untreated ventricular fibrillation evenly stratified into 6, 9, and 12 minutes: AMSA-Driven (AD), guided by an AMSA algorithm; Guidelines-Driven (GD), according to cardiopulmonary resuscitation guidelines; and Guidelines-Driven/AMSA-Enabled (GDAE), as per GD but allowing earlier shocks upon exceeding an AMSA threshold. Shocks delivered using the AD, GD, and GDAE protocols were 21, 40, and 62, with GDAE delivering only 2 AMSA-enabled shocks. The corresponding 240-minute survival was 8/12, 6/12, and 2/12 (log-rank test, P</i>=0.035) with AD exceeding GDAE (P</i>=0.026). The time to first shock (seconds) was (median [Q1-Q3]) 272 (161-356), 124 (124-125), and 125 (124-125) (P</i><0.001) with AD exceeding GD and GDAE (P</i><0.05); the average coronary perfusion pressure before first shock (mm Hg) was 16 (9-30), 10 (6-12), and 3 (-1 to 9) (P</i>=0.002) with AD exceeding GDAE (P</i><0.05); and AMSA preceding the first shock (mV·Hz, mean±SD) was 13.3±2.2, 9.0±1.6, and 8.6±2.0 (P</i><0.001) with AD exceeding GD and GDAE (P</i><0.001). The AD protocol delivered fewer unsuccessful shocks (ie, less shock burden) yielding less postresuscitation myocardial dysfunction and higher 240-minute survival.</AbstractText>The AD protocol improved the time precision for shock delivery, resulting in less shock burden and less postresuscitation myocardial dysfunction, potentially improving survival compared with time-fixed, guidelines-driven, shock delivery protocols.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
19,968 | Long-Term Survival Trends of Medicare Patients After In-Hospital Cardiac Arrest: Insights from Get With The Guidelines-Resuscitation<sup>®</sup>. | Although rates of survival to hospital discharge after in-hospital cardiac arrest (IHCA) have improved over the last decade, it is unknown if these survival gains are sustained after hospital discharge.</AbstractText>To examine 1-year survival trends overall and by rhythm after IHCA.</AbstractText>Using Medicare beneficiaries (age≥65years) with IHCA occurring between 2000 and 2011 at Get With The Guidelines®-Resuscitation Registry participating hospitals we used multivariable regression, to examine temporal trends in risk-adjusted rates of 1-year survival.</AbstractText>Among 45,567 patients with IHCA, the unadjusted 1-year survival was 9.4%. Unadjusted 1-year survival was 21.8% among the 9,223 (20.2%) of patients with Ventricular Fibrillation or Pulseless Ventricular Tachycardia (VF/VT) and 6.2% among the 36,344 (79.8%) of patients with Pulseless Electrical Activity or asystole (PEA/asystole). After adjustment for patient and arrest characteristics, 1-year survival increased over time for all IHCA from 8.9% in 2000-2001 to 15.2% in 2011 (adjusted rate ratio [RR] per year, 1.05; 95% CI, 1.03-1.06; P<0.001 for trend). Improvements in 1-year risk adjusted survival were also observed for VF/VT (19.4% in 2000-2001 to 25.6% in 2011 [RR per year, 1.02; 95% CI, 1.01-1.04; P 0.004 for trend]) and PEA/asystole arrests (4.7% in 2000-2001 to 10.2% in 2011 [RR per year, 1.07; 95% CI, 1.05-1.08; P<0.001 for trend]).</AbstractText>Among Medicare beneficiaries in the GWTG-Resuscitation registry, 1-year survival after IHCA has increased for over the past decade. Temporal improvements in survival were noted for both shockable and non-shockable presenting arrest rhythms.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
19,969 | Coronary Venous Dissection from Left Ventricular Lead Placement During Cardiac Resynchronization Therapy With Defibrillator Implantation and Associated in-Hospital Adverse Events (from the NCDR ICD Registry). | Coronary venous dissection is a known complication of left ventricular lead placement during implantation of a cardiac resynchronization with defibrillator (CRT-D) system. A large-scale evaluation of the prevalence of coronary venous dissection and associated in-hospital clinical outcomes has not been performed. We sought to identify predictors of coronary venous dissection and evaluate subsequent in-hospital adverse events in those with the complication. We studied 140,991 first-time CRT-D recipients in the implantable cardioverter-defibrillator (ICD) Registry implanted between 2006 and 2011. Using hierarchical multivariable logistic regression adjusting for patient, implanting physician, and hospital characteristics, we examined predictors of coronary venous dissection and its association with other major complications, length of hospital stay, and in-hospital mortality. Coronary venous dissection occurred in 392 patients (0.28%). After multivariable adjustment, female gender and left bundle branch block were associated with greater odds of coronary venous dissection. Conversely, atrial fibrillation, previous coronary artery bypass graft, and higher implanter procedure volume were associated with lower odds of coronary venous dissection (all p values <0.05). After multivariable adjustment, CRT-D recipients with coronary venous dissection had greater odds of major complications (odds ratio [OR] 10.47, 95% confidence interval [CI] 6.75 to 16.24, p <0.0001), postprocedural hospital stays >3 days (OR 1.71, 95% CI 1.29 to 2.29, p <0.0001), but not in-hospital death (OR 0.78, 95% CI 0.12 to 5.25, p = 0.8012). In conclusion, in a large population of first-time CRT-D recipients, specific patient and implanter characteristics predicted coronary venous dissection risk. Coronary venous dissection was associated with major in-hospital complications and prolonged hospitalization, but not death. |
19,970 | Iodinated Contrast Administration Resulting in Cardiogenic Shock in Patient with Uncontrolled Graves Disease. | Thyroid storm (also known as thyroid or thyrotoxic crisis) is part of the spectrum of thyrotoxicosis and represents the extreme end of that spectrum. The condition is quite rare, yet mortality rates are high and may approach 10-30%.</AbstractText>A 34-year-old-man who had a history of Graves disease presented in atrial fibrillation with rapid ventricular response and mild congestive heart failure. During the course of his Emergency Department (ED) stay he deteriorated into cardiogenic shock. Roughly 10 h transpired between his presentation and the development of cardiogenic shock. He had received an intravenous contrast load of iohexol shortly after initial presentation, and the associated iodine bolus, we suspect, contributed to his abrupt deterioration into cardiogenic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Thyroid storm is infrequently seen in the ED, and there is potential for management errors that can lead to a detrimental patient outcome.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,971 | Role of angiotensin II type 2 receptor during electrophysiological remodeling of left ventricular hypertrophic myocardium in spontaneously hypertensive rats. | The objective was to investigate the role of angiotensin II type 2 receptor during electrophysiological remodeling of left ventricular hypertrophic myocardium in spontaneously hypertensive rats (SHRs). A total of 36, aged 10 weeks, male SHRs were divided into three groups: control, valsartan, and valsartan + PD123319 groups (n = 12 in each). The systolic blood pressure, left ventricular mass index, ventricular effective refractory period, and ventricular fibrillation threshold (VFT) were also measured after 8 weeks. At the same time, INa</sub>, ICaL</sub>, Ito</sub>, and membrane capacitance were measured in left ventricular myocytes by whole-cell patch-clamp. The VFT of valsartan was higher than that of control (valsartan vs.</AbstractText>17.4 ± 0.6 mA vs. 15.8 ± 0.5 mA, P < .05). The VFT of valsartan was higher than that of valsartan + PD123319 (valsartan vs. valsartan + PD123319: 17.4 ± 0.6 mA vs. 16.6 ± 0.9 mA, P < .05). The density of Ito</sub> of valsartan was higher than that of control (valsartan vs.</AbstractText>14.7 ± 0.42 pA/pF vs. 11.2 ± 0.15 pA/pF, P < .05). The density of Ito</sub> of valsartan was higher than that of valsartan + PD123319 (valsartan vs. valsartan + PD123319: 14.7 ± 0.42 pA/pF vs. 13.6 ± 0.30 pA/pF, P < .05). The density of ICaL</sub> of valsartan was lower than that of control (valsartan vs.</AbstractText>-4.6 ± 0.2 pA/pF vs. -6.9 ± 0.1 pA/pF, P < .05). The density of ICaL</sub> of valsartan was lower than that of valsartan + PD123319 (valsartan vs. valsartan + PD123319: -4.6 ± 0.2 pA/pF vs. -5.4 ± 0.1 pA/pF, P < .05). These results demonstrated that the stimulation of angiotensin II type 2 receptor improved electrophysiological remodeling of left ventricular hypertrophic myocardium in SHR.</AbstractText>Copyright © 2017 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,972 | Anemia and the Risk of Life-threatening Ventricular Tachyarrhythmias from the Israeli Implantable Cardioverter Defibrillator Registry. | Anemia was shown to be associated with increased risk for adverse events in patients with heart failure (HF). However, there are limited data on the association between anemia and the risk for ventricular arrhythmias (VAs) in patients with an implantable cardioverter defibrillator (ICD). The present study population comprised 2,352 patients who were enrolled and prospectively followed up in the Israeli ICD Registry. The risk for a first appropriate ICD shock for VA was assessed by the presence of anemia, categorized at the lower tertile of hemoglobin distribution (≤12 g/dL [n = 753]). Patients who had anemia displayed higher risk clinical characteristics including older age, more advanced HF symptoms, and atrial fibrillation (p <0.01 for all). Kaplan-Meier survival analysis showed that at 2.5 years of follow-up the rate of appropriate shocks was significantly higher in patients with low (11%) versus high (6%) hemoglobin (log-rank p <0.005). Multivariate analysis showed that anemia was independently associated with a significant 56% increased risk for first appropriate ICD shock (p <0.026). When hemoglobin was assessed as a continuous measure, each 1 g/dL reduction in hemoglobin was independently associated with a significant 8% increased risk for first appropriate shock (p <0.03). Anemia was also associated with increased risk for all-cause mortality (hazard ratio [HR] 1.78, 95% confidence interval [CI] 1.4 to 2.27], p <0.001), HF hospitalizations or death (HR 1.78, 95% CI 1.48 to 1.13, p <0.001), but not with inappropriate ICD shocks (HR 1.24, 95% CI 0.70 to 2.21, p = 0.47). In conclusion, our findings suggest that the presence of anemia in patients with ICD is associated with increased risk for VA during long-term follow-up. |
19,973 | Pharmacological heart rate lowering in patients with a preserved ejection fraction-review of a failing concept. | Epidemiological studies have demonstrated that high resting heart rates are associated with increased mortality. Clinical studies in patients with heart failure and reduced ejection fraction have shown that heart rate lowering with beta-blockers and ivabradine improves survival. It is therefore often assumed that heart rate lowering is beneficial in other patients as well. Here, we critically appraise the effects of pharmacological heart rate lowering in patients with both normal and reduced ejection fraction with an emphasis on the effects of pharmacological heart rate lowering in hypertension and heart failure. Emerging evidence from recent clinical trials and meta-analyses suggest that pharmacological heart rate lowering is not beneficial in patients with a normal or preserved ejection fraction. This has just begun to be reflected in some but not all guideline recommendations. The detrimental effects of pharmacological heart rate lowering are due to an increase in central blood pressures, higher left ventricular systolic and diastolic pressures, and increased ventricular wall stress. Therefore, we propose that heart rate lowering per se reproduces the hemodynamic effects of diastolic dysfunction and imposes an increased arterial load on the left ventricle, which combine to increase the risk of heart failure and atrial fibrillation. Pharmacologic heart rate lowering is clearly beneficial in patients with a dilated cardiomyopathy but not in patients with normal chamber dimensions and normal systolic function. These conflicting effects can be explained based on a model that considers the hemodynamic and ventricular structural effects of heart rate changes. |
19,974 | Implantable loop recorders in the real world: a study of two Canadian centers. | Implantable loop recorders (ILRs) are increasingly being used for ambulatory electrocardiography. We sought to evaluate ILR indications, diagnostic yield, ILR-guided interventions, and complications in two Canadian centers.</AbstractText>This was a retrospective study using electronic medical records to identify ILR implants at Queen's University and the University of Manitoba. Information was collected on patient characteristics, medications, indication for implant, results of prior investigations, diagnostic outcome, and subsequent management.</AbstractText>A total of 540 patients were identified; 386 had completed monitoring at time of analysis. Forty patients were lost to follow-up. Indications were unexplained syncope 84.8%, palpitations 12.8%, and suspected atrial fibrillation 11.7%. For syncope, ILRs documented arrhythmia or conduction disorder in 46%. Most common conditions were asystole/sinus pause (22%), complete heart block (10.4%), and atrial fibrillation (AF) (6.9%). After ILR diagnosis, 39.9% of implanted patients received pacemaker/ICD and 2.7% underwent catheter ablation. For palpitations, ILRs documented arrhythmia or conduction disorder in 60.4%. Most common conditions were AVNRT, AF, complete heart block, and ventricular tachycardia. After diagnosis, 25% underwent catheter ablation and 22.9% received pacemaker/ICD. For suspected AF, AF was diagnosed in 40%. Complications were observed in 3.3% of implanted patients: implant site infection 1.5%, non-infectious implant site pain requiring device removal or pocket revision 1.5%, 0.2% hypertrophic scar, and 0.2% device malfunction.</AbstractText>An ILR has excellent diagnostic yield for syncope, palpitations, and suspected AF, and a considerable proportion of patients undergo ILR-directed interventions following monitoring. ILR implantation is a low-risk procedure.</AbstractText> |
19,975 | Systematic review for the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. | Although large randomized clinical trials have found that primary prevention use of an implantable cardioverter-defibrillator (ICD) improves survival in patients with cardiomyopathy and heart failure symptoms, patients who receive ICDs in practice are often older and have more comorbidities than patients who were enrolled in the clinical trials. In addition, there is a debate among clinicians on the usefulness of electrophysiological study for risk stratification of asymptomatic patients with Brugada syndrome.</AbstractText>Our analysis has 2 objectives. First, to evaluate whether ventricular arrhythmias (VAs) induced with programmed electrostimulation in asymptomatic patients with Brugada syndrome identify a higher risk group that may require additional testing or therapies. Second, to evaluate whether implantation of an ICD is associated with a clinical benefit in older patients and patients with comorbidities who would otherwise benefit on the basis of left ventricular ejection fraction and heart failure symptoms.</AbstractText>Traditional statistical approaches were used to address 1) whether programmed ventricular stimulation identifies a higher-risk group in asymptomatic patients with Brugada syndrome and 2) whether ICD implantation for primary prevention is associated with improved outcomes in older patients (>75 years of age) and patients with significant comorbidities who would otherwise meet criteria for ICD implantation on the basis of symptoms or left ventricular function.</AbstractText>Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63-8.66; p=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67-0.83; p<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65-0.79; p<0.0001), and a second "minimal overlap" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61-0.82; p<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60-0.85; p<0.001).</AbstractText>Copyright © 2018 American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,976 | Systematic Review for the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. | Although large randomized clinical trials have found that primary prevention use of an implantable cardioverter-defibrillator (ICD) improves survival in patients with cardiomyopathy and heart failure symptoms, patients who receive ICDs in practice are often older and have more comorbidities than patients who were enrolled in the clinical trials. In addition, there is a debate among clinicians on the usefulness of electrophysiological study for risk stratification of asymptomatic patients with Brugada syndrome.</AbstractText>Our analysis has 2 objectives. First, to evaluate whether ventricular arrhythmias (VAs) induced with programmed electrostimulation in asymptomatic patients with Brugada syndrome identify a higher risk group that may require additional testing or therapies. Second, to evaluate whether implantation of an ICD is associated with a clinical benefit in older patients and patients with comorbidities who would otherwise benefit on the basis of left ventricular ejection fraction and heart failure symptoms.</AbstractText>Traditional statistical approaches were used to address 1) whether programmed ventricular stimulation identifies a higher-risk group in asymptomatic patients with Brugada syndrome and 2) whether ICD implantation for primary prevention is associated with improved outcomes in older patients (>75 years of age) and patients with significant comorbidities who would otherwise meet criteria for ICD implantation on the basis of symptoms or left ventricular function.</AbstractText>Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63-8.66; p=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67-0.83; p<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65-0.79; p<0.0001), and a second "minimal overlap" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61-0.82; p<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60-0.85; p<0.001).</AbstractText>Copyright © 2018 American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
19,977 | Lamin A/C cardiomyopathy: young onset, high penetrance, and frequent need for heart transplantation. | Lamin A/C (LMNA) mutations cause familial dilated cardiomyopathy (DCM) with frequent conduction blocks and arrhythmias. We explored the prevalence, cardiac penetrance, and expressivity of LMNA mutations among familial DCM in Norway. Furthermore, we explored the risk factors and the outcomes in LMNA patients.</AbstractText>During 2003-15, genetic testing was performed in patients referred for familial DCM. LMNA genotype-positive subjects were examined by electrocardiography, Holter monitoring, cardiac magnetic resonance imaging, and echocardiography. A positive cardiac phenotype was defined as the presence of atrioventricular (AV) block, atrial fibrillation/flutter (AF), ventricular tachycardia (VT), and/or echocardiographic DCM. Heart transplantation was recorded and compared with non-ischaemic DCM of other origin. Of 561 unrelated familial DCM probands, 35 (6.2%) had an LMNA mutation. Family screening diagnosed an additional 93 LMNA genotype-positive family members. We clinically followed up 79 LMNA genotype-positive [age 42 ± 16 years, ejection fraction (EF) 45 ± 13%], including 44 (56%) with VT. Asymptomatic LMNA genotype-positive family members (age 31 ± 15 years) had a 9% annual incidence of a newly documented cardiac phenotype and 61% (19/31) of cardiac penetrance during 4.4 ± 2.9 years of follow-up. Ten (32%) had AV block, 7 (23%) AF, and 12 (39%) non-sustained VT. Heart transplantation was performed in 15 of 79 (19%) LMNA patients during 7.8 ± 6.3 years of follow-up.</AbstractText>LMNA mutation prevalence was 6.2% of familial DCM in Norway. Cardiac penetrance was high in young asymptomatic LMNA genotype-positive family members with frequent AV block and VT, highlighting the importance of early family screening and cardiological follow-up. Nearly 20% of the LMNA patients required heart transplantation.</AbstractText> |
19,978 | Heart Failure with Preserved Ejection Fraction: Diagnosis and Management. | Heart failure with preserved ejection fraction, also referred to as diastolic heart failure, causes almost one-half of the 5 million cases of heart failure in the United States. It is more common among older patients and women, and results from abnormalities of active ventricular relaxation and passive ventricular compliance, leading to a decline in stroke volume and cardiac output. Heart failure with preserved ejection fraction should be suspected in patients with typical symptoms (e.g., fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema) and signs (S3 heart sound, displaced apical pulse, and jugular venous distension) of chronic heart failure. Echocardiographic findings of normal ejection fraction with impaired diastolic function confirm the diagnosis. Measurement of natriuretic peptides is useful in the evaluation of patients with suspected heart failure with preserved ejection fraction in the ambulatory setting. Multiple trials have not found medications to be an effective treatment, except for diuretics. Patients with congestive symptoms should be treated with a diuretic. If hypertension is present, it should be treated according to evidence-based guidelines. Exercise and treatment by multidisciplinary teams may be helpful. Atrial fibrillation should be treated using a rate-control strategy and appropriate anticoagulation. Revascularization should be considered for patients with heart failure with preserved ejection fraction and coronary artery disease. The prognosis is comparable to that of heart failure with reduced ejection fraction and is worsened by higher levels of brain natriuretic peptide, older age, a history of myocardial infarction, and reduced diastolic function. |
19,979 | Antifibrillatory effects of renal denervation on ventricular fibrillation in a canine model of pacing-induced heart failure. | What is the central question of this study? In the present study, we investigated the effects of renal denervation on the vulnerability to ventricular fibrillation and the ventricular electrical properties in a rapid pacing-induced heart failure canine model. What is the main finding and its importance? Renal denervation significantly attenuated the process of heart failure and improved left ventricular systolic dysfunction, stabilized ventricular electrophysiological properties and decreased the vulnerability of the heart to ventricular fibrillation during heart failure. Thus, renal denervation can attenuate ventricular electrical remodelling and exert a potential antifibrillatory action in a pacing-induced heart failure canine model. In this study, we investigated the effects of renal denervation (RDN) on the vulnerability to ventricular fibrillation (VF) and the ventricular electrical properties in a canine model of pacing-induced heart failure (HF). Eighteen beagles were divided into the following three groups: control (n = 6), HF (n = 6) and HF+RDN (n = 6). Heart failure was induced by rapid right ventricular pacing. Renal denervation was performed simultaneously with the pacemaker implantation in the HF+RDN group. A 64-unipolar basket catheter was used to perform global endocardial mapping of the left ventricle. The restitution properties and dispersion of refractoriness were estimated from the activation recovery intervals (ARIs) by a pacing protocol. The VF threshold (VFT) was defined as the maximal pacing cycle length required to induce VF using a specific pacing protocol. The defibrillation threshold (DFT) was measured by an up-down algorithm. Renal denervation partly restored left ventricular systolic function and attenuated the process of HF. Compared with the control group, the VFT in the HF group was decreased by 27% (106 ± 8.0 versus 135 ± 10 ms, P < 0.01). However, RDN increased the VFT by 13% (135 ± 10 versus 118 ± 7.5 ms, P < 0.05) and decreased the DFT by 27% (30 ± 6.3 versus 21.8 ± 4.7 J, P < 0.05) in the treated hearts compared with the failing hearts. Renal denervation significantly flattened the ventricular ARI restitution curve by 15% (1.48 ± 0.2 versus 1.26 ± 0.11, P < 0.05) and decreased the dispersion of ARI by 25% (0.08 ± 0.02 versus 0.06 ± 0.01, P < 0.01) in the treated group compared with the HF group. The findings of this study suggest that RDN can attenuate ventricular electrical remodelling and exert a potential antifibrillatory action on VF in a canine model of pacing-induced HF. |
19,980 | Epicardial exposure provided by a novel thoracoscopic pericardectomy technique compared to standard pericardial window. | (1) To describe a novel technique for thoracoscopic pericardectomy using a pericardial window with vertical pericardial fillets (PW+F). (2) To compare epicardial exposure between a standard pericardial window (PW) and PW+F.</AbstractText>Experimental study.</AbstractText>Purpose-bred research dogs (n = 12).</AbstractText>PW was performed through a 3-port subxiphoid thoracoscopic approach. After PW, vertical fillets were made in the pericardium for PW+F. Thoracoscopic images from 3 views were acquired after each procedure, and percentage of epicardial surface exposed (PESE) was compared. Epicardial exposure and iatrogenic damage to surrounding structures were directly assessed via postmortem gross examination.</AbstractText>The exposed epicardial surface (PESE) was increased with our novel compared to the standard technique. Median surgery time for PW+F was 25 minutes. The procedure was performed in 11 of 12 dogs without iatrogenic damage to surrounding structures. In 1 dog, the electrosurgery device contacted the epicardium and caused fatal ventricular fibrillation while performing PW+F. Based on postmortem assessment in all dogs with PW+F, the pericardium could move freely away from the heart, exposing the majority of the epicardial surface.</AbstractText>Thoracoscopic PW+F is a novel technique that improves the exposure of the epicardium compared to standard PW. While PW+F can be performed successfully and in an efficient manner, the surgeon must be aware of the risk of iatrogenic trauma to thoracic structures when using electrosurgery.</AbstractText>PW+F offers a relatively safe, efficient, and effective minimally invasive method that improves the exposure of the epicardium compared to PW.</AbstractText>© 2017 The American College of Veterinary Surgeons.</CopyrightInformation> |
19,981 | Effect of Wenxin Granules on Gap Junction and MiR-1 in Rats with Myocardial Infarction. | Myocardial infarction (MI) patients are at high risk of potential lethal arrhythmia. Gap junction and microRNA-1 (miR-1) are both arrhythmia generating conditions. The present study investigated whether Wenxin Granules (Wenxin-Keli, WXKL) could prevent potential lethal arrhythmia by improving gap junctions and miR-1 following MI. Male Sprague-Dawley rats were divided randomly into control, model, metoprolol, low dose WXKL, and high dose WXKL groups. The MI rat model was created by coronary artery ligation. Treatments were administrated intragastrically to the rats for 4 weeks. Conventional transmission electron microscopy was performed to observe the ultrastructure of gap junctions. Quantitative real-time PCR and western blotting were used to detect the expression of miR-1, protein kinase C (PKC), and related proteins. Additionally, a programmatic electrophysiological stimulation test was performed to detect the ventricular fibrillation threshold (VFT). WXKL protected the ultrastructure of the gap junctions and their constituent Cx43 by regulating miR-1 and PKC mediated signal transduction and increased the VFT significantly in the rat MI model. The results suggested that WXKL is an effective alternative medicine to prevent potentially lethal arrhythmia following MI. |
19,982 | Associates and Prognosis of Giant Left Atrium; Single Center Experience. | Left atrial (LA) remodeling develops as a result of longstanding pressure overload. However, determinants and clinical outcome of excessive remodeling, so called giant left atrium (GLA), are not clear.</AbstractText>Clinical characteristics of patients with GLA (antero-posterior diameter higher than 65 mm), including echo-Doppler parameters, and follow-up clinical outcomes from a tertiary referral hospital were investigated.</AbstractText>Among 68519 consecutive primary patients who underwent echocardiography over a period of 10 years, data from 163 GLA cases (0.24%) were analyzed. Main causes were significant rheumatic mitral stenosis (n = 58, 36%); other causes comprised significant rheumatic mitral regurgitation (MR; n = 10, 6%), mitral valve (MV) prolapse or congenital mitral valvular disease (MVD) (n = 20, 12%), and functional MR (n = 25, 15%). However, mild rheumatic MV disease (n = 4, 3%) or left ventricular (LV) systolic or diastolic dysfunction without significant MR (n = 46, 28%) were also causes of GLA. During median follow-up of 22 months, 42 cases (26%) underwent composite events. MV surgery was related to lower rate of composite events. In multivariate analysis, MV surgery, elevated pulmonary arterial systolic pressure, and increased LA volume index were independent predictors of future events (p</i> < 0.05) regardless of underlying diseases or history of MV surgery.</AbstractText>Although rheumatic MVD with atrial fibrillation is the main contributor to GLA, longstanding atrial fibrillation with LV dysfunction but without MVD also could be related to GLA. Even in GLA state, accurate measurement of LA volume is crucial for risk stratification for future events, regardless of underlying disease.</AbstractText> |
19,983 | Repolarization abnormalities unmasked with exercise in sudden cardiac death survivors with structurally normal hearts. | Models of cardiac arrhythmogenesis predict that nonuniformity in repolarization and/or depolarization promotes ventricular fibrillation and is modulated by autonomic tone, but this is difficult to evaluate in patients. We hypothesize that such spatial heterogeneities would be detected by noninvasive ECG imaging (ECGi) in sudden cardiac death (SCD) survivors with structurally normal hearts under physiological stress.</AbstractText>ECGi was applied to 11 SCD survivors, 10 low-risk Brugada syndrome patients (BrS), and 10 controls undergoing exercise treadmill testing. ECGi provides whole heart activation maps and >1,200 unipolar electrograms over the ventricular surface from which global dispersion of activation recovery interval (ARI) and regional delay in conduction were determined. These were used as surrogates for spatial heterogeneities in repolarization and depolarization. Surface ECG markers of dispersion (QT and Tpeak-end intervals) were also calculated for all patients for comparison.</AbstractText>Following exertion, the SCD group demonstrated the largest increase in ARI dispersion compared to BrS and control groups (13 ± 8 ms vs. 4 ± 7 ms vs. 4 ± 5 ms; P = 0.009), with baseline dispersion being similar in all groups. In comparison, surface ECG markers of dispersion of repolarization were unable to discriminate between the groups at baseline or following exertion. Spatial heterogeneities in conduction were also present following exercise but were not significantly different between SCD survivors and the other groups.</AbstractText>Increased dispersion of repolarization is apparent during physiological stress in SCD survivors and is detectable with ECGi but not with standard ECG parameters. The electrophysiological substrate revealed by ECGi could be the basis of alternative risk-stratification techniques.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
19,984 | Late potentials and their correlation with ventricular structure in patients with ventricular arrhythmias. | The presence of late potentials (LP) may indicate a predisposition to ventricular arrhythmias and sudden cardiac death. We investigated the association between presence of LP and structural cardiac anomalies assessed by magnetic resonance (CMR) in patients presenting with ventricular arrhythmias.</AbstractText>We included 42 patients admitted with ventricular tachycardia or fibrillation who had undergone both signal-averaged ECG recording and CMR imaging. Clinical data and CMR findings were compared in patients with and without LP.</AbstractText>The majority, 26 (62%) patients, were sudden cardiac death survivors and the remaining 16 (38%) were admitted with ventricular tachycardia. After full diagnostic work-up, the most common diagnoses in the cohort were idiopathic ventricular tachycardia/ventricular fibrillation (25 patients, 60%) or cardiomyopathies (11 patients, 26%). LPs were positive in 29 (69%) when using the revised Task Force criteria. When comparing patients with and without late potentials, there were no significant differences in right ventricular size relative to body surface area (102 mL/m2</sup> vs 92 mL/m2</sup> ), right ventricular ejection fraction (55% vs 58%), or positive late gadolinium enhancement (29% vs 24%).</AbstractText>Among patients with malignant arrhythmias, the presence of LP does not distinguish between patients with normal and abnormal RV structure or function on CMR. LP may indicate the presence of an arrhythmic heart disease beyond what can be inferred from CMR. The frequent finding of late potentials indicates that the diagnostic value of LP as an ARVC criteria should be tested in larger studies comparing ARVC patients and controls.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
19,985 | Impact of Atrial Fibrillation on Exercise Capacity and Mortality in Heart Failure With Preserved Ejection Fraction: Insights From Cardiopulmonary Stress Testing. | Atrial fibrillation (AF) has been objectively associated with exercise intolerance in patients with heart failure with reduced ejection fraction; however, its impact in patients with heart failure with preserved ejection fraction has not been fully scrutinized.</AbstractText>We identified 1744 patients with heart failure and ejection fraction ≥50% referred for cardiopulmonary stress testing at the Cleveland Clinic (Cleveland, OH), 239 of whom had AF. We used inverse probability of treatment weighting to balance clinical characteristics between patients with and without AF. A weighted linear regression model, adjusted for unbalanced variables (age, sex, diagnosis, hypertension, and β-blocker use), was used to compare metabolic stress parameters and 8-year total mortality (social security index) between both groups. Weighted mean ejection fraction was 58±5.9% in the entire population. After adjusting for unbalanced weighted variables, patients with AF versus those without AF had lower mean peak oxygen consumption (18.5±6.2 versus 20.3±7.1 mL/kg per minute), oxygen pulse (12.4±4.3 versus 12.9±4.7 mL/beat), and circulatory power (2877±1402 versus 3351±1788 mm Hg·mL/kg per minute) (P</i><0.001 for all comparisons) but similar submaximal exercise capacity (oxygen consumption at anaerobic threshold, 12.0±5.1 versus 12.4±6.0mL/kg per minute; P</i> =0.3). Both groups had similar peak heart rate, whereas mean peak systolic blood pressure was lower in the AF group (150±35 versus 160±51 mm Hg; P</i><0.001). Moreover, AF was associated with higher total mortality.</AbstractText>In the largest study of its kind, we demonstrate that AF is associated with peak exercise intolerance, impaired contractile reserve, and increased mortality in patients with heart failure with preserved ejection fraction. Whether AF is the primary offender in these patients or merely a bystander to worse diastolic function requires further investigation.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
19,986 | Atrial Fibrillation Should Guide Prophylactic Tricuspid Procedures During Left Ventricular Assist Device Implantation. | Atrial fibrillation (AF) and tricuspid regurgitation (TR) are common in patients undergoing left ventricular assist device (LVAD) implantation. TR progression is associated with the presence of AF, and questions remain as to who benefits from tricuspid valve procedures (TVPs). We examined the impact of preoperative AF on TR progression after LVAD implantation. From February 2007 to May 2014, 250 patients underwent LVAD implantation at our institution. Patients with concomitant TVP were excluded from this analysis (113 patients). The indication for LVAD was destination therapy in 80 patients (58%) and the etiology of heart failure was ischemic in 73 (53%). Follow-up was available in all early survivors for a total of 393 patient-years of support. Of the 137 non-TVP patients, 52 (38%) had AF preoperatively. Observed overall survival at 1, 3, and 5 years was 82%, 67%, and 55%, respectively. Median grade of TR increased from 2 preoperatively to 3 (p = 0.04) in the AF group and 2.2 (p = 0.75) in the non-AF group at 5 years of follow-up. We also observed a significant difference in the degree of TR between groups at 3 months (p = 0.03) and 12 months (p = 0.01) postimplantation, and a trend toward significance at 18 (p = 0.06) and 24 (p = 0.07) months. The presence of AF is associated with early progression of TR after LVAD implantation. Addition of concomitant TVP in patients with preoperative AF may be considered in patients with less than severe TR. The impact of these findings on right ventricular failure/remodeling remains to be evaluated. |
19,987 | Systematic Review for the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. | Although large randomized clinical trials have found that primary prevention use of an implantable cardioverter-defibrillator (ICD) improves survival in patients with cardiomyopathy and heart failure symptoms, patients who receive ICDs in practice are often older and have more comorbidities than patients who were enrolled in the clinical trials. In addition, there is a debate among clinicians on the usefulness of electrophysiological study for risk stratification of asymptomatic patients with Brugada syndrome.</AbstractText>Our analysis has 2 objectives. First, to evaluate whether ventricular arrhythmias (VAs) induced with programmed electrostimulation in asymptomatic patients with Brugada syndrome identify a higher risk group that may require additional testing or therapies. Second, to evaluate whether implantation of an ICD is associated with a clinical benefit in older patients and patients with comorbidities who would otherwise benefit on the basis of left ventricular ejection fraction and heart failure symptoms.</AbstractText>Traditional statistical approaches were used to address 1) whether programmed ventricular stimulation identifies a higher-risk group in asymptomatic patients with Brugada syndrome and 2) whether ICD implantation for primary prevention is associated with improved outcomes in older patients (>75 years of age) and patients with significant comorbidities who would otherwise meet criteria for ICD implantation on the basis of symptoms or left ventricular function.</AbstractText>Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63-8.66; P=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67-0.83; P<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65-0.79; P<0.0001), and a second "minimal overlap" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61-0.82; P<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60-0.85; P<0.001).</AbstractText> |
19,988 | Omega-3 Index and Anti-Arrhythmic Potential of Omega-3 PUFAs. | Omega-3 polyunsaturated fatty acids (PUFAs), namely eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are permanent subjects of interest in relation to the protection of cardiovascular health and the prevention of the incidence of both ventricular and atrial arrhythmias. The purpose of this updated review is to focus on the novel cellular and molecular effects of omega-3 PUFAs, in the context of the mechanisms and factors involved in the development of cardiac arrhythmias; to provide results of the most recent studies on the omega-3 PUFA anti-arrhythmic efficacy and to discuss the lack of the benefit in relation to omega-3 PUFA status. The evidence is in the favor of omega-3 PUFA acute and long-term treatment, perhaps with mitochondria-targeted antioxidants. However, for a more objective evaluation of the anti-arrhythmic potential of omega-3 PUFAs in clinical trials, it is necessary to monitor the basal pre-interventional omega-3 status of individuals, i.e., red blood cell content, omega-3 index and free plasma levels. In the view of evidence-based medicine, it seems to be crucial to aim to establish new approaches in the prevention of cardiac arrhythmias and associated morbidity and mortality that comes with these conditions. |
19,989 | Fitness to Drive in Cardiovascular Disease. | Medical students are taught little or nothing about the medical considerations related to the driving of motor vehicles. Physicians treating patients with cardiovascular disease need to acquire competence in traffic medicine in order to be able to advise them about their fitness to drive.</AbstractText>We present the current governmental regulations and recommendations concerning fitness to drive in patients with cardiovascular disease. We also review pertinent publications that were retrieved by a selective search in PubMed with the search terms "cardiovascular disease and traffic accidents" and "cardiovascular disease and traffic deaths" for the decade 2007-2016, as well as further publications collected by us individually.</AbstractText>Cardiovascular disease can make a driver lose control of a vehicle without warning and thereby lead to an accident. The main pathophysiological mechanisms of sudden loss of control are disturbances of brain perfusion (e.g., syncope with or without cardiac arrhythmia, sudden cardiac death due to ventricular fibrillation or asystole, stroke, aneurysm rupture) and marked general weakness (e.g., after major surgery or in cardiac insufficiency).</AbstractText>Patients with cardiovascular disease should be advised by their physicians about their fitness to drive, and the discussion should be documented in writing. Because of the German law on the confidentiality of medical data, only the affected patient should receive this information, with very few exceptions.</AbstractText> |
19,990 | [Analysis on clinical characteristics and prognosis of patients with mitral valve prolapse]. | <b>Objective:</b> To evaluate the clinical characteristics and prognosis of patients with mitral valve prolapse (MVP). <b>Methods:</b> We retrospectively analyzed the clinical characteristics and prognosis of 148 MVP patients who underwent mitral valve surgery in Fuwai hospital from January 2012 to December 2015.The patients were divided into mucoid degeneration group (52 cases) and without mucoid degeneration group(19 cases) according to pathological examination of leaflets and chordate. <b>Results:</b> The clinical symptoms of MVP patients included dyspnea (59.5%(88/148)), chest distress and pain (52.7%(78/148)), and palpitations (36.5% (54/148)). Mitral valve repair was performed in 144 cases (97.3%), and mitral valve replacement was performed in 4 cases (2.7%). Posterior leaflet prolapse was the most common form of MVP (68.9%, 102/148). Pathological examination revealed myxomatous degeneration in 73.2% patients (52/71), fibrosis in 8.5% patients (6/71), and fibrinoid necrosis in 8.5% patients (6/71). Patients with mucoid degeneration had less atrial fibrillation before surgery (5.8%(3/52) vs. 42.1%(8/19), <i>P</i><0.01), smaller preoperative left atrium diameter ((43.2±6.5) mm vs. (48.2±8.9) mm, <i>P</i><0.05), more posterior leaflet prolapse (94.2%(49/52) vs. 63.2%(12/19), <i>P</i><0.01), redundant chordae (26.9%(14/52) vs. 0, <i>P</i><0.05) and leaflet thickening (76.9%(40/52) vs. 52.6%(10/19), <i>P</i><0.05) when compared with patients without mucoid degeneration.Echocardiography examination at the postoperative follow-up of 39.0(22.3, 57.0) months revealed smaller left atrium diameter((38.5±7.1) mm vs. (45.3±8.3) mm, <i>P</i><0.01), left ventricular end-diastolic diameter ((48.9±6.2) mm vs. (57.5±7.6) mm, <i>P</i><0.01), reduced left ventricular ejection fraction ((61.2±7.1)% vs. (65.1±6.2)%, <i>P</i><0.01) and less moderate or severe mitral regurgitation (1.4%(2/148) vs. 100.0%(148/148), <i>P</i><0.01) compared with the corresponding preoperative values. <b>Conclusions:</b> Dyspnea is the main symptom, and mucoid degeneration characterized by redundant chordae and leaflet thickening are the main pathological features of MVP patients.The surgical treatment of MVP patients is related with satisfactory outcome results.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Guo</LastName><ForeName>Y</ForeName><Initials>Y</Initials><AffiliationInfo><Affiliation>Department of Special Medical Treatment Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Wang</LastName><ForeName>S Y</ForeName><Initials>SY</Initials></Author><Author ValidYN="Y"><LastName>Duan</LastName><ForeName>X J</ForeName><Initials>XJ</Initials></Author><Author ValidYN="Y"><LastName>Wu</LastName><ForeName>X</ForeName><Initials>X</Initials></Author><Author ValidYN="Y"><LastName>Zheng</LastName><ForeName>X X</ForeName><Initials>XX</Initials></Author><Author ValidYN="Y"><LastName>Lu</LastName><ForeName>J</ForeName><Initials>J</Initials></Author><Author ValidYN="Y"><LastName>Huang</LastName><ForeName>X H</ForeName><Initials>XH</Initials></Author></AuthorList><Language>chi</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList></Article><MedlineJournalInfo><Country>China</Country><MedlineTA>Zhonghua Xin Xue Guan Bing Za Zhi</MedlineTA><NlmUniqueID>7910682</NlmUniqueID><ISSNLinking>0253-3758</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D006348" MajorTopicYN="Y">Cardiac Surgical Procedures</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D003971" MajorTopicYN="N">Diastole</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D004452" MajorTopicYN="Y">Echocardiography</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005500" MajorTopicYN="N">Follow-Up Studies</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008943" MajorTopicYN="N">Mitral Valve</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008944" MajorTopicYN="N">Mitral Valve Insufficiency</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008945" MajorTopicYN="Y">Mitral Valve Prolapse</DescriptorName><QualifierName UI="Q000473" MajorTopicYN="N">pathology</QualifierName><QualifierName UI="Q000601" MajorTopicYN="N">surgery</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D011379" MajorTopicYN="N">Prognosis</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012189" MajorTopicYN="N">Retrospective Studies</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D016277" MajorTopicYN="N">Ventricular Function, Left</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="chi"><b>目的：</b> 探讨二尖瓣脱垂(MVP)患者的临床特点及预后。 <b>方法：</b> 选取2012年1月至2015年12月在阜外医院行外科手术的MVP患者148例，回顾性分析其临床特点，并在术后进行随访。根据瓣叶和腱索病理检查结果，将其中71例MVP患者分为黏液样变性组(52例)和非黏液样变性组(19例)。 <b>结果：</b> MVP患者的临床症状中呼吸困难占59.5%(88/148)，胸闷和胸痛占52.7%(78/148)，心悸占36.5%(54/148)。采用的手术方式包括二尖瓣修复成形术144例(97.3%)和二尖瓣瓣膜置换术4例(2.7%)。MVP患者中二尖瓣后叶脱垂占68.9%(102/148)，病理类型中黏液样变性占73.2%(52/71)，纤维化变性占8.5%(6/71)，纤维素样坏死占8.5%(6/71)。与非黏液样变性组比较，黏液样变性组术前合并心房颤动比率较低[5.8%(3/52)比42.1%(8/19)，<i>P</i><0.01]，术前左心房内径较小[(43.2±6.5) mm比(48.2±8.9) mm，<i>P</i><0.05]，后叶脱垂、腱索延长和瓣叶增厚比率均较高[分别为94.2%(49/52)比63.2%(12/19)，<i>P</i><0.01；26.9%(14/52)比0，<i>P</i><0.05；76.9%(40/52)比52.6%(10/19)，<i>P</i><0.05]。术后随访39.0(22.3，57.0)个月，随访期间超声心动图显示左心房内径[(38.5±7.1) mm比(45.3±8.3) mm，<i>P</i><0.01]、左心室舒张末期内径[(48.9±6.2) mm比(57.5±7.6) mm，<i>P</i><0.01]、左心室射血分数[(61.2±7.1)%比(65.1±6.2)%，<i>P</i><0.01]和二尖瓣中量以上反流比率[1.4%(2/148)比100.0%(148/148)，<i>P</i><0.01]均小于术前。 <b>结论：</b> MVP患者的临床症状以呼吸困难为主，黏液样变性是MVP最主要的病理类型，腱索延长和瓣叶增厚是其特征性改变。MVP患者通过外科手术可取得满意的治疗效果。. |
19,991 | Forward Left Ventricular Ejection Fraction: A Simple Risk Marker in Patients With Primary Mitral Regurgitation. | The timing of mitral valve surgery in asymptomatic patients with primary mitral regurgitation (MR) is controversial. We hypothesized that the forward left ventricular (LV) ejection fraction (LVEF; ie, LV outflow tract stroke volume divided by LV end-diastolic volume) is superior to the total LVEF to predict outcomes in MR. The objective of this study was to examine the association between echocardiographic parameters of MR severity and LV function and outcomes in patients with MR.</AbstractText>The clinical and Doppler-echocardiographic data of 278 patients with ≥mild MR and no class I indication of mitral valve surgery at baseline were retrospectively analyzed. The primary study end point was the composite of mitral valve surgery or death. During a mean follow-up of 5.4±3.2 years, there were 147 (53%) events: 96 (35%) MV surgeries and 66 (24%) deaths. Total LVEF and global longitudinal strain were not associated with the occurrence of events, whereas forward LVEF (P</i><0.0001) and LV end-systolic diameter (P</i>=0.0003) were. After adjustment for age, sex, MR severity, Charlson probability, coronary artery disease, and atrial fibrillation, forward LVEF remained independently associated with the occurrence of events (adjusted hazard ratio: 1.09, [95% confidence interval]: 1.02-1.17 per 5% decrease; P</i>=0.01), whereas LV end-systolic diameter was not (P</i>=0.48).</AbstractText>The results of this study suggest that the forward LVEF may be superior to the total LVEF and LV end-systolic diameter to predict outcomes in patients with primary MR. This simple and easily measurable parameter may be useful to improve risk stratification and select the best timing for intervention in patients with primary MR.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
19,992 | Non-ion channel therapeutics for heart failure and atrial fibrillation: Are CaMKII inhibitors ready for clinical use? | The Ca<sup>2+</sup>-calmodulin dependent protein kinase II (CaMKII) is an established central mediator of electrophysiological and contractile responses to cardiac stress, and its hyper-activation in cardiac diseases has been linked to heart failure (HF) and arrhythmia. Here we summarize the evidence supporting the role of CaMKII as a critical nodal point for therapeutic intervention against HF and atrial and ventricular tachyarrhythmias. Targeting of CaMKII in heart with inhibitors possessing appropriate selectivity might represent a novel therapeutic approach for HF and arrhythmias. |
19,993 | Compatibility of ZOLL Defibrillators in Simulation-Based Training. | In response to the need for high-quality cardiopulmonary resuscitation (CPR) during cardiac arrest, our institution recently purchased ZOLL R Series monitor/defibrillators. This defibrillator provides CPR quality metrics and displays a filtered rhythm through compressions. Purchase of this defibrillator resulted in a practice change and heavily impacted our simulation-based training courses by requiring providers to practice CPR and defibrillation in as close to the real environment as possible. Thus, our objective was to determine which commercial simulators would be compatible with the ZOLL R Series defibrillator system and its CPR feedback functionality in a simulation-based training setting.</AbstractText>Our simulation center uses primarily Gaumard Scientific and Laerdal Medical simulators ranging in size from neonate to adult. Through an iterative process in the laboratory, we evaluated if, and to what level, the CPR display metrics, filtered rhythm, and idle time display could be demonstrated with CPR on the different simulators using infant, pediatric, and adult pads.</AbstractText>Certain simulators allow demonstration and real-time practice of defibrillator functions better than others with the ZOLL R Series system when used in the context of CPR training. We have no high-fidelity infant-sized simulators that can meet the depth recommendation for chest compressions given by the American Heart Association. Ventricular fibrillation is the only rhythm that offers a filtered option. Idle time can be reliably displayed for simulators where CPR is detected.</AbstractText>When a primary learning objective for simulation-based training involves training on the ZOLL R Series defibrillator, there are a limited number of simulators and rhythms that can accurately represent its features.</AbstractText> |
19,994 | Left Versus Biventricular Assist Devices in Cardiac Arrest. | Maintaining adequate organ perfusion during cardiac arrest remains a challenge, and various assist techniques have been evaluated. We assessed whether a right ventricular impeller assist device (RVAD) in adjunct to a left ventricular impeller assist device (LVAD) is beneficial. Twenty anesthetized pigs were randomized to maximized circulatory support by percutaneously implanted left- or biventricular assist device(s) during 30 minutes of electrically induced ventricular fibrillation followed by three attempts of cardioversion. Continuous hemodynamic variables were recorded. Cardiac output and myocardial, cerebral, renal, and ileum mucosa tissue perfusion were measured with fluorescent microspheres, and repeated blood gas analyses were obtained. With biventricular support, an increased LVAD output was found compared with left ventricular (LV) support; 3.2 ± 0.2 (SEM) vs. 2.0 ± 0. 2 L/minute just after start of ventricular fibrillation, 3.2 ± 0.1 vs. 2.0 ± 0.1 L/minute after 15 minutes, and 3.0 ± 0.1 vs. 2.1 ± 0.1 L/minute after 30 minutes of cardiac arrest (pg < 0.001). Biventricular support also increased aortic and LV pressure, in addition to end-tidal CO2. Tissue blood flow rates were increased for most organs with biventricular support. Blood gas analyses showed improved oxygenation and lower s-lactate values. However, myocardial perfusion was degraded with biventricular support and return of spontaneous circulation less frequent (5/10 vs. 10/10; p = 0.033). Biventricular support was associated with high intraventricular pressure and decreased myocardial perfusion pressure, correlating significantly with flow rates in the LV wall. A transmural flow gradient was observed for both support modes, with better maintained subepicardial than midmyocardial and subendocardial perfusion. |
19,995 | Restitution characteristics of His bundle and working myocardium in isolated rabbit hearts. | The Purkinje system (PS) and the His bundle have been recently implicated as an important driver of the rapid activation rate after 1-2 minutes of ventricular fibrillation (VF). It is unknown whether activations during VF propagate through the His-Purkinje system to other portions of the the working myocardium (WM). Little is known about restitution characteristic differences between the His bundle and working myocardium at short cycle lengths. In this study, rabbit hearts (n = 9) were isolated, Langendorff-perfused, and electromechanically uncoupled with blebbistatin (10 μM). Pacing pulses were delivered directly to the His bundle. By using standard glass microelectrodes, action potentials duration (APD) from the His bundle and WM were obtained simultaneously over a wide range of stimulation cycle lengths (CL). The global F-test indicated that the two restitution curves of the His bundle and the WM are statistically significantly different (P<0.05). Also, the APD of the His bundle was significantly shorter than that of WM throughout the whole pacing course (P<0.001). The CL at which alternans developed in the His bundle vs. the WM were shorter for the His bundle (134.2±13.1ms vs. 148.3±13.3ms, P<0.01) and 2:1 block developed at a shorter CL in the His bundle than in WM (130.0±10.0 vs. 145.6±14.2ms, P<0.01). The His bundle APD was significantly shorter than that of WM under both slow and rapid pacing rates, which suggest that there may be an excitable gap during VF and that the His bundle may conduct wavefronts from one bundle branch to the other at short cycle lengths and during VF. |
19,996 | CMR assessment and clinical outcomes of hypertrophic cardiomyopathy with or without ventricular remodeling in the end-stage phase. | End-stage phase of hypertrophic cardiomyopathy (ES-HCM) is a recognized part of HCM disease spectrum. Information on cardiac magnetic resonance (CMR) studies for ES-HCM especially for those without ventricular remodeling has been limited. We aimed to evaluate the morpho-functional and tissue features of ES-HCM with or without ventricular remodeling and to explore CMR prognostic value in these patients. We analysed CMR scans of sixty-three ES-HCM patients and divided them into those with ventricular dilatation (D-ES, n = 41) and those with normal ventricular size (N-ES, n = 22). Cox proportional hazards models were used to assess the association between CMR parameters and outcomes. Patients in D-ES showed hypokinetic-dilated HCM phenotype, while patients in N-ES showed hypokinetic-restrictive HCM phenotype. LGE extent was significantly larger in D-ES (34.7% ± 15.4% vs. 22.8% ± 7.7%; P < 0.01). Atrial fibrillation and edema of lower extremity were more common in N-ES (72.7 vs. 29.3% and 54.5 vs. 24.4%, respectively; P < 0.05). Log-rank test found no significant difference between 2 groups in combined end point of cardiovascular events (χ<sup>2</sup> = 0.66, P = 0.418). In multivariate analysis, LGE (HR 1.57-1.83 per 10% LGE increase, P < 0.01) and indexed left atrial volume (LAVI) (HR 1.14-1.21 per 20 mL/m<sup>2</sup> increase, P < 0.05) remained independently associated with combined end point when adjusted by other risk factors. The CMR features of HCM in end-stage span between two extremes. LGE is more extensive in those with ventricular remodeling and LAVI is larger in those with normal ventricular size. Both LGE and LAVI are significant predictors of poor outcomes. |
19,997 | [Ventricular arrhythmias : What has been confirmed in therapy?]. | Ventricular arrhythmias include a wide range of potentially benign single ventricular premature contractions to ventricular tachycardia and ventricular fibrillation with a risk for sudden cardiac death. The diagnosis of ventricular arrhythmia is made by 12-lead electrocardiogram, 24 h Holter monitoring, an external or implantable loop recorder, or during in-hospital monitoring. Especially the diagnosis of wide complex tachycardias is challenging in terms of differentiating between ventricular tachycardia and supraventricular tachycardia with aberrant atrioventricular conduction. After documentation of ventricular arrhythmias, diagnostic work-up with respect to structural or electrical cardiomyopathy is mandatory followed by risk stratification for sudden cardiac death. Therapeutic options for treatment of ventricular arrhythmias range from pharmacological therapy and interventional procedures such as catheter ablation and implantable devices. The current article provides an overview of the diagnosis of ventricular tachycardia and underlying cardiomyopathies. Furthermore, medical and interventional therapies are described. In addition, the indications for implantable and wearable defibrillators are presented. |
19,998 | Circular mapping catheter entrapment in mitral valve apparatus requiring emergency surgery: a rarely reported complication of pulmonary vein isolation procedure for atrial fibrillation. | Lasso catheter (Biosense Webster) is one of the most commonly employed circular mapping catheters during pulmonary vein isolation (PVI) procedure for atrial fibrillation (AF). Although this catheter has greatly facilitated arrhythmia mapping, it can be associated with serious complications. We report a case of a 59-year-old man who underwent PVI procedure for persistent AF. During the procedure, the Lasso catheter inadvertently slipped into the left ventricular cavity and entangled in the mitral valve apparatus. Various percutaneous manoeuvres to release the catheter were unsuccessful and the patient ultimately required emergency open heart surgery to remove the catheter and repair the valve. To the best of our knowledge, such a case has not previously been reported in the UK necessitating an immediate open heart surgery, avoiding replacement of the valve. |
19,999 | High-resolution three-dimensional late gadolinium-enhanced cardiac magnetic resonance imaging to identify the underlying substrate of ventricular arrhythmia. | Cardiac magnetic resonance (CMR) is recommended as a second-line method to diagnose ventricular arrhythmia (VA) substrate. We assessed the diagnostic yield of CMR including high-resolution late gadolinium-enhanced (LGE) imaging.</AbstractText>Consecutive patients with sustained ventricular tachycardia (VT), non-sustained VT (NSVT), or ventricular fibrillation/aborted sudden death (VF/SCD) underwent a non-CMR diagnostic workup according to current guidelines, and CMR including LGE imaging with both a conventional breath-held and a free-breathing method enabling higher spatial resolution (HR-LGE). The diagnostic yield of CMR was compared with the non-CMR workup, including the incremental value of HR-LGE. A total of 157 patients were enrolled [age 54 ± 17 years; 75% males; 88 (56%) sustained VT, 52 (33%) NSVT, 17 (11%) VF/SCD]. Of these, 112 (71%) patients had no history of structural heart disease (SHD). All patients underwent electrocardiography and echocardiography, 72% coronary angiography, and 51% exercise testing. Pre-CMR diagnoses were 84 (54%) no SHD, 39 (25%) ischaemic cardiomyopathy (ICM), 11 (7%) non-ischaemic cardiomyopathy (NICM), 3 (2%) arrhythmogenic right ventricular cardiomyopathy (ARVC), 2 (1%) hypertrophic cardiomyopathy (HCM), and 18 (11%) other. CMR modified these diagnoses in 48 patients (31% of all and 43% of those with no SHD history). New diagnoses were 9 ICM, 28 NICM, 8 ARVC, 1 HCM, and 2 other. CMR modified therapy in 19 (12%) patients. In patients with no SHD after non-CMR tests, SHD was found in 32 of 84 (38%) patients. Eighteen of these patients showed positive HR-LGE and negative conventional LGE. Thus, HR-LGE significantly increased the CMR detection of SHD (17-38%, P < 0.001).</AbstractText>CMR including HR-LGE imaging has high diagnostic value in patients with VAs. This has major prognostic and therapeutic implications, particularly in patients with negative pre-CMR workup.</AbstractText> |
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