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20,000 | Changes in paced signals may predict in-hospital cardiac arrest. | An increasing number of patients with chronic illnesses have implanted cardiac rhythm devices such as pacemakers and implantable cardioverter-defibrillators (ICDs). This study was conducted to identify potentially useful predictors of in-hospital cardiac arrest (I-HCA) within paced electrocardiogram (ECG) signals from cardiovascular patients with implanted medical devices.</AbstractText>In this retrospective study of 17 subjects, full-disclosure ECG traces prior to the time of documented I-HCA were analyzed to determine R-R intervals and QRS durations (QRSd).</AbstractText>Ventricular paced QRSd prolongation was observed prior to I-HCA in 10/16 (63%) subjects. QRSd was significantly greater immediately preceding cardiac arrest than during each of the 8 hours prior to cardiac arrest (P < 0.05). Heart rate changes (measured using standard deviation) within 15 minutes of cardiac arrest were significantly greater in subjects with pulseless electrical activity (PEA)/asystolic arrest compared to those with cardiac arrests due to ventricular tachycardia/ventricular fibrillation (VT/VF) (10.13 vs 3.31; P  =  0.024). Significant differences over the 8 hours preceding cardiac arrest in heart rate (74 vs 86 beats/min; P  =  0.002) and QRS duration (172 ms vs 137 ms; P < 0.001) were observed between subjects with initial rhythms of VT/VF and those with initial rhythms of PEA/asystole.</AbstractText>Patterns of diagnostic ECG features can be extracted from the telemetry data of patients with implanted medical devices prior to adverse events including I-HCA. The detection of these significant changes might have an immediate prognostic impact on the timely treatment of some patients at risk of adverse events.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,001 | Arrhythmia Evaluation in Wearable ECG Devices. | This study evaluates four databases from PhysioNet: The American Heart Association database (AHADB), Creighton University Ventricular Tachyarrhythmia database (CUDB), MIT-BIH Arrhythmia database (MITDB), and MIT-BIH Noise Stress Test database (NSTDB). The ANSI/AAMI EC57:2012 is used for the evaluation of the algorithms for the supraventricular ectopic beat (SVEB), ventricular ectopic beat (VEB), atrial fibrillation (AF), and ventricular fibrillation (VF) via the evaluation of the sensitivity, positive predictivity and false positive rate. Sample entropy, fast Fourier transform (FFT), and multilayer perceptron neural network with backpropagation training algorithm are selected for the integrated detection algorithms. For this study, the result for SVEB has some improvements compared to a previous study that also utilized ANSI/AAMI EC57. In further, VEB sensitivity and positive predictivity gross evaluations have greater than 80%, except for the positive predictivity of the NSTDB database. For AF gross evaluation of MITDB database, the results show very good classification, excluding the episode sensitivity. In advanced, for VF gross evaluation, the episode sensitivity and positive predictivity for the AHADB, MITDB, and CUDB, have greater than 80%, except for MITDB episode positive predictivity, which is 75%. The achieved results show that the proposed integrated SVEB, VEB, AF, and VF detection algorithm has an accurate classification according to ANSI/AAMI EC57:2012. In conclusion, the proposed integrated detection algorithm can achieve good accuracy in comparison with other previous studies. Furthermore, more advanced algorithms and hardware devices should be performed in future for arrhythmia detection and evaluation. |
20,002 | Syncope in a young man: Role of Purkinje fibres in idiopathic ventricular fibrillation. | A young man suffered cardiac arrests with polymorphic ventricular tachycardia (PVT) and ventricular fibrillation (VF) triggered by ventricular premature contractions (PVCs). The arrhythmia was resistant to anti-arrhythmics, so after ICD implantation he underwent successful ablation of the triggering VE beat, which was pace-mapped to the left posterior hemi-fascicle. We review the evidence for the role of the Purkinje network in the initiation and maintenance of PVT and VF, postulating a channelopathy as a possible underlying cause, and provide recommendations for PVC ablation. |
20,003 | Ventricular dyssynchrony as a marker of latent carditis in children with acute rheumatic fever: A tissue Doppler imaging. | We aimed to investigate the hypothesis that the presence of left ventricular (LV) dyssynchrony in children with acute rheumatic fever (ARF) children may be a predictor of latent rheumatic carditis.</AbstractText>Eighty-nine children with ARF and 45 healthy control children were included the study. LV dyssynchrony was investigated by color-coded tissue Doppler imaging.</AbstractText>LV dyssynchrony parameters including Ts-SD-12, Ts-12, Ts-SD-6, and Ts-6 were found to be prolonged in children with ARF than in controls (P < .001). We found that 45.2% in children with ARF without carditis had LV dyssynchrony (Ts-SD-12 ≥ 34.4 ms), while 63.4% in children with ARF with carditis had LV dyssynchrony. Follow-up analysis demonstrated that children with arthritis and without dyssynchrony had no adverse events (recurrent rheumatic activity, development of valvular diseases; heart failure and atrial fibrillation), while those with LV dyssynchrony had events rate of 40.9% (P < .001). Likewise, children with carditis had event rates of 63.4%. Ts-SD-12 was found to be correlated with hs-CRP (r = .63; P < .001). Receiver-operating characteristic (ROC) curve analysis showed that a Ts-SD-12 ≥ 36.5 was the optimal cutoff value in predicting unfavorable outcome in patients with ARF, with a sensitivity of 95% and specificity of 82%.</AbstractText>We found that children with ARF without any evidence of carditis had a significant LV systolic dyssynchrony spite of normal EF. LV dyssynchrony in those children had a significant event rates on follow-up. These results highlighted the incremental value of LV dyssynchrony as a marker of subclinical carditis in children with ARF.</AbstractText>© 2017, Wiley Periodicals, Inc.</CopyrightInformation> |
20,004 | Estimating risk of adverse cardiac event after vascular surgery using currently available online calculators. | The decision to proceed with vascular surgical interventions requires evaluation of cardiac risk. Recently, several online risk calculators were created to predict outcomes and to lead to a more informed conversation between surgeons and patients. The objective of this study was to compare and further validate these online calculators with actual adverse cardiac outcomes at a single institution.</AbstractText>All patients from January 2011 through December 2015 undergoing carotid endarterectomy (CEA), infrainguinal lower extremity bypass, open abdominal aortic aneurysm (AAA) repair, and endovascular aneurysm repair (EVAR) on the vascular surgical service were included using the Society for Vascular Surgery Vascular Quality Initiative database at our health system. Additional information was collected through retrospective chart review. Each patient was entered through three online risk calculators: (1) the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) estimates the risk of cardiac arrest and myocardial infarction (MI); (2) the Revised Cardiac Risk Index (RCRI) estimates risk of MI, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block; and (3) the Vascular Study Group of New England (VSGNE) Cardiac Risk Index estimates risk of postoperative MI only. Observed adverse cardiac events (ACEs) were compared with expected values for each calculator using a χ2</sup> goodness-of-fit test. Institutional Review Board exemption was obtained.</AbstractText>A total of 856 cases were included: 350 CEAs, 210 infrainguinal bypasses, 77 open AAA repairs, and 219 EVARs. For CEA, no risk calculator showed statistically significant variation from the observed values (NSQIP, P = .45; RCRI, P = .17; VSGNE, P = .24). For infrainguinal bypass, NSQIP slightly underpredicted adverse events (P = .054), RCRI strongly underpredicted (P = .002), and VSGNE showed no difference (P = .42). For open AAA repair, NSQIP (P = .51) and VSGNE (P = .98) were adequate predictors, but RCRI strongly underpredicted the adverse events (P ≤ .0001). Finally, EVAR cardiac outcomes showed greater adverse events than predicted by all three calculators (NSQIP, P = .02; RCRI, P = .0002; and VSGNE, P = .025). Pooled data for the entire group documented that the VSGNE proved an accurate tool for prediction (P = .34), whereas ACEs were underpredicted by NSQIP (P = .0055) and RCRI (P ≤ .001).</AbstractText>Although online cardiac risk calculators of adverse surgical events are easy to use and to reference in broad surgical decision-making, there is significant variability in their predictability at the procedure and institutional level. Our data suggest that ACEs often occur at a higher rate than expected on the basis of calculated risks profiles, thus creating a platform for future discussion about preoperative evaluation and postoperative care decision-making models.</AbstractText>Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,005 | Amiodarone-induced pulmonary toxicity. | Amiodarone is widely used to prevent ventricular and supraventricular dysrhythmias but has a number of toxicities. One of the most devastating adverse reactions to this drug is pulmonary toxicity, which can present in a myriad of different ways. Toxicity is difficult to diagnose because many of its features also are seen in nontoxic patients. This article reviews the pathophysiology, presentation, diagnosis, and treatment of amiodarone-induced pulmonary toxicity. |
20,006 | Outcome after cardiopulmonary resuscitation in patients with congenital heart disease. | Outcome after cardiopulmonary resuscitation (CPR) in patients with underlying congenital heart disease is uncertain. This study aimed at evaluating outcome after CPR in patients with underlying congenital heart disease, factors related to worse outcome after CPR and whether survivors of sudden cardiac death (SCD) have a worse outcome when compared to an age, gender and disease-matched control population.</AbstractText>Between 1984 and 2015, all patients with congenital heart disease who received in or out-of-hospital CPR were identified from the database of congenital heart disease from the University Hospitals Leuven. Postoperative and neonatal (<6 months of age) CPR was excluded. For each survivor of SCD, two control patients matched for gender, age and underlying heart defect were included in the study.</AbstractText>Thirty-eight patients (66% men; median age 25 years (interquartile range 9-40); 68% out-of-hospital) were identified, of which 27 (66%) survived the event. The main cause of SCD was ventricular tachycardia or fibrillation ( n=21). Heart defect complexity (odds ratio (OR) 5.1; 95% confidence interval (CI) 1.2-21.9; P=0.027), pulmonary hypertension (OR 13.8; 95% CI 2.1-89.5; P=0.006) and time to return of spontaneous circulation (OR 1.1; 95% CI 1.0-1.1; P=0.046) were related to worse outcome. Survivors of SCD had a worse prognosis when compared to an age, gender and disease-matched control group (5-year survival 76% vs. 98%; P=0.002).</AbstractText>The complexity of underlying heart defect, pulmonary hypertension and time to return of spontaneous circulation are related to worse outcome in the case of CPR. Survivors of SCD have a worse outcome when compared to matched controls, indicating the need for adequate implantable cardioverter defibrillator indication assessment and for stringent follow-up of patients with worsening haemodynamics.</AbstractText> |
20,007 | Long-term outcome of catheter ablation and other form of therapy for electrical storm in patients with implantable cardioverter-defibrillators. | Radiofrequency catheter ablation (RFCA) for electrical storm (ES) has become a widely used therapeutic method. Its effectiveness in comparison to other forms of ES treatment is however uncertain.</AbstractText>This single-centre retrospective study investigated the long-term clinical outcome after RFCA for ES and compared long-time effects of ablation to other forms of treatment. The study population consisted of 70 consecutive patients hospitalised between January 2010 and June 2015 due to ES. Patients were recruited for the study if the following criteria were fulfilled: first ES caused by ventricular tachycardia (VT) or ventricular fibrillation (VF), implanted cardioverter defibrillator or cardiac resynchronisation therapy device and left ventricular ejection fraction < 50%. The follow-up data on VT/ES recurrence was obtained from pacemaker/implanted cardioverter defibrillator memory. Data on all-cause mortality was collected during outpatient visits or by telephone contact.</AbstractText>Of the 70 patients enrolled, 28 (40%) were treated with RFCA (group A) and 42 (60%) received other forms of treatment for ES (group B). During a mean (±SD) 864 (629) days of follow-up, death occurred in 4 (14.3%) patients in the ablation group and in 16 (38.1%) patients treated with other methods [p = 0.03]. There was no significant between-group difference in VT/VF and ES recurrence. Statistical analysis revealed that the presence of cardiac resynchronisation therapy device during ES, stroke and/or transient ischaemic attack and lower baseline hematocrit level were the multivariate predictors of all-cause mortality.</AbstractText>In patients treated with RFCA for ES, all-cause mortality was significantly lower compared to the group treated with other methods.</AbstractText> |
20,008 | Paradoxical embolism: Experiences from a single center. | To present our treatment experiences and the follow-up data of patients with paradoxical embolism (PDE).</AbstractText>The clinical characteristics, management, and follow-up data of all included patients who were diagnosed with PDE at Fuwai Hospital from January 1994 to October 2015 were recorded.</AbstractText>Twelve patients were included; all had a pulmonary embolism, and 8 had deep venous thrombosis. The artery embolisms involved the cerebral artery (7 patients), renal artery (2 patients), mesentery artery (2 patients), popliteal artery (1 patient), descending aorta thrombus (1 patient), and thrombus-straddled patent foramen ovale (PFO) (1 patient). PFO was found in 3 cases. One patient underwent thrombectomy and PFO closure; Six patients received thrombolysis; and 3 patients were implanted with a vena cava filter. Long-term anticoagulation with warfarin was recommended for each patient. One patient died from ventricular fibrillation despite cardiopulmonary resuscitation. Eleven patients were discharged with improvements. No late mortality occurred in 8 patients with a complete follow-up of 10.6-17.7 years. One had a recurrent deep venous thrombosis. No patient had a recurrent pulmonary or arterial embolism. Two patients changed their treatment from warfarin to aspirin; others remained on warfarin. Only 1 case had an occasional gum bleeding.</AbstractText>PDE treatment including thrombolysis, anticoagulation, and embolectomy should be individualized. We recommend long-term anticoagulation therapy to prevent the recurrence of PDE, especially to those with an intracardiac communication or persistent risk factors for re-thrombosis.</AbstractText> |
20,009 | Metabolic disturbances induce malignant heart arrhythmias in rats. | Metabolic disturbances are considered to condition the occurrence of malignant heart arrhythmias and negatively influence the chances of a patient to survive. To test this assumption, a model of metabolic syndrome was selected in which rats were receiving a diet resembling that of the westernized population.</AbstractText>Metabolic syndrome is a comorbidity of major cardiovascular risk factors (dyslipidemia, hypertension, impaired glucose tolerance or insulin resistance, diabetes mellitus, and obesity), all facilitating cardiovascular complications leading to morbidity and mortality of patients.</AbstractText>Hearts were isolated and perfused according to Langendorff. Global ischemia was induced in the hearts and arrhythmia occurrence in reperfusion was monitored. All hearts were stimulated with the electro-cardio-stimulator to test the electrical inducibility of heart arrhythmia.</AbstractText>Isolated hearts from rats with the metabolic syndrome were more susceptible to ventricular arrhythmias. The high-fat diet increased the occurrence of malignant heart arrhythmias in rats with metabolic syndrome to an even greater extent. All subjects with metabolic syndrome were sensitive to ventricular tachyarrhythmia with significantly decreased threshold to its induction in cardio-stimulation.</AbstractText>These results indicate that metabolic syndrome patients may be more sensitive to the occurrence of malignant heart arrhythmias following myocardial infarction or other heart diseases (Tab. 1, Fig. 2, Ref. 34).</AbstractText> |
20,010 | An autonomous medical monitoring system: Validation on arrhythmia detection. | In this paper, we present a generic platform for autonomous medical monitoring and diagnostics. We validated the platform in the context of arrhythmia detection with publicly available databases. The big advantage of this platform is its capacity to deal with various types of physiological signals. Many pre-processing steps are performed to bring the input information into a uniform state that will be explored by a machine learning algorithm. Since this block plays a crucial role in the entire processing pipeline, three different methods were evaluated for detection and classification of anomalies. The results presented in this work are validated on cardiac beats, where the highest accuracy was obtained on the classification of normal beats (94%). On the other hand, atrial fibrillation and premature ventricular contraction beats were classified with an accuracy of 78%. |
20,011 | Cardiac safety profile for Random Complex Waveforms. | A rigorous method for assessing the Ventricular Fibrillation (VF) risk of a Random Complex Waveform (RCW) has not been previously available. Real-life hazardous events motivated us to develop such method. An RCW is observable and recordable. It consists of multiple different components randomly added one to the other. Assessment for VF risk exists for non-random waveforms, particularly VF thresholds for 50/60 Hz alternating currents, but not for RCWs.</AbstractText>We developed a method which considers exposure to a segment of an RCW. It transforms complex segment exposure to values which can be compared with AC root-mean-square (rms) magnitude/duration curves, for determination of VF risk. Human contact could occur for any given time duration within the segment. The current of most risk is the greatest found for all possible instances of that duration. This is termed the "Probable Current" (PC) for that duration. All possible exposure durations in the waveform segment are considered, giving a set of PCs, thus allowing the plotting of a PC curve. The PC set is compared with a criterion for VF risk, termed the Justified Current (JC) curve.</AbstractText>The theory is presented. Demonstrations and examples are given. Code is shown for generating the PC curve.</AbstractText>VF risk can be found for an RCW using the rigorous algorithm presented.</AbstractText>The VF for RCWs has not been considered previously. A rigorous statement of a method for VF risk assessment allows extension from regular waveforms to RCWs.</AbstractText> |
20,012 | New conducted electrical weapons: Finite element modeling of safety margins. | Introduction-We have previously published on the ventricular fibrillation (VF) risk with TASER<sup>®</sup> X26 conducted electrical weapon (CEW). Our risk model accounted for realistic body mass index distributions, modeled the effects of partial or oblique dart penetration, and used epidemiological CEW statistics. As new CEWs have become available to law enforcement, their cardiac safety profile was not quantified. Therefore, we applied our VF probability model to evaluate their cardiac risk. Methods and Results-An eXperimental Rotating-Field (XRF) waveform CEW and the X2 CEW are new 2-shot electrical weapon models designed to target a precise amount of delivered charge per pulse, 64 μC and 62 μC, respectively. They can deploy 1 or 2 probe pairs, delivered by 2 separate cartridges. New Smart Probes (SP), which carry 11.5 mm long CEW darts, can be used with XRF and X2 CEWs. Finite element modeling (FEM) was used to approximate the current and charge densities produced by XRF and X2 CEWs in tissues located in the vicinity of darts, including accounting for the effects of fat, anisotropic skeletal muscles, sternum, ribs, and lungs. Using our previous cardiac risk probabilistic model, the new XRF and X2 CEWs operated with 11.5 mm SPs, had an estimated overall theoretical VF risk of less than 1 in 1 300 000 and 1 in 1 490 000 cases, respectively. We also found that the XRF and X2 CEWs had increased cardiac safety margins with respect to those previously reported for the X26 CEWs when all three CEW models were operated with 9 mm CEW darts. Lastly, the cardiac risk of these new CEWs (<; 0.76 ppm) was found to be much lower than reported levels of CEW non-cardiac fatal injuries (e.g. falls and burns, > 7.2 ppm). Conclusions-While not risk-free, the new TASER XRF and X2 CEWs offer increased cardiac safety margins and extremely low cardiac risk profiles. |
20,013 | Cardiac arrhythmia detection using photoplethysmography. | Cardiovascular Diseases (CVDs) cause a very large number of casualties around the world every year and cardiac arrhythmias contribute to significant proportion of CVD related deaths. Bedside cardiac activity monitors in hospitals are based on electrocardiogram (ECG) processing and are known to produce too many false alarms. Moving beyond bedside care, ECG is not very suitable for use in wearable devices. Photoplethysmography (PPG) on the other hand provides an inexpensive and more wearable device-friendly alternative. This work presents a technique to detect life threatening arrhythmias using only PPG waveforms. PhysioNet Challenge 2015 data is used to detect five types of arrhythmias namely, tachycardia, bradycardia, asystole, ventricular tachycardia and ventricular fibrillation. A novel technique is employed to assign pulse quality index to every PPG pulse and highest quality portion of the signal is used for detection. Results indicate that PPG provides a viable alternative for conventional ECG based detection. An overall true positive rate (TPR) of 93% was achieved with true negative rate (TNR) of 53.78% suggesting that PPG is a viable option for arrhythmia detection. |
20,014 | Efficacy and tolerability of mexiletine treatment in patients with recurrent ventricular tachyarrhythmias and implantable cardioverter-defibrillator shocks. | Antiarrhythmic treatment of patients with recurrent ventricular tachyarrhythmia, in whom catheter ablation and amiodarone treatment were ineffective or contraindicated, is an unsolved clinical problem.</AbstractText>The study aims to evaluate the efficacy and tolerability of mexiletine in patients with recurrent ventricular tachyarrhythmias and/or electrical storm events, in whom standard treatment strategies failed to prevent ventricular tachyarrhythmia.</AbstractText>We performed a retrospective cohort analysis of all patients treated with mexiletine for recurrent ventricular tachycardia and/or ventricular fibrillation in our institution between January 2011 and September 2015. The primary endpoints were total number of electrical storm events and ventricular tachycardia/ventricular fibrillation (VT/VF) episodes after the beginning of mexiletine therapy. Secondary endpoints were total number of implantable cardioverter-defibrillator (ICD) therapies and discontinuation of the therapy. Events were compared with a matched duration period before initiating mexiletine. Patients served as self-controls.</AbstractText>Seventeen patients were included in the study; 11 patients were males. Mean age was 64.2 ± 15.4 years. The median time of mexiletine treatment was eight months (interquartile range [IR]: 1-22 months). The mexiletine dose was 600 mg/day in 13 patients and 400 mg/day in four patients. In four patients the dose was modified during treatment in a range from 400 to 600 mg/day depending on clinical decision. Treatment with mexiletine significantly reduced the number of electrical storm events (14 episodes vs. two episodes; median and IR for 17 patients: 1 [0-1] vs. 0 [0-0], p = 0.0010), VT/VF episodes (285 vs. 74 episodes; median and IR for 17 patients: 7 [5-27] vs. 0 [0-5], p = 0.0115), and ICD interventions (317 interven-tions vs. nine interventions; median and IR for 17 patients: 10 [5-25] vs. 0 [0-2], p = 0.0006), in comparison with a matched period before initiation of treatment. In 14 out of 17 patients (82%) sufficient tolerability of mexiletine was observed. Only in three (18%) patients severe side effects of mexiletine treatment occurred requiring discontinuation of therapy.</AbstractText>Mexiletine was a sufficiently tolerated antiarrhythmic drug in short-term treatment of ventricular tachyarrhyth-mias in the studied population. Mexiletine may be effective in the treatment of recurring ventricular tachyarrhythmias or electrical storm events.</AbstractText> |
20,015 | Relationship Between Left Ventricle Position and Haemodynamic Parameters During Cardiopulmonary Resuscitation in a Pig Model. | From the viewpoint of cardiac pump theory, the area of the left ventricle (LV) subjected to compression increases as the LV lies closer to the sternum, possibly resulting in higher blood flow in patients with LV closer to the sternum. However, no study has evaluated LV position during cardiac arrest or its relationship with haemodynamic parameters during cardiopulmonary resuscitation (CPR). The objectives of this study were to determine whether the position of the LV relative to the anterior-posterior axis representing the direction of chest compression shifts during cardiac arrest and to examine the relationship between LV position and haemodynamic parameters during CPR.</AbstractText>Subcostal view echocardiograms were obtained from 15 pigs with the transducer parallel to the long axis of the sternum before inducing ventricular fibrillation (VF) and during cardiac arrest. Computed tomography was performed in three pigs to objectively observe LV position during cardiac arrest. LV position parameters including the shortest distance between the anterior-posterior axis and the mid-point of the LV chamber (DAP-MidLV</sub>), the shortest distance between the anterior-posterior axis and the LV apex (DAP-Apex</sub>), and the area fraction of the LV located on the right side of the anterior-posterior axis (LVARight</sub>/LVATotal</sub>) were measured.</AbstractText>DAP-MidLV</sub>, DAP-Apex</sub>, and LVARight</sub>/LVATotal</sub> decreased progressively during untreated VF and basic life support (BLS), and then increased during advanced cardiovascular life support (ACLS). A repeated measures analysis of variance revealed significant time effects for these parameters. During BLS, the end-tidal carbon dioxide and systolic right atrial pressure were significantly correlated with the LV position parameters. During ACLS, systolic arterial pressure and systolic right atrial pressure were significantly correlated with DAP-MidLV</sub> and DAP-Apex</sub>.</AbstractText>Left ventricular position changed significantly during cardiac arrest compared to the pre-arrest baseline. LV position during CPR had significant correlations with haemodynamic parameters.</AbstractText>Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,016 | Functional Tricuspid Regurgitation After Transcatheter Closure of Atrial Septal Defect in Adult Patients: Long-Term Follow-Up. | This study aimed to assess the fate of tricuspid regurgitation (TR) after transcatheter atrial septal defect (ASD) closure.</AbstractText>Although TR frequently occurs in patients with ASD, the change in TR during long-term follow-up after ASD closure remains unknown.</AbstractText>A total of 419 adult patients who underwent transcatheter ASD closure were enrolled. TR severity was graded by TR jet area on echocardiography.</AbstractText>At baseline, 113 patients had severe/moderate TR and 306 patients had mild TR. Among the 113 patients with severe/moderate TR, the TR jet area significantly decreased during a median follow-up of 30 months after the procedure; this decrease was related to the improvement in right ventricular morphology. The severity of TR decreased to mild in 79 (70%) patients. Persistent TR, defined as severe or moderate TR after the procedure, was independently associated with the prevalence of permanent atrial fibrillation. Regarding clinical outcomes, 7 patients with severe/moderate TR and 2 with mild TR were hospitalized because of heart failure. Patients with severe/moderate TR had the worse event-free survival rate than those with mild TR, but more than 90% of them had no cardiovascular events. New York Heart Association functional class and plasma B-type natriuretic peptide levels improved in patients with severe/moderate TR, similar to those with mild TR.</AbstractText>Significant TR decreased during the long-term follow-up period after transcatheter ASD closure. Heart failure symptoms improved in patients with severe/moderate TR. Our findings suggest that transcatheter closure alone can be valuable in patients with ASD complicated with TR.</AbstractText>Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,017 | Achieving ventricular rate control in patients taking chronic beta-blocker therapy. | The objective of this study is to evaluate the difference in response to ventricular rate control with intravenous (IV) metoprolol compared to IV diltiazem in patients taking chronic beta-blocker therapy who present to the emergency department (ED) in atrial fibrillation (AF) with rapid ventricular rate (RVR).</AbstractText>This was a single-center, retrospective study of adult patients taking chronic oral metoprolol. Chronic metoprolol therapy was defined as patients prescribed and taking oral metoprolol within 5days of study inclusion. Rate control was defined as either a decrease in ventricular rate<100bpm or <120bpm if the decrease was at least 20% from the presenting heart rate.</AbstractText>A total of 332 patients were included, with 16 patients in the IV diltiazem group and 316 patients in the IV metoprolol group. In the diltiazem arm, 68.8% of patients achieved successful rate control compared to 42.4% of patients in the metoprolol group (p=0.067). Treatment with IV metoprolol resulted in more hospital admissions (58% vs. 6.25% with diltiazem, p<0.001). Treatment with diltiazem was associated with a greater incidence of bradycardia compared to IV metoprolol (13% vs. 0%, p=0.002).</AbstractText>The use of IV diltiazem was associated with a higher rate of successful response to rate control compared to IV metoprolol in patients in AF with RVR on chronic beta-blocker therapy, however the difference between groups was not statistically significant.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,018 | Incremental Prognostic Utility of Left Ventricular Global Longitudinal Strain in Hypertrophic Obstructive Cardiomyopathy Patients and Preserved Left Ventricular Ejection Fraction. | In obstructive hypertrophic cardiomyopathy patients with preserved left ventricular (LV) ejection fraction, we sought to determine whether LV global longitudinal strain (LV-GLS) provided incremental prognostic utility.</AbstractText>We studied 1019 patients with documented hypertrophic cardiomyopathy (mean age, 50±12 years; 63% men) evaluated at our center between 2001 and 2011. We excluded age <18 years, maximal LV outflow tract gradient <30 mm Hg, bundle branch block or atrial fibrillation, past pacemaker/cardiac surgery, including myectomy/alcohol ablation, and obstructive coronary artery disease. Average resting LV-GLS was measured offline on 2-, 3-, 4-chamber views using Velocity Vector Imaging (Siemens, Malvern, PA). Outcome was a composite of cardiac death and appropriate internal defibrillator (implantable cardioverter defibrillator) discharge. Maximal LV thickness, LV ejection fraction, indexed left atrial dimension, rest and maximal LV outflow tract gradient, and LV-GLS were 2.0±0.2 cm, 62±4%, 2.2±4 cm/m2</sup>, 52±42 mm Hg, 103±36 mm Hg, and -13.6±4%. During 9.4±3 years of follow-up, 668 (66%), 166 (16%), and 122 (20%), respectively, had myectomy, atrial fibrillation, and implantable cardioverter defibrillator implantation, whereas 69 (7%) had composite events (62 cardiac deaths). Multivariable competing risk regression analysis revealed that higher age (subhazard ratio, 1.04 [1.02-1.07]), AF during follow-up (subhazard ratio, 1.39 [1.11-1.69]), and worsening LV-GLS (subhazard ratio, 1.11 [1.05-1.22]) were associated with worse outcomes, whereas myectomy (subhazard ratio, 0.44 [0.25-0.72]) was associated with improved outcomes (all P</i><0.01). Sixty-one percent of events occurred in patients with LV-GLS worse than median (-13.7%).</AbstractText>In obstructive hypertrophic cardiomyopathy patients with preserved LV ejection fraction, abnormal LV-GLS was independently associated with higher events, whereas myectomy was associated with improved outcomes.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,019 | Electroceuticals in medicine - The brave new future. | Electroceuticals are a new category of therapeutic agents which act by targeting the neural circuits of organs. The therapy involves mapping the neural circuitry and delivering neural impulses to these specific targets. The impulse is administered via an implantable device. In cardiology besides pacemaker, defibrillation and resynchronization applications it could have usefulness in heart failure, atrial fibrillation, coronary artery disease, myocarditis, resistant hypertension, atrial and ventricular tachyarrhythmias, pulseless electrical activity, and refractory angina. |
20,020 | Electrocardiographic features: Various atrial site pacing. | Atrial pacing is done for either symptomatic sinus node dysfunction (SND) or for maintenance of atrio-ventricular synchrony in a dual chamber pacemaker. Conventionally, atrial lead is placed in the right atrial appendage. Atrial conduction disorder in patients with permanent pacing results in higher incidence of atrial fibrillation. Atrial septal pacing has emerged as a solution to this problem. So, it is extremely important to understand the different features of paced P wave from various atrial pacing sites. Conventional right atrial appendage pacing in presence of atrial conduction disorder results in marked latency with prolonged P wave duration with reduced amplitude. The morphology is similar to sinus rhythm. Atrial septal pacing causes short and sharp P wave with negative polarity in inferior leads and positive polarity in lead V1 in lower septal pacing, whereas positive polarity in inferior leads and negative polarity in lead V1 during pacing from upper septum. |
20,021 | Brugada syndrome is associated with scar and endocardial involvement: Insights from high-density mapping with the Rhythmia™ mapping system. | The authors report the first catheter ablation of Brugada syndrome in the literature using the Rhythmia™ mapping system. Learning points include: (1) low voltage areas can be documented while mapping in some individuals, suggesting that Brugada syndrome may not be a pure ion channel disorder; (2) typical long fractionated potentials can also be identified in the endocardium, supporting the need to map the endocardium in all Brugada patients requiring ablation; (3) disappearance of the typical coved pattern following ablation does not necessarily predict cure, as the patient we present experienced ventricular fibrillation recurrence a few months later. |
20,022 | [Epidemiology of early repolarization pattern in Maghreb]. | An early repolarization variant (ERV) in inferolateral leads has recently been associated with vulnerability to ventricular fibrillation. These studies have been conducted in the occidental countries. The prevalence of ERV in the population of the Maghreb is unknown. The aim of this study was to evaluate the prevalence and risk factors of ERV in a young population from Algeria.</AbstractText>We assessed the prevalence of ERV within a population of 441 healthy subjects (mean age 25 years) using 12-lead electrocardiography. ERV was stratified by three independent cardiologists according to the J-point elevation (≥0.1mV) in the inferior, apicolateral or both leads with QRS slurring or notching.</AbstractText>The inferolateral ERV pattern was present in 55 subjects (12.4%). A malign ERV (>2mm) was present in 5 subjects (9% of ER) and ER in inferior and lateral leads in 40% of ER. An ERV pattern was more frequently associated with young age, male, bradycardia and T wave in V1 lead.</AbstractText>An ERV is a common finding in a healthy Algerian young population. This prevalence seems to be more important than other studies due to young age and not to a racial difference. Our population were more at risk that other studies, and we found more T waves in V1 lead in this people, due to an ethnic particularities or a phenotypic association with the Brugada syndrome.</AbstractText>Copyright © 2017 Elsevier Masson SAS. All rights reserved.</CopyrightInformation> |
20,023 | Ventricular fibrillation due to overdose of loperamide, the "poor man's methadone". | Loperamide is an over-the-counter antidiarrheal agent that is considered by many patients to be safe, but has been used as a drug of abuse due to its opioid properties. However, cardiotoxicity has been reported, prompting the FDA to release a warning regarding the arrhythmogenic potential of loperamide. We present a case of a 38-year-old female presenting with cardiac arrest thought to be secondary to abuse of the loperamide that she was using to alleviate the heroin withdrawal symptoms. Cardiac ischemia and other drug toxicities were ruled out. Loperamide induces QTc prolongation and cardiac dysrhythmias. She had recurrent ventricular arrhythmias with multiple cardiac arrests. The persistence of the cardiotoxicity for a longer duration than previously reported in the literature is unique in this clinical presentation. We also highlight the potential mechanisms for loperamide cardiotoxicity and its challenging management. <b>Abbreviations:</b> ACLS: Advanced cardiac life support; GI: Gastrointestinal. |
20,024 | Computational Cardiac Modeling Reveals Mechanisms of Ventricular Arrhythmogenesis in Long QT Syndrome Type 8: <i>CACNA1C</i> R858H Mutation Linked to Ventricular Fibrillation. | Functional analysis of the L-type calcium channel has shown that the <i>CACNA1C</i> R858H mutation associated with severe QT interval prolongation may lead to ventricular fibrillation (VF). This study investigated multiple potential mechanisms by which the <i>CACNA1C</i> R858H mutation facilitates and perpetuates VF. The Ten Tusscher-Panfilov (TP06) human ventricular cell models incorporating the experimental data on the kinetic properties of L-type calcium channels were integrated into one-dimensional (1D) fiber, 2D sheet, and 3D ventricular models to investigate the pro-arrhythmic effects of <i>CACNA1C</i> mutations by quantifying changes in intracellular calcium handling, action potential profiles, action potential duration restitution (APDR) curves, dispersion of repolarization (DOR), QT interval and spiral wave dynamics. R858H "mutant" L-type calcium current (<i>I</i><sub><i>CaL</i></sub> ) augmented sarcoplasmic reticulum calcium content, leading to the development of afterdepolarizations at the single cell level and focal activities at the tissue level. It also produced inhomogeneous APD prolongation, causing QT prolongation and repolarization dispersion amplification, rendering R858H "mutant" tissue more vulnerable to the induction of reentry compared with other conditions. In conclusion, altered <i>I</i><sub><i>CaL</i></sub> due to the <i>CACNA1C</i> R858H mutation increases arrhythmia risk due to afterdepolarizations and increased tissue vulnerability to unidirectional conduction block. However, the observed reentry is not due to afterdepolarizations (not present in our model), but rather to a novel blocking mechanism. |
20,025 | The Prognostic Implications of Two-Dimensional Speckle Tracking Echocardiography in Hypertrophic Cardiomyopathy: Current and Future Perspectives. | Two-dimensional speckle tracking echocardiography represents a novel, simple, and reproducible technique for the estimation of left ventricular myocardial deformation (strain) and the evaluation of left ventricular twist mechanics. During the last few years, its clinical and prognostic implications in cardiomyopathies and hypertrophic cardiomyopathy (HCM), in particular, have been rapidly increasing. Reduced global longitudinal strain is associated with more severe disease and confers an increased risk for major cardiac events, independently of other clinical and echocardiographic risk factors. Left ventricular dyssynchrony also seems promising as a risk factor for sudden cardiac events. With respect to left atrial mechanics, left atrial reservoir, conduit, and contractile strain may also confer an increased prognostic value for atrial fibrillation, major cardiac events, and even sudden death. Although right ventricular global longitudinal strain is impaired in HCM compared with healthy controls and individuals with physiological hypertrophy, its prognostic significance is currently unknown. Conclusively, 2-dimensional speckle tracking imaging seems promising for HCM. However, future studies are needed to incorporate this new imaging technique in the standard evaluation of an HCM individual. |
20,026 | Low Prevalence of Inappropriate Shocks in Patients With Inherited Arrhythmia Syndromes With the Subcutaneous Implantable Defibrillator Single Center Experience and Long-Term Follow-Up. | Up to 40% of patients with transvenous implantable cardioverter-defibrillator (ICD) experience lead-associated complications and may suffer from high complication rates when lead extraction is indicated. Subcutaneous ICD may represent a feasible alternative; however, the efficacy of the subcutaneous ICD in the detection and treatment of ventricular arrhythmias in patients with hereditary arrhythmia syndromes has not been fully evaluated.</AbstractText>Patients with primary hereditary arrhythmia syndromes who fulfilled indication for defibrillator placement were eligible for enrollment. Between 2010 and 2016, 62 consecutive patients with primary hereditary arrhythmia syndromes, without indication for antibradycardia therapy, were enrolled in the study. Mean follow-up was 31.0±14.2 months. The study cohort comprised of 24 patients with Brugada syndrome, 17 with idiopathic ventricular fibrillation, 6 with long-QT syndrome, 1 with short-QT syndrome, 3 with catecholaminergic polymorphic ventricular tachycardia, 8 with hypertrophic cardiomyopathy, and 3 with arrhythmogenic right ventricular cardiomyopathy. Thirty-nine patients were implanted for secondary prevention. Twenty-two patients had a previous transvenous ICD implanted, but required revision because of infection or lead defects. A total of 20 spontaneous ventricular tachyarrhythmias requiring shock intervention occurred in 10 patients during follow-up. All episodes were terminated within the first ICD shock delivery with 80 J. Two patients had inappropriate therapies caused by oversensing following an uneventful implantation. No pocket-site infections and no premature revisions have occurred during follow-up.</AbstractText>Our study supports the use of the subcutaneous ICD for both secondary and primary prevention of sudden cardiac death as a reliable alternative to the conventional transvenous ICD.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,027 | Impact of Beta-Blockade on Cardiac Events in Patients with Chronic Severe Nonischemic Mitral Regurgitation. | The aim of this study was to examine the impact of beta-blockade on cardiac events among patients with initially asymptomatic chronic severe nonischemic mitral valve regurgitation (MR).</AbstractText>Data from 52 consecutive patients in our prospective natural history study of isolated chronic severe nonischemic MR were assessed post hoc over 19 years to examine the relation of chronic beta-blockade use to subsequent cardiac events (death or indications for mitral valve surgery, MVS). At entry, all patients were free of surgical indications; 9 received beta-blockers. Cardiac event rate differences were analyzed by Kaplan-Meier log rank comparison.</AbstractText>During follow-up, cardiac events included sudden death (1), heart failure (8), atrial fibrillation (6), left ventricular dimensions at systole ≥4.5 cm (11), left ventricular ejection fraction <60% (6), right ventricular ejection fraction <35% (2), and a combination of cardiac events (7). The cardiac event risk was 4-fold higher among patients receiving beta-blockers (average annual risk = 60.6%) versus those not receiving beta-blockers (average annual risk = 15.2%; p = 0.001). These effects remained statistically significant (p = 0.005) when analysis was adjusted for other baseline covariates.</AbstractText>Beta-blockade appears to confer an increased risk of sudden cardiac death or indications for MVS among patients with chronic severe nonischemic MR. Randomized trials are needed to confirm these findings.</AbstractText>© 2017 S. Karger AG, Basel.</CopyrightInformation> |
20,028 | Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for emergency cardiac support. | Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may provide benefit to patients in refractory cardiac arrest and cardiogenic shock. We aim to summarize our center's 6-year experience with resuscitative VA-ECMO.</AbstractText>A retrospective medical record review (April 2009 to 2015) was performed on consecutive non-cardiotomy patients who were managed with VA-ECMO due to refractory in- or out-of-hospital cardiac (IHCA/OHCA) arrest (E-CPR) or refractory cardiogenic shock (E-CS) with or without preceding cardiac arrest. Our primary outcome was survival to hospital discharge and good neurological status (Cerebral Performance Category 1-2).</AbstractText>There were a total of 22 patients who met inclusion criteria of whom 9 received E-CPR (8 IHCA, 1 OHCA) and 13 received E-CS. The median age for E-CPR patients was 52 [IQR 45, 58] years, and 54 [IQR 38, 64] years for E-CS patients. Cardiac arrest duration was 70.33 (SD 39.56) min for the E-CPR patients, and 24.67 (SD 26.73) min for the 9 patients treated with E-CS who had previously arrested. Initial cardiac arrest rhythms were pulseless electrical activity (39%), ventricular fibrillation (33%), or ventricular tachycardia (28%). A total of 18/22 patients were successfully weaned from VA-ECMO (78%); 16 patients survived to hospital discharge (73%) with 15 in good neurological condition.</AbstractText>The initiation of VA-ECMO at our center for treatment of refractory cardiac arrest and cardiogenic shock yielded a high proportion of survivors and favorable neurological outcomes.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,029 | Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials. | Recent guidelines recommend that patients with heart failure and left ventricular ejection fraction (LVEF) 40-49% should be managed similar to LVEF ≥ 50%. We investigated the effect of beta-blockers according to LVEF in double-blind, randomized, placebo-controlled trials.</AbstractText>Individual patient data meta-analysis of 11 trials, stratified by baseline LVEF and heart rhythm (Clinicaltrials.gov: NCT0083244; PROSPERO: CRD42014010012). Primary outcomes were all-cause mortality and cardiovascular death over 1.3 years median follow-up, with an intention-to-treat analysis. For 14 262 patients in sinus rhythm, median LVEF was 27% (interquartile range 21-33%), including 575 patients with LVEF 40-49% and 244 ≥ 50%. Beta-blockers reduced all-cause and cardiovascular mortality compared to placebo in sinus rhythm, an effect that was consistent across LVEF strata, except for those in the small subgroup with LVEF ≥ 50%. For LVEF 40-49%, death occurred in 21/292 [7.2%] randomized to beta-blockers compared to 35/283 [12.4%] with placebo; adjusted hazard ratio (HR) 0.59 [95% confidence interval (CI) 0.34-1.03]. Cardiovascular death occurred in 13/292 [4.5%] with beta-blockers and 26/283 [9.2%] with placebo; adjusted HR 0.48 (95% CI 0.24-0.97). Over a median of 1.0 years following randomization (n = 4601), LVEF increased with beta-blockers in all groups in sinus rhythm except LVEF ≥50%. For patients in atrial fibrillation at baseline (n = 3050), beta-blockers increased LVEF when < 50% at baseline, but did not improve prognosis.</AbstractText>Beta-blockers improve LVEF and prognosis for patients with heart failure in sinus rhythm with a reduced LVEF. The data are most robust for LVEF < 40%, but similar benefit was observed in the subgroup of patients with LVEF 40-49%.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
20,030 | Pathophysiological and therapeutic implications in patients with atrial fibrillation and heart failure. | Heart failure and atrial fibrillation are common and responsible for significant mortality of patients. Both share the same risk factors like hypertension, ischemic heart disease, diabetes, obesity, arteriosclerosis, and age. A variety of microscopic and macroscopic changes favor the genesis of atrial fibrillation in patients with preexisting heart failure, altered subcellular Ca<sup>2+</sup> homeostasis leading to increased cellular automaticity as well as concomitant fibrosis that are induced by pressure/volume overload and altered neurohumoral states. Atrial fibrillation itself promotes clinical deterioration of patients with preexisting heart failure as atrial contraction significantly contributes to ventricular filling. In addition, atrial fibrillation induced tachycardia can even further compromise ventricular function by inducing tachycardiomyopathy. Even though evidence has been provided that atrial functions significantly and independently of confounding ventricular pathologies, correlate with mortality of heart failure patients, rate and rhythm controls have been shown to be of equal effectiveness in improving mortality. Yet, it also has been shown that cohorts of patients with heart failure benefit from a rhythm control concept regarding symptom control and hospitalization. To date, amiodarone is the most feasible approach to restore sinus rhythm, yet its use is limited by its extensive side-effect profile. In addition, other therapies like catheter-based pulmonary vein isolation are of increasing importance. A wide range of heart failure-specific therapies are available with mixed impact on new onset or perpetuation of atrial fibrillation. This review highlights pathophysiological concepts and possible therapeutic approaches to treat patients with heart failure at risk for or with atrial fibrillation. |
20,031 | Left ventricular torsional parameters before and after atrial fibrillation ablation: a velocity vector imaging study. | Effects of atrial fibrillation (AF) and its ablative treatment on LV torsion have not yet been fully investigated. This study aimed to examine whether AF patterns of LV contraction and its ablative correction can exert a significant impact on LV torsion by velocity vector imaging (VVI).</AbstractText>This case-control study conducted in Rajaie Cardiovascular, Medical and Research Center between October 2012 and June 2013. Study participants were 30 consecutive patients with symptomatic paroxysmal AF who met the inclusion criteria. The control group included 24 healthy participants with no history of cardiovascular disease. All individuals were in sinus rhythm at the time of echocardiography before and after the ablation procedure. Two-dimensional (2D) and Doppler echocardiography on a commercially available ultrasound system was performed for all the patients. Scanning was done by a wide-band ultrasound transducer with the frequency range between 2.5-3.5 MHz. The two short-axis views at basal and apical levels were subsequently processed off-line by VVI XStrain software. In order for data analysis, SPSS 16 utilized using paired and independent t-test. p-value ≤0.05 was considered significant.</AbstractText>LV torsion (°/cm) mean ± SD was significantly lower in paroxysmal AF patients before ablation (0.8±0.3) than the control group (1.5±0.4) (p<0.001) and increased significantly after ablation (1.1±0.5) compared with before ablation (p=0.004), but still significantly lower than the control group (p=0.003). LV Twist, twist rate and untwist rate mean ± SD were significantly lower in paroxysmal AF patients before ablation than the control group and increased significantly after ablation compared with before ablation, but still significantly lower than the control group.</AbstractText>Subclinical LV dysfunction may be detected in paroxysmal AF rhythm by measuring torsional parameters through VVI which improves after AF ablation.</AbstractText> |
20,032 | Unique ECG presentations and clinical management of a symptomatic LQT2 female carrying a novel de novo KCNH2 mutation. | A 26-year-old woman, 12 days in postpartum, developed recurrent syncope and cardiac arrest. Her ECG revealed QT-prolongation associated with LQT2-specific T-U wave patterns, T wave alternans, long QT-dependent torsade de pointes (TdP) and ventricular fibrillation (VF). She also had intermittent LBBB (80bpm) on alternate beats and RBBB at sinus tachycardia (113bpm). Family genotyping revealed a novel de novo missense mutation G604C of KCNH2. Propranolol slowed heart rate and further prolonged QT interval (610ms) that caused TdP recurrence. Mexiletine combined with magnesium and potassium supplements prevented TdP/VF recurrence. This patient has remained event-free after 9-month follow-up. |
20,033 | "Homozygous, and compound heterozygous mutation in 3 Turkish family with Jervell and Lange-Nielsen syndrome: case reports". | Jervell and Lange-Nielsen syndrome (JLNS) isa recessive model of long QT syndrome which might also be related to possible hearing loss. Although the syndrome has been demonstrated to be originated from homozygous or compound heterozygous mutations in either the KCNQ1 or KCNE1 genes, additional mutations in other genetic loci should be considered, particularly in malignant course patients.</AbstractText>Three patients were admitted into hospital due to recurrent seizures/syncope, intrauterine and postnatal bradycardia respectively; moreover all three patients had congenital sensorineural hearing-loss. Their electrocardiograms showed markedly prolonged QT interval. Implantable defibrillator was implanted and left cardiac sympathetic denervation was performed due to the progressive disease in case 1. She had countless ventricular fibrillation and appropriate shock while using an implantable defibrillator. The DNA sequencing analysis of the KCNQ1 gene disclosed a homozygous c.728G > A (p.Arg243His) missense mutation in case1. Further targeted next generation sequencing of cardiac panel comprising 68 gene revealed a heterozygous c.1346 T > G (p.Ile449Arg) variant in RYR2 gene and a heterozygous c.809G > A (p.Cys270Tyr) variant in NKX2-5 gene in the same patient. Additional gene alterations in RYR2 and NKX2-5 genes were thought to be responsible for progressive and malignant course of the disease. As a result of DNA sequencing analysis of KCNQ1 and KCNE1 genes, a compound heterozygosity for two mutations had been detected in KCNQ1 gene in case 2: a maternally derived c.477 + 1G > A splice site mutation and a paternally derived c.520C > T (p.Arg174Cys) missense mutation. Sanger sequencing of KCNQ1 and KCNE1 genes displayed a homozygous c.1097G > A (p.Arg366Gln) mutation in KCNQ1 gene in case 3. β-blocker therapy was initiated to all the index subjects.</AbstractText>Three families of JLNS who presented with long QT and deafness and who carry homozygous, or compound heterozygous mutation in KCNQ1 gene were presented in this report. It was emphasized that broad targeted cardiac panels may be useful to predict the outcome especially in patients with unexplained phenotype-genotype correlation. Clinical presentations and molecular findings will be discussed further to clarify the phenotype genotype associations.</AbstractText> |
20,034 | Pediatric Emergency Medicine Simulation Curriculum: Submersion Injury With Hypothermia and Ventricular Fibrillation. | Submersion injury or drowning is a leading preventable cause of pediatric mortality and morbidity. Submersion injuries are often accompanied by hypothermia and asphyxia that can lead to inadequate oxygen delivery to tissues and subsequent cardiac arrhythmias.</AbstractText>This simulation-based curriculum involves the identification and management of a submersion injury in a 4-year-old boy who was rescued from a cold-water submersion. The simulated patient is apneic, pulseless, bradycardic, and hypothermic; he is being bag-mask ventilated on arrival without intravenous access. He ultimately develops ventricular fibrillation. Providers must recognize the degree of submersion injury, initiate early airway protection, adequately address circulation, and be alert to developing hypothermia and cardiac arrhythmias to prevent further decompensation. This scenario can be modified based on trainee level (pediatric residents vs. pediatric emergency medicine fellows).</AbstractText>A total of 22 trainees (PGY 1-PGY 6 pediatric residents and pediatric emergency medicine fellows) participated in this simulation curriculum on separate occasions and rated it as an overall positive learning experience. The curriculum's goal is to provide learners with an opportunity to manage life-threatening pediatric submersion injuries, where the correct steps need to be taken in a limited period of time.</AbstractText>We have provided preparatory materials to help instructors set up, run, and debrief the scenario in a standardized fashion. The debriefing tools allow for adaptation depending on learners' needs and individual experiences during the simulated scenario. Also included are supporting educational materials and a learner feedback form that can be used to evaluate the session.</AbstractText> |
20,035 | Identification of optimal reference genes for transcriptomic analyses in normal and diseased human heart. | Quantitative real-time RT-PCR (RT-qPCR) has become the method of choice for mRNA quantification, but requires an accurate normalization based on the use of reference genes showing invariant expression across various pathological conditions. Only few data exist on appropriate reference genes for the human heart. The objective of this study was to determine a set of suitable reference genes in human atrial and ventricular tissues, from right and left cavities in control and in cardiac diseases.</AbstractText>We assessed the expression of 16 reference genes (ACTB, B2M, GAPDH, GUSB, HMBS, HPRT1, IPO8, PGK1, POLR2A, PPIA, RPLP0, TBP, TFRC, UBC, YWHAZ, 18S) in tissues from: right and left ventricles from healthy controls and heart failure (HF) patients; right-atrial tissue from patients in sinus rhythm with (SRd) or without (SRnd) atrial dilatation, patients with paroxysmal (pAF) or chronic (cAF) atrial fibrillation or with HF; and left-atrial tissue from patients in SR or cAF. Consensual analysis (by geNorm and Normfinder algorithms, BestKeeper software tool and comparative delta-Ct method) of the variability scores obtained for each reference gene expression shows that the most stably expressed genes are: GAPDH, GUSB, IPO8, POLR2A, and YWHAZ when comparing either right and left ventricle or ventricle from healthy controls and HF patients; GAPDH, IPO8, POLR2A, PPIA, and RPLP0 when comparing either right and left atrium or right atria from all pathological groups. ACTB, TBP, TFRC, and 18S genes were identified as the least stable.</AbstractText>The overall most stable reference genes across different heart cavities and disease conditions were GAPDH, IPO8, POLR2A and PPIA. YWHAZ or GUSB could be added to this set for some specific experiments. This study should provide useful guidelines for reference gene selection in RT-qPCR studies in human heart.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For Permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
20,036 | Feasibility evaluation of long-term use of beta-blockers and calcium antagonists in patients with Brugada syndrome. | Beta-blockers (BBs) and calcium antagonists (CAs) are reported to aggravate ST-segment elevation in some patients with Brugada syndrome (BrS). The feasibility of their long-term use in BrS still remains unknown. We investigated the safety of long-term use of BB and CA in BrS patients.</AbstractText>Of the 360 consecutive BrS patients, 29 [5: a history of ventricular fibrillation (VF), 17: syncope, 7: asymptomatic] took BB and/or CA (BB: 22, CA: 8) for more than 1 year for the treatment of co-morbidities such as atrial tachyarrhythmia, vasospastic angina, and neurally mediated syncope. The electrocardiographic changes and clinical outcome after the treatment were evaluated. Eleven patients showed type 1 electrocardiogram (ECG) at baseline. BBs and CAs were used within normal dosage range in all patients. After starting a BB and/or CA, type 1 ECG was still observed in 9 patients. There were no significant differences in the ECG parameters such as the amplitude of J-point, QRS duration, and corrected QT intervals before and after starting BB and/or CA. During follow-up of 89 ± 65 months after initiation of the drugs, 1 patient experienced a VF recurrence without significant changes of ECG parameters 2 years after BB therapy was started.</AbstractText>Long-term intake of BB or CA within normal dosage range was not associated with the aggravation of ECG parameters and clinical outcome in patients with BrS. The use of BBs and CAs is acceptable under careful observation.</AbstractText> |
20,037 | Association between implantable cardioverter-defibrillator therapy and different lead positions in patients with cardiac resynchronization therapy. | To evaluate the impact of different right and left ventricular lead positions (RV-LP and LV-LP) on the risk of therapy for ventricular tachycardia/ventricular fibrillation in patients with a cardiac resynchronization therapy device (CRT-D).</AbstractText>We performed a large nationwide cohort study on patients in Denmark receiving a CRT-D device from 2008 to 2012 from the Danish Pacemaker and implantable cardioverter defibrillator (ICD) registry. Lead positions were registered during the implantation and categorized as anterior/lateral/posterior and basal/mid-ventricular/apical for the LV-LP, and as apical/non-apical for the RV-LP. Appropriate and inappropriate therapies were registered during follow-up via remote monitoring or at device interrogations. Time to event was summarized with Kaplan-Meier plots, and competed risk regression analysis was used to calculate adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Following variables were included in the analysis: gender, age, heart failure aetiology, New York heart association class, left ventricular ejection fraction, QRS duration, indication (secondary or primary prophylactic), RV-LP, LV-LP, and antiarrhythmic therapy. We included 1643 patients [mean age 68 (±10) years, 1343 (83%) men]. After a mean of 2.0 years, 322 (20%) patients received appropriate and 66 (4%) patients received inappropriate therapy. The aHR for appropriate therapy with a non-apical RV-LP was 0.70 95% CI (0.55-0.87, P = 0.002) as compared with an apical. We observed no significant association between appropriate therapy and LV-LP in left anterior oblique or right anterior oblique views or inappropriate therapy between any lead positions.</AbstractText>An apical RV-LP is associated with an increased risk of appropriate therapy for ventricular tachyarrhythmia in patients with a CRT-D device.</AbstractText> |
20,038 | Novel Quantitative Analytical Approaches for Rotor Identification and Associated Implications for Mapping. | Clinical studies identifying rotors and confirming these sites for ablation in treating cardiac arrhythmias have had inconsistent results with the currently available analysis techniques. The aim of this study is to evaluate four new signal analysis approaches-multiscale frequency (MSF), Shannon entropy (SE), Kurtosis (Kt), and multiscale entropy (MSE)-in their ability to identify the pivot point of rotors.</AbstractText>Optical mapping movies of ventricular tachycardia were used to evaluate the performance and robustness of SE, Kt, MSF, and MSE techniques with respect to several clinical limitations: decreased time duration, reduced spatial resolution, and the presence of meandering rotors. To quantitatively assess the robustness of the four techniques, results were compared to the "true" rotor(s) identified using optical mapping-based phase maps.</AbstractText>The results demonstrate that MSF, Kt, and MSE accurately identified both stationary and meandering rotors. In addition, these techniques remained accurate under simulated clinical limitations: shortened electrogram duration and decreased spatial resolution. Artifacts mildly affected the performance of MSF, Kt, and MSE, but strongly impacted the performance of SE.</AbstractText>These results motivate further validation using intracardiac electrograms to see if these approaches can map rotors in a clinical setting and whether they apply to more complex arrhythmias including atrial or ventricular fibrillation.</AbstractText>New techniques providing more accurate rotor localization could improve characterization of arrhythmias and, in turn, offer a means to accurately evaluate whether rotor ablation is a viable and effective treatment for chaotic cardiac arrhythmias.</AbstractText> |
20,039 | Cerebral and Limb Tissue Oxygenation During Peripheral Venoarterial Extracorporeal Life Support. | Femoral access in extracorporeal life support (ECLS) has been associated with regional variations in arterial oxygen saturation, potentially predisposing the patient to ischemic tissue damage. Current monitoring techniques, however, are limited to intermittent bedside evaluation of capillary refill among other factors. The aim of this study was to assess whether cerebral and limb regional tissue oxygen saturation (rSO<sub>2</sub>) values reflect changes in various patient-related parameters during venoarterial ECLS (VA-ECLS). This retrospective observational study included adults assisted by femorofemoral VA-ECLS. Bifrontal cerebral and bilateral limb tissue oximetry was performed for the entire duration of support. Hemodynamic data were analyzed parallel to cerebral and limb rSO<sub>2</sub>. A total of 23 patients were included with a median ECLS duration of 5 [1-20] days. Cardiac arrhythmias were observed in 12 patients, which was associated with a decreased mean rSO<sub>2</sub> from 61%±11% to 51%±10% during atrial fibrillation and 67%±9% to 58%±10% during ventricular fibrillation (<i>P</i><0.001 for both). A presumably sudden increase in cardiac output due to myocardial recovery (n=8) resulted in a significant decrease in mean cerebral rSO<sub>2</sub> from 73%±7% to 54%±6% and from 69%±9% to 53%±8% for the left and right cerebral hemisphere, respectively (<i>P</i>=0.012 for both hemispheres). Also, right radial artery partial gas pressure for oxygen decreased from 15.6±2.8 to 8.3±1.9 kPa (<i>P</i>=0.028). No differences were found in cerebral desaturation episodes between patients with and without neurologic complications. In six patients, limb rSO<sub>2</sub> increased from on average 29.3±2.7 to 64.0±5.1 following insertion of a distal cannula in the femoral artery (<i>P</i>=0.027). Likewise, restoration of flow in a clotted distal cannula inserted in the femoral artery was necessary in four cases and resulted in increased limb rSO<sub>2</sub> from 31.3±0.8 to 79.5±9.0; <i>P</i>=0.068. Non-invasive tissue oximetry adequately reflects events influencing cerebral and limb perfusion and can aid in monitoring tissue perfusion in patients assisted by ECLS. |
20,040 | The effect of head-up tilt upon markers of heart rate variability in patients with atrial fibrillation. | Heart rate variability (HRV) analysis is uncommonly undertaken in patients with atrial fibrillation (AF) due to an assumption that ventricular response is random. We sought to determine the effects of head-up tilt (HUT), a stimulus known to elicit an autonomic response, on HRV in patients with AF; we contrasted the findings with those of patients in sinus rhythm (SR).</AbstractText>Consecutive, clinically indicated tilt tests were examined for 207 patients: 176 in SR, 31 in AF. Patients in AF were compared to an age-matched SR cohort (n = 69). Five minute windows immediately before and after tilting were analyzed using time-domain, frequency-domain and nonlinear HRV parameters. Continuous, noninvasive assessment of blood pressure, heart rate and stroke volume were available in the majority of patients.</AbstractText>There were significant differences at baseline in all HRV parameters between AF and age matched SR. HUT produced significant hemodynamic changes, regardless of cardiac rhythm. Coincident with these hemodynamic changes, patients in AF had a significant increase in median [quartile 1, 2] DFA-α2 (+0.14 [-0.03, 0.32], p < .005) and a decrease in sample entropy (-0.17 [-0.50, -0.01], p < .005).</AbstractText>In the SR cohort, increasing age was associated with fewer HRV changes on tilting. Patients with AF had blunted HRV responses to tilting, mirroring those seen in an age matched SR group. It is feasible to measure HRV in patients with AF and the changes observed on HUT are comparable to those seen in patients in sinus rhythm.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,041 | Left atrial deformation: Useful index for early detection of cardiac damage in chronic mitral regurgitation. | In chronic mitral regurgitation (MR) left atrium is one of the first cardiac structures that is involved in remodeling and ultrastructural changes for a progressive volume overload. Severe left atrial (LA) dilation on echocardiography and new onset of atrial fibrillation in asymptomatic patients with preserved Left Ventricular (LV) function, appeared as a Class IIb recommendation for consideration for surgical mitral valve repair in the actual guidelines. However, before atrial dilatation and dysfunction, several ultrastructural changes appear in the atrial muscle tissue that are difficult to identify with the standard echocardiography. Speckle tracking echocardiography (STE) can analyze LA function: it has been showed that it can indirectly identify structural tissue modifications from excessive atrial effort in the early stages of MR up to the full depression of atrial function in the late stages where there are advanced ultrastructural alterations. This review aims to summarize current knowledge on the role of atrial strain identifying early structural alterations of the atrial tissue in the rising stages of MR considering that Left Atrial Peak Longitudinal Strain (PALS) considered useful parameter for a more extensive evaluation of MR patients. |
20,042 | Relation of elevated serum uric acid levels to first-degree heart block and other cardiac conduction defects in hospitalized patients with type 2 diabetes. | Several studies have reported that moderately elevated serum uric acid levels are associated with an increased risk of tachyarrhythmias (mainly atrial fibrillation) in patients with and without type 2 diabetes mellitus (T2DM). It is currently unknown whether an association also exists between elevated serum uric acid levels and cardiac conduction defects in patients with T2DM.</AbstractText>We retrospectively analyzed a hospital-based sample of 967 patients with T2DM discharged from our Division of Endocrinology over the years 2007-2014. Standard electrocardiograms were performed on all patients and were interpreted by expert cardiologists.</AbstractText>Overall, 267 (27.6%) patients had some type of conduction defects on electrocardiograms (defined as at least one block among first-degree atrio-ventricular block, second-degree block, third-degree block, left bundle branch block, right bundle branch block, left anterior hemi-block or left posterior hemi-block). Patients in the 3rd serum uric acid tertile had a higher prevalence of any cardiac conduction defects than those belonging to 2nd or 1st tertile, respectively (35.8% vs. 25.0% vs. 22.6%; p<0.0001). Elevated serum uric acid levels were associated with a nearly twofold increased risk of cardiac conduction defects after adjustment for age, sex, hemoglobin A1c, diabetes duration, metabolic syndrome, chronic kidney disease, chronic obstructive pulmonary disease, ischemic heart disease, valvular heart disease and medication use (adjusted-odds ratio 1.84, 95% confidence intervals 1.2-2.9; p=0.009).</AbstractText>Moderately elevated serum uric acid levels are associated with an increased prevalence of any cardiac conduction defects in hospitalized patients with T2DM, independent of multiple risk factors and potential confounding variables.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,043 | Comparison of Outcome After Percutaneous Mitral Valve Repair With the MitraClip in Patients With Versus Without Atrial Fibrillation. | Percutaneous mitral valve repair with the MitraClip is an established treatment for patients with mitral regurgitation (MR) who are inoperable or at high risk for surgery. Atrial Fibrillation (AF) frequently coincides with MR, but only scarce data of the influence of AF on outcome after MitraClip is available. The aim of the current study was to compare the clinical outcome after MitraClip treatment in patients with versus without atrial fibrillation. Between January 2009 and January 2016, all consecutive patients treated with a MitraClip in 5 Dutch centers were included. Outcome measures were survival, symptoms, MR grade, and stroke incidence. In total, 618 patients were treated with a MitraClip. Patients with AF were older, had higher N-terminal B-type natriuretic peptide levels, more tricuspid regurgitation, less often coronary artery disease and a better left ventricular function. Survival of patients treated with the MitraClip was similar for patients with AF (82%) and without AF (non-AF; 85%) after 1 year (p = 0.30), but significantly different after 5-year follow-up (AF 34%; non-AF 47%; p = 0.006). After 1 month, 64% of the patients with AF were in New York Heart Association class I or II, in contrast to 77% of the patients without AF (p = 0.001). The stroke incidence appeared not to be significantly different (AF 1.8%; non-AF 1.0%; p = 0.40). In conclusion, patients with AF had similar 1-year survival, MR reduction, and stroke incidence compared with non-AF patients. However, MitraClip patients with AF had reduced long-term survival and remained more symptomatic compared with those without AF. |
20,044 | The genetics underlying idiopathic ventricular fibrillation: A special role for catecholaminergic polymorphic ventricular tachycardia? | Ventricular fibrillation (VF) is a major cause of sudden cardiac death. In some cases clinical investigations fail to identify the underlying cause and the event is classified as idiopathic (IVF). Since mutations in arrhythmia-associated genes frequently determine arrhythmia susceptibility, screening for disease-predisposing variants could improve IVF diagnostics.</AbstractText>The study included 76 Finnish and Italian patients with a mean age of 31.2years at the time of the VF event, collected between the years 1996-2016 and diagnosed with idiopathic, out-of-hospital VF. Using whole-exome sequencing (WES) and next-generation sequencing (NGS) approaches, we aimed to identify genetic variants potentially contributing to the life-threatening arrhythmias of these patients. Combining the results from the two study populations, we identified pathogenic or likely pathogenic variants residing in the RYR2, CACNA1C and DSP genes in 7 patients (9%). Most of them (5, 71%) were found in the RYR2 gene, associated with catecholaminergic polymorphic ventricular tachycardia (CPVT). These genetic findings prompted clinical investigations leading to disease reclassification. Additionally, in 9 patients (11.8%) we detected 10 novel or extremely rare (MAF<0.005%) variants that were classified as of unknown significance (VUS).</AbstractText>The results of our study suggest that a subset of patients originally diagnosed with IVF may carry clinically-relevant variants in genes associated with cardiac channelopathies and cardiomyopathies. Although misclassification of other cardiac channelopathies as IVF appears rare, our findings indicate that the possibility of CPVT as the underlying disease entity should be carefully evaluated in IVF patients.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,045 | Does permanent atrial fibrillation modify response to cardiac resynchronization therapy in heart failure patients? | The benefits of cardiac resynchronization therapy (CRT) documented in heart failure (HF) may be influenced by atrial fibrillation (AF). We aimed to compare CRT response in patients in AF and in sinus rhythm (SR).</AbstractText>We prospectively studied 101 HF patients treated by CRT. Rates of clinical, echocardiographic and functional response, baseline NYHA class and variation, left ventricular ejection fraction, volumes and mass, atrial volumes, cardiopulmonary exercise test (CPET) duration (CPET dur), peak oxygen consumption (VO2</sub>max) and ventilatory efficiency (VE/VCO2</sub> slope) were compared between AF and SR patients, before and at three and six months after implantation of a CRT device.</AbstractText>All patients achieved ≥95% biventricular pacing, and 5.7% underwent atrioventricular junction ablation. Patients were divided into AF (n=35) and SR (n=66) groups; AF patients were older, with larger atrial volumes and lower CPET dur and VO2</sub>max before CRT. The percentages of clinical and echocardiographic responders were similar in the two groups, but there were more functional responders in the AF group (71% vs. 39% in SR patients; p=0.012). In SR patients, left atrial volume and left ventricular mass were significantly reduced (p=0.015 and p=0.021, respectively), whereas in AF patients, CPET dur (p=0.003) and VO2</sub>max (p=0.001; 0.083 age-adjusted) showed larger increases.</AbstractText>Clinical and echocardiographic response rates were similar in SR and AF patients, with a better functional response in AF. Improvement in left ventricular function and volumes occurred in both groups, but left ventricular mass reduction and left atrial reverse remodeling were seen exclusively in SR patients (ClinicalTrials.gov identifier: NCT02413151; FCT code: PTDC/DES/120249/2010).</AbstractText>Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.</CopyrightInformation> |
20,046 | Usefulness of the CRT-SCORE for Shared Decision Making in Cardiac Resynchronization Therapy in Patients With a Left Ventricular Ejection Fraction of ≤35. | Individualized estimation of prognosis after cardiac resynchronization therapy (CRT) remains challenging. Our aim was to develop a multiparametric prognostic risk score (CRT-SCORE) that could be used for patient-specific clinical shared decision making about CRT implantation. The CRT-SCORE was derived from an ongoing CRT registry, including 1,053 consecutive patients (age 67 ± 10 years, 76% male). Using preimplantation variables, 100 multiple imputed datasets were generated for model calibration. Based on multivariate Cox regression models, cross-validated linear prognostic scores were calculated, as well as survival fractions at 1 and 5 years. Specifically, the CRT-SCORE was calculated using atrioventricular junction ablation, age, gender, etiology, New York Heart Association class, diabetes, hemoglobin level, renal function, left bundle branch block, QRS duration, atrial fibrillation, left ventricular systolic and diastolic functions, and mitral regurgitation, and showed a good discriminative ability (areas under the curve 0.773 at 1 year and 0.748 at 5 years). During the long-term follow-up (median 60 months, interquartile range 31 to 85), all-cause mortality was observed in 494 (47%) patients. Based on the distribution of the CRT-SCORE, lower- and higher-risk patient groups were identified. Estimated mean survival rates of 98% at 1 year and 92% at 5 years were observed in the lowest 5% risk group (L5 CRT-SCORE: -4.42 to -1.60), whereas the highest 5% risk group (H5 CRT-SCORE: 1.44 to 2.89) showed poor survival rates: 78% at 1 year and 22% at 5 years. In conclusion, the CRT-SCORE allows accurate prediction of 1- and 5-year survival rates after CRT using readily available and CRT-specific clinical, electrocardiographic, and echocardiographic parameters. The model may assist clinicians in counseling patients and in decision making. |
20,047 | Baseline fragmented QRS increases the risk of major arrhythmic events in Brugada syndrome: Systematic review and meta-analysis. | Fragmented QRS reflects disturbances in the myocardium predisposing the heart to ventricular tachyarrhythmias. Recent studies suggest that fragmented QRS (fQRS) is associated with major arrhythmic events in Brugada syndrome. However, a systematic review and meta-analysis of the literature has not been done. We assessed the association between fQRS and major arrhythmic events in Brugada syndrome by a systematic review of the literature and a meta-analysis.</AbstractText>We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2017. Included studies were published prospective or retrospective cohort studies that compared major arrhythmic events (ventricular fibrillation, sustained ventricular tachycardia, sudden cardiac arrest, or sudden cardiac death) in Brugada syndrome with fQRS versus normal QRS. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals.</AbstractText>Nine studies from January 2012 to May 2017 were included in this meta-analysis involving 2,360 subjects with Brugada syndrome (550 fQRS and 1,810 non-fQRS). Fragmented QRS was associated with major arrhythmic events (pooled risk ratio =3.36, 95% confidence interval: 2.09-5.38, p < .001, I2</sup>  = 50.9%) as well as fatal arrhythmia (pooled risk ratio =3.09, 95% confidence interval: 1.40-6.86, p = .005, I2</sup>  = 69.7%).</AbstractText>Baseline fQRS increased major arrhythmic events up to 3-fold. Our study suggests that fQRS could be an important tool for risk assessment in patients with Brugada syndrome.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,048 | The prognostic significance of early and late right precordial lead (V<sub>4</sub> R) ST-segment elevation in patients with acute anterior myocardial infarction. | The predictive significance of ST-segment elevation (STE) in lead V4</sub> R in patients with anterior ST-segment elevation myocardial infarction (STEMI) has not been well-understood. In this study, we evaluated the prognostic value of early and late STE in lead V4</sub> R in patients with anterior STEMI.</AbstractText>A total 451 patients with anterior STEMI who treated with primary percutaneous coronary intervention (PPCI) were prospectively enrolled in this study. All patients were classified according to presence of STE (>1 mm) in lead V4</sub> R at admission and/or 60 min after PPCI. Based on this classification, all patients were divided into three subgroups as no V4</sub> R STE (Group 1), early but not late V4</sub> R STE (Group 2) and late V4</sub> R STE (Group 3).</AbstractText>In-hospital mortality had higher rates at group 2 and 3 and that had 2.1 and 4.1-times higher mortality than group 1. Late V4</sub> R STE remained as an independent risk factor for cardiogenic shock (odds ratio [OR] 2.6; 95% confidence interval [CI] 1.9-4.3; p < .001) and in-hospital mortality (OR 2.3; 95% CI 1.8-4.1; p < .001). The 12-month overall survival for group 1, 2, and 3 were 91.1%, 82.4%, and 71.4% respectively. However, the long-term mortality also had the higher rate at group 3; late V4</sub> R STE did not remain as an independent risk factor for long-term mortality (OR 1.5; 95% CI 0.8-4.1; p: .159).</AbstractText>Late V4</sub> R STE in patients with anterior STEMI is strongly associated with poor prognosis. The record of late V4</sub> R in patients with anterior STEMI has an important prognostic value.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,049 | Right Ventricular Pacing Increases Risk of Appropriate Implantable Cardioverter-Defibrillator Shocks Asymmetrically: An Analysis of the ALTITUDE Database. | Right ventricular pacing (RVP) increases risk of atrial fibrillation in patients with implantable cardioverter-defibrillators (ICDs), but ventricular proarrhythmia is less clear. We analyzed a large remote monitoring database to assess this question.</AbstractText>Patients with single- or dual-chamber ICDs, engaged in remote monitoring for at least 6 months and with unchanged tachycardia programming, were included. %RVP was derived for each weekly transmission. ICD electrograms preceding the first shock were adjudicated. Among 425 625 transmissions received from 8435 patients, 389 appropriate shocks occurred over a mean follow-up of 15.0±8.8 months. In a time-dependent Cox proportional hazards model, transmissions with 80% to 98% RVP were associated with a hazard ratio of 1.56 for an appropriate shock in the subsequent week compared with <1% RVP (95% CI, 1.01-2.41; P</i>=0.04). By contrast, ≥98% RVP trended toward a lower risk of an appropriate shock (hazard ratio, 0.61; 95% CI, 0.33-1.12; P</i>=0.108). Lifetime cumulative %RVP was closely correlated with weekly %RVP (R</i>2</sup>=0.907) and was similarly associated with increased risk of appropriate shocks at 80% to 98% RVP (hazard ratio, 1.57; 95% CI, 1.01-2.44; P</i>=0.046) but not at ≥98% RVP (hazard ratio, 0.49; 95% CI, 0.24-1.01; P</i>=0.052). These results were driven by dual-chamber devices, but unaffected by PVC counts or programming. Male sex and age were also associated with appropriate ICD shocks.</AbstractText>Increasing frequency of RVP is associated with a progressively increased risk of appropriate ICD shocks until ≥98% RVP. RVP may have ventricular proarrhythmia because of competition of paced and intrinsic rhythm in ICD patients.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,050 | Immediate coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac cause: Who benefits? | Immediate coronary angiography (iCA) and primary percutaneous coronary angioplasty (pPCI) in patients successfully resuscitated after out-of-hospital cardiac arrest (OHCA) of suspected cardiac cause is controversial. Our aims were to assess the results of iCA, the prognostic impact of pPCI after OHCA, and to identify subgroups most likely to benefit from this strategy.</AbstractText>In this single-centre retrospective study, patients aged ≥18 years with sustained return of spontaneous circulation after OHCA and no evidence of a non-cardiac cause underwent routine iCA at admission, with pPCI if indicated. Results of iCA, and factors associated with in-hospital survival were analysed.</AbstractText>Between 2006 and 2013, 160 survivors from OHCA presumed of cardiac origin were included (median age, 60 years; 85% males). iCA showed significant coronary-artery lesions in 75% of patients, and acute occlusion or unstable lesion in only 41%. pPCI was performed in 34% of patients and was not associated with survival by univariate or multivariate analysis (P=0.67). ST-segment elevation predicted acute coronary occlusion in 40%. An initial shockable rhythm was associated with higher in-hospital survival (52% vs. 19%; P<0.001). After initial defibrillation, the first rhythm recorded by 12-lead electrocardiography was highly associated with prognosis: secondary asystole had a very low survival rate (5%, 1/21) despite PCI in 43% of patients, compared to sustained ventricular tachycardia/fibrillation (42%, 15/36) and supraventricular rhythm (71%, 50/70) (P<0.001).</AbstractText>In our experience, the prevalence of acute coronary occlusion or unstable lesion immediately after OHCA of likely cardiac cause is only 41%. Immediate CA in OHCA survivors, with pPCI if indicated, should be restricted to highly selected patients.</AbstractText>Copyright © 2017 Elsevier Masson SAS. All rights reserved.</CopyrightInformation> |
20,051 | Large-scale assessment of aortic stenosis: facing the next cardiac epidemic? | Aortic stenosis (AS) is the most frequent valvular disease in developed countries. As society grows older, the prevalence of AS increases. However, the real burden, current aetiology, severity distribution, and echocardiographic patterns of AS are not fully clear. The aim of the present study is to provide an accurate overall picture of AS, focusing on its epidemiology, aetiology, and echocardiographic features.</AbstractText>A total of 29 502 consecutive echocardiograpies were prospectively included in this multicentre study. The present sample was composed of patients with advanced age (mean 75.2 years) and similar gender distribution. High proportion (7.2%) showed any grade of AS, with important number of patients (2.8%) presenting severe AS, most of them aged 75 years or more. Coexisting valvular disease appeared in almost half of the sample (49.6%), being the most frequently diagnosed aortic regurgitation (AR) (22%) followed by mitral regurgitation (MR) (15.6%). Degenerative aetiology was found in the vast majority (93.4%) of the studies whereas rheumatic is currently infrequent (3.35%). Low flow-low gradient (LFLG) appeared in 24.6% of patients with severe AS. Atrial fibrillation (23.1% vs. 11.6%; P = 0.002), MR (23.3% vs. 15.1%; P = 0.018), and right ventricle dysfunction (13.3% vs. 5.2%; P = 0.003) appeared frequently in LFLG group.</AbstractText>Burden of AS is higher than previously assumed. Degenerative aetiology is the main cause of AS. Most of the patients are elder with high prevalence of significant co-existing valvular disease. LFLG severe AS is present in an important proportion of patients, showing high grade of left ventricle remodelling.</AbstractText> |
20,052 | Progression of late postoperative atrial fibrillation in patients with tetralogy of Fallot. | ToF patients are at risk for ventricular deterioration at a relatively young age, which can be aggravated by AF development. Therefore, knowledge on AF development and its timespan of progression is essential to guide treatment strategies for AF.</AbstractText>We examined late postoperative AF onset and progression in ToF patients during long-term follow-up after ToF correction. In addition, coexistence of AF with regular supraventricular tachyarrhythmias (SVT) and ventricular tachyarrhythmias (VTA) was analyzed.</AbstractText>ToF patients (N  =  29) with AF after ToF correction referred to the electrophysiology department between 2000 and 2015 were included. All available rhythm registrations were reviewed for AF, regular SVT, and VTA. AF progression was defined as transition from paroxysmal AF to (longstanding) persistent/permanent AF or from (longstanding) persistent AF to permanent AF. At the age of 44 ± 12 years, ToF patients presented with paroxysmal (N  =  14, 48%), persistent (N  =  13, 45%) or permanent AF (N  =  2, 7%). Age of AF development was similar among patients who either underwent initial shunt creation (N  =  15, 45 ± 11 [25-57] years) or primary total ToF correction (N  =  14, 43 ± 13 [26-66] years) (P  =  0.785). AF coexisted with regular SVT (N  =  18, 62%) and VTA (N  =  13, 45%). Progression of AF occurred in 11 patients (38%) within 5 ± 5 years after AF onset despite antiarrhythmic drug class II (AAD, P  =  0.052) or III (P  =  0.587) usage.</AbstractText>AF in our ToF population developed at a young age and showed rapid progression. Rhythm control by pharmacological therapy was ineffective in preventing AF progression.</AbstractText>© 2017 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals, Inc.</CopyrightInformation> |
20,053 | [Usefulness of spectral tissue Doppler (E/e' ratio) in the management of patients with atrial fibrillation]. | Atrial fibrillation is the most common cardiac rhythm disorder encountered in daily clinical practice. It carries high morbidity and mortality rates, mainly related to sudden death, heart failure and stroke. Validation of noninvasive markers in the diagnosis of heart failure with preserved ejection fraction and risk stratification is therefore attractive in this clinical setting. The spectral tissue Doppler-derived E/e' ratio is a simple and user-friendly index which has been validated in the assessment of left ventricular diastolic pressures, regardless of rhythm. A septal E/e' >11 is associated with invasive left ventricular diastolic pressures >15mmHg in patients with atrial fibrillation. Several studies have reported the clinical relevance of abnormal values of E/e' at rest and during exercise in the diagnosis and risk stratification of heart failure with preserved ejection fraction in patients with atrial fibrillation. There is now convincing evidence that increased E/e' is associated with adverse outcome in patients with atrial fibrillation and predicts the recurrence of arrhythmia after cardioversion or catheter ablation. In conclusion, we recommend the measurement of E/e' in each patient with atrial fibrillation referred for clinically indicated transthoracic Doppler echocardiography. |
20,054 | Drugs in cardiac arrest: the rise and fall of antiarrhythmics. | Since the publication of 2000 guidelines for resuscitation, amiodarone is considered the antiarrhythmic drug of choice for refractory ventricular fibrillation/pulseless ventricular tachycardia. However, to date there is no proven benefit in terms of neurologically intact survival to hospital discharge. A comprehensive search of the recent literature on amiodarone, nifekalant and lidocaine in cardiac arrest was performed. Amiodarone and nifekalant are superior to lidocaine with regards to the return of spontaneous circulation and survival to hospital admission. Nifekalant shows a trend towards quicker termination of ventricular fibrillation compared to amiodarone. There is great uncertainty about the efficacy of antiarrhythmics in cardiac arrest. Failure to show improvements regarding meaningful survival questions their current use and suggests the need for re-evaluating their place in cardiopulmonary resuscitation. |
20,055 | Global longitudinal strain corrected by RR interval is a superior predictor of all-cause mortality in patients with systolic heart failure and atrial fibrillation. | Quantification of systolic function in patients with atrial fibrillation (AF) is challenging. A novel approach, based on RR interval correction, to counteract the varying heart cycle lengths in AF has recently been proposed. Whether this method is superior in patients with systolic heart failure (HFrEF) with AF remains unknown. This study investigates the prognostic value of RR interval-corrected peak global longitudinal strain {GLSc = GLS/[RR^(1/2)]} in relation to all-cause mortality in HFrEF patients displaying AF during echocardiographic examination.</AbstractText>Echocardiograms from 151 patients with HFrEF and AF during examination were analysed offline. Peak global longitudinal strain (GLS) was averaged from 18 myocardial segments obtained from three apical views. GLS was indexed with the square root of the RR interval {GLSc = GLS/[RR^(1/2)]}. Endpoint was all-cause mortality. During a median follow-up of 2.7 years, 40 patients (26.5%) died. Neither uncorrected GLS (P = 0.056) nor left ventricular ejection fraction (P = 0.053) was significantly associated with all-cause mortality. After RR^(1/2) indexation, GLSc became a significant predictor of all-cause mortality (hazard ratio 1.16, 95% confidence interval 1.02-1.22, P = 0.014, per %/s^(1/2) decrease). GLSc remained an independent predictor of mortality after multivariable adjustment (age, sex, mean heart rate, mean arterial blood pressure, left atrial volume index, and E/e') (hazard ratio 1.17, 95% confidence interval 1.05-1.31, P = 0.005 per %/s^(1/2) decrease).</AbstractText>Decreasing {GLSc = GLS/[RR^(1/2)]}, but not uncorrected GLS nor left ventricular ejection fraction, was significantly associated with increased risk of all-cause mortality in HFrEF patients with AF and remained an independent predictor after multivariable adjustment.</AbstractText>© 2017 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.</CopyrightInformation> |
20,056 | Impact of atrial fibrillation on rest and exercise haemodynamics in heart failure with mid-range and preserved ejection fraction. | Heart failure with preserved (HFpEF) and mid-range ejection fraction (HFmrEF) are becoming the most prevalent forms of heart failure. Patients with HFpEF/HFmrEF in atrial fibrillation (AF) have poorer survival and quality of life, but the mechanism underpinning this is unknown. We sought to investigate the influence of AF on the haemodynamic profile of HFpEF/HFmrEF patients at rest and during exercise.</AbstractText>We invasively measured central haemodynamics at rest and during symptom-limited supine bicycle exercise in HFpEF/HFmrEF patients, 35 in sinus rhythm and 20 in AF with matched left ventricular ejection fraction. At rest, AF patients had significantly increased pulmonary capillary wedge pressure, lower cardiac index and reduced left ventricular stroke work index, despite similar resting heart rate. Under resting conditions, calculated oxygen consumption and systemic arteriovenous oxygen gradient were not different between the two groups. During supine cycling at similar levels of workload, AF patients exhibited a reduced capacity to increase their oxygen consumption and this was accompanied by a persistently impaired cardiac index and left ventricular stroke work index.</AbstractText>The adverse interaction of AF and HFpEF/HFmrEF may be accounted for by an adverse impact on left ventricular systolic function and peripheral oxygen kinetics.</AbstractText>© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.</CopyrightInformation> |
20,057 | Prevalence and predictive factors of left atrial tachycardia occurring after second-generation cryoballoon ablation of atrial fibrillation. | Assess the prevalence and predictors of left atrial tachycardia (LAT) after cryoballoon ablation of pulmonary veins.</AbstractText>Patients who underwent catheter ablation of pulmonary veins with a second-generation cryoballoon for symptomatic paroxysmal (151 of 270, 56%) or persistent (119 of 270, 44%) atrial fibrillation were entered in a single-center prospective registry. Patients who experienced postcryoballoon LAT (pcryo-LAT) were selected on the basis of 12-lead ECG characteristics. Left atrial origin was confirmed during conventional EP study and electroanatomical activation mapping, and patients were treated by RF catheter ablation. Pcryo-LAT was observed in 15 (5.6%) of 270 patients and was attributed to a reentrant mechanism in 11 patients (73%). The other four cases of pcryo-LAT were due to focal atrial tachycardia associated with reconnection of one pulmonary vein. In comparison with patients who remained in sinus rhythm, LA area (HR = 1.09; CI 1.01, 1.2; P = 0.02), LVEF (HR = 0.94; CI 0.90, 0.97; P < 0.001), and LVEF <50% (HR = 8.5; CI 3.1, 23.6; P < 0.001) were predictors of pcryo-LAT. After multivariate Cox analysis, only left ventricular ejection fraction < 50% remained predictive of pcryo-LAT, (HR = 7.8, CI 2.3 26.7, P = 0.002). With a mean survival of 23 months, 73% of patients who experienced pcryo-LAT were in sinus rhythm versus 78% of patients without pcryo-LAT (log rank P = 0.85).</AbstractText>The prevalence of pcryo-LAT in patients with atrial fibrillation is low. Left ventricular ejection fraction < 50% is associated with an increased risk of pcryo-LAT. When treated by RF catheter ablation, the presence of pcryo-LAT is not a predictive factor of subsequent recurrence of atrial fibrillation during follow-up.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,058 | Minimally invasive, pericardial implantable cardioverter-defibrillator placement in a young child. | We report the successful minimally invasive placement of a pericardial implantable cardioverter-defibrillator (ICD) in a 16-kg child. A transvenous ICD dual coil was advanced through a small subxiphoid incision and screwed into the oblique sinus pericardium under fluoroscopic guidance. An additional sense-pace lead was sutured onto the right ventricular apex, and the generator was placed in the upper abdominal wall through the same incision. Threshold testing demonstrated successful defibrillation at 15 J. After implantation, the patient had two episodes of appropriate shock for ventricular fibrillation. The ICD system continues to show stable impedance at 6 months of follow-up. |
20,059 | Incidence and predictors of pericardial effusion as an early complication of catheter ablation for atrial fibrillation: The Japanese Catheter Ablation Registry of Atrial Fibrillation (J-CARAF). | Pericardial effusion (PE) is one of the most frequent complications from catheter ablation of atrial fibrillation (AF). We assessed the prevalence and predictive factors of PE that require invasive treatment as an early complication of AF ablation.</AbstractText>The Japanese Heart Rhythm Society requested electrophysiology centers to register the relevant data of patients who underwent AF ablation during 6 months from 2011 to 2015. We compared the clinical profiles and the procedures of AF ablation between patients who had ablation-related PE and those who did not.</AbstractText>Two-hundred-and-eight institutions reported the data of 8319 AF ablation sessions (age 63.4±10.7 years). A total of 414 complications occurred in 401 patients (4.8%). The incidence of invasively treated critical PE was 1.0% (n=85) of total procedures, while conservatively treated noncritical PE appeared in 95 subjects. When clinical and procedural variables were compared between patients who suffered critical PE and 8140 PE-free patients, deep sedation (p=0.030), impaired left ventricular function (p=0.031), and periprocedural warfarin (p=0.023) significantly increased the incidence of critical PE in univariate analysis. Use of 3-D imaging system (p<0.001) and a periprocedural direct oral anticoagulant (DOAC, p=0.002) were related with lower incidence of critical PE. Among these factors, multivariate logistic regression analysis showed that 3-D imaging system (odds ratio 0.23 [95% CI: 0.14-0.39], p<0.001) and a periprocedural DOAC (odds ratio 0.49 [95% CI: 0.27-0.90], p=0.020) are independent predictors of the lower incidence of PE.</AbstractText>Critical PE occurred in 1% of AF ablation procedures in Japan. Our results suggest that 3-D imaging system use independently reduces the frequency of PE. DOACs in the setting of catheter ablation of AF seemed to be non-inferior to warfarin in terms of safety and effectiveness.</AbstractText> |
20,060 | Burden of Arrhythmias in Epilepsy Patients: A Nationwide Inpatient Analysis of 1.4 Million Hospitalizations in the United States. | Arrhythmias have been one of the common complications in epilepsy patients and have also been the reason for death. However, limited data exist about the burden and outcomes of arrhythmias by subtypes in epilepsy. Our study aims at evaluating the burden and differences in outcomes of various subtypes of arrhythmias in epilepsy patient population. The Nationwide Inpatient Sample (NIS) database from 2014 was examined for epilepsy and arrhythmias related discharges using appropriate International Classification of Disease, Ninth Revision Clinical Modification (ICD-9-CM) codes. The frequency of arrhythmias, gender differences in arrhythmia by subtypes, in-hospital outcomes and mortality predictors was analyzed. A total of 1,424,320 weighted epilepsy patients was determined and included in this study. Around 23.9% (n =277,230) patients had cardiac arrhythmias. The most frequent arrhythmias in the descending frequency were: atrial fibrillation (AFib) 9.7%, other unspecified causes 7.3%, sudden cardiac arrest (SCA) 1.4%, bundle branch block (BBB) 1.2%, ventricular tachycardia (VT) 1%. Males were more predisposed to cardiac arrhythmias compared to females (OR [odds ratio]: 1.1, p <0.001). The prevalence of most subtypes arrhythmias was higher in males. Arrhythmias were present in nearly a quarter of patients with epilepsy. Life threatening arrhythmias were more common in male patients. The length of stay (LOS) and mortality were significantly higher in epilepsy patients with arrhythmia. It is imperative to develop early diagnosis and prompt therapeutic measures to reduce this burden and poor outcomes due to concomitant arrhythmias in epilepsy patients. |
20,061 | Prophylactic Catheter Ablation for Ventricular Tachycardia: Are We There Yet? | Ventricular tachycardia (VT), often degenerating into ventricular fibrillation, is the leading cause of sudden cardiac death. Catheter ablation of VT is associated with relatively low, long-term success rates, while the optimal timing of ablation in patients with ischaemic and non-ischaemic cardiomyopathy remains unclear. Contemporary practice in most centres is to consider ablation late in the disease process following the failure of anti-arrhythmic medications and/or following recurrent implantable cardioverter-defibrillator shocks. Three major randomised, controlled trials have been published investigating the role of prophylactic catheter ablation for VT. In the present review, we assess the evidence from these and other related trials in VT ablation to understand if there is sufficient evidence to advocate prophylactic catheter ablation in patients with VT. |
20,062 | Limitations and Challenges in Mapping Ventricular Tachycardia: New Technologies and Future Directions. | Recurrent episodes of ventricular tachycardia in patients with structural heart disease are associated with increased mortality and morbidity, despite the life-saving benefits of implantable cardiac defibrillators. Reducing implantable cardiac defibrillator therapies is important, as recurrent shocks can cause increased myocardial damage and stunning, despite the conversion of ventricular tachycardia/ventricular fibrillation. Catheter ablation has emerged as a potential therapeutic option either for primary or secondary prevention of these arrhythmias, particularly in post-myocardial infarction cases where the substrate is well defined. However, the outcomes of catheter ablation of ventricular tachycardia in structural heart disease remain unsatisfactory in comparison with other electrophysiological procedures. The disappointing efficacy of ventricular tachycardia ablation in structural heart disease is multifactorial. In this review, we discuss the issues surrounding this and examine the limitations of current mapping approaches, as well as newer technologies that might help address them. |
20,063 | Termination of Vernakalant-Resistant Atrial Fibrillation by Inhibition of Small-Conductance Ca<sup>2+</sup>-Activated K<sup>+</sup> Channels in Pigs. | Evidence has emerged that small-conductance Ca2+</sup>-activated K+</sup> (SK) channels constitute a new target for treatment of atrial fibrillation (AF). SK channels are predominantly expressed in the atria as compared with the ventricles. Various marketed antiarrhythmic drugs are limited by ventricular adverse effects and efficacy loss as AF progresses.</AbstractText>A total of 43 pigs were used for the studies. AF reversion in conscious long-term tachypaced pigs: Pigs were subjected to atrial tachypacing (7 Hz) until they developed sustained AF that could not be reverted by vernakalant 4 mg/kg (18.8±3.3 days of atrial tachypacing). When the SK channel inhibitor AP14145 was tested in these animals, vernakalant-resistant AF was reverted to sinus rhythm, and reinduction of AF by burst pacing (50 Hz) was prevented in 8 of 8 pigs. Effects on refractory period and AF duration in open chest pigs: The effects of AP14145 and vernakalant on the effective refractory periods and acute burst pacing-induced AF were examined in anaesthetized open chest pigs. Both vernakalant and AP14145 significantly prolonged atrial refractoriness and reduced AF duration without affecting the ventricular refractoriness or blood pressure in pigs subjected to 7 days atrial tachypacing, as well as in sham-operated control pigs.</AbstractText>SK currents play a role in porcine atrial repolarization, and pharmacological inhibition of these with AP14145 demonstrates antiarrhythmic effects in a vernakalant-resistant porcine model of AF. These results suggest SK channel blockers as potentially interesting anti-AF drugs.</AbstractText>© 2017 The Authors.</CopyrightInformation> |
20,064 | Distinct Cellular Basis for Early Cardiac Arrhythmias, the Cardinal Manifestation of Arrhythmogenic Cardiomyopathy, and the Skin Phenotype of Cardiocutaneous Syndromes. | Arrhythmogenic cardiomyopathy is caused primarily by mutations in genes encoding desmosome proteins. Ventricular arrhythmias are the cardinal and typically early manifestations, whereas myocardial fibroadiposis is the pathological hallmark. Homozygous DSP</i> (desmoplakin) and JUP</i> (junction protein plakoglobin) mutations are responsible for a subset of patients with arrhythmogenic cardiomyopathy who exhibit cardiac arrhythmias and dysfunction, palmoplanter keratosis, and hair abnormalities (cardiocutaneous syndromes).</AbstractText>To determine phenotypic consequences of deletion of Dsp</i> in a subset of cells common to the heart and skin.</AbstractText>Expression of CSPG4 (chondroitin sulfate proteoglycan 4) was detected in epidermal keratinocytes and the cardiac conduction system. CSPG4pos</sup> cells constituted ≈5.6±3.3% of the nonmyocyte cells in the mouse heart. Inducible postnatal deletion of Dsp</i> under the transcriptional control of the Cspg4</i> locus led to ventricular arrhythmias, atrial fibrillation, atrioventricular conduction defects, and death by 4 months of age. Cardiac arrhythmias occurred early and in the absence of cardiac dysfunction and excess cardiac fibroadipocytes, as in human arrhythmogenic cardiomyopathy. The mice exhibited palmoplantar keratosis and progressive alopecia, leading to alopecia totalis, associated with accelerated proliferation and impaired terminal differentiation of keratinocytes. The phenotype is similar to human cardiocutaneous syndromes caused by homozygous mutations in DSP</i>.</AbstractText>Deletion of Dsp</i> under the transcriptional regulation of the CSPG4 locus led to lethal cardiac arrhythmias in the absence of cardiac dysfunction or fibroadiposis, palmoplantar keratosis, and alopecia, resembling the human cardiocutaneous syndromes. The findings offer a cellular basis for early cardiac arrhythmias in patients with arrhythmogenic cardiomyopathy and cardiocutaneous syndromes.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,065 | Circulatory Dynamics During Pulmonary Vein Isolation Using the Second-Generation Cryoballoon. | Circulatory dynamics change during pulmonary vein (PV) isolation using cryoballoons. This study sought to investigate the circulatory dynamics during cryoballoon-based PV isolation procedures and the contributing factors.</AbstractText>This study retrospectively included 35 atrial fibrillation patients who underwent PV isolation with 28-mm second-generation cryoballoons and single 3-minute freeze techniques. Blood pressures were continuously monitored via arterial lines. The left ventricular function was evaluated with intracardiac echocardiography throughout the procedure in 5 additional patients. Overall, 126 cryoapplications without interrupting freezing were analyzed. Systolic blood pressure (SBP) significantly increased during freezing (138.7±28.0 to 148.0±27.2 mm Hg, P</i><0.001) and sharply dropped (136.3±26.0 to 95.0±17.9 mm Hg, P</i><0.001) during a mean of 21.0±8.0 seconds after releasing the occlusion during thawing. In the multivariate analyses, the left PVs (P</i>=0.008) and lower baseline SBP (P</i><0.001) correlated with a larger SBP rise, whereas a higher baseline SBP (P</i><0.001), left PVs (P</i>=0.017), lower balloon nadir temperature (P</i>=0.027), and female sex (P</i>=0.045) correlated with larger SBP drops. These changes were similarly observed regardless of preprocedural atropine administration and the target PV order. PV occlusions without freezing exhibited no SBP change. PV antrum freezing without occlusions similarly increased the SBP, but the SBP drop was significantly smaller than that with occlusions (P</i><0.001). The SBP drop time-course paralleled the left ventricular ejection fraction increase (66.8±8.1% to 79.3±6.7%, P</i><0.001) and systemic vascular resistance index decrease (2667±1024 to 1937±513 dynes-sec/cm2</sup> per m2</sup>, P</i>=0.002).</AbstractText>With second-generation cryoballoon-based PV isolation, SBP significantly increased during freezing owing to atrial tissue freezing and dropped sharply after releasing the occlusion, presumably because of the peripheral vascular resistance decrease mainly by circulating chilled blood.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,066 | Unusual complications from amitriptyline intoxication. | Althoughtricyclic antidepressants(TCAs) are frequently prescribed to patients with depression, these drugs can also be misused. A 21-year-old comatose patient was referred to our hospital presenting with ventricular tachycardia. Despite initial treatment including intravascular lipid emulsion, ventricular fibrillation occurred soon after arrival. Venoarterial extracorporeal membrane oxygenation and therapeutic hypothermia were administered. Refractory arrhythmia disappeared on the next day. A high concentration of amitriptyline was identified in his blood samples on arrival. Mechanical bowel obstruction followed after abdominal compartment syndrome caused by anticholinergic effects, and refractory seizure occurred due to TCA intoxication. Although seizure was brought under control with anticonvulsant agents, his Glasgow Coma Scale did not recover to the full score. MRI presented irreversible damage to the bilateral frontal lobe and insula. Amitriptyline has the potential to cause unusual serious complications, such as abdominal compartment syndrome, irreversible central nervous system disability and lethal arrhythmia. |
20,067 | [Influence of Rhubarb extract on the expression of NGAL and IL-18 in the kidney of rabbits after CPR]. | To study the preventive effect and mechanism of Rhubarb extract on renal injury after cardiopulmonary resuscitation (CPR) in rabbits with cardiac arrest (CA).</AbstractText>Twenty-four male Japanese big-ear rabbits were divided into sham operation group, CPR model group and Rhubarb pretreatment group by random number table method, with 8 rabbits in each group. The rabbits in Rhubarb pretreatment group were treated with Rhubarb extract 5 mL×kg-1</sup>×d-1</sup> for 7 days; and those in sham operation group and CPR model group were fed with 0.9% normal saline 10 mL/d for 7 days. After 7 days, ventricular fibrillation (VF) was produced in CPR model group and Rhubarb pretreatment group by 50 V alternating currents stimulation through bottom of the heart leads to the apex to prepare CPR model. The rabbits of the CPR model group and Rhubarb pretreatment group were sacrificed at 2 hours after successful resuscitation, and the animals in the sham operated group were sacrificed directly after anesthesia. The levers of blood urea nitrogen (BUN) and creatinine (Cr) in serum were examined by automatic biochemical analyzer. The positive expression area of neutrophil gelatinase-associated lipocalin (NGAL) and interleukin-18 (IL-18) in kidney were examined by immunohistochemistry.</AbstractText>Compared with the sham operation group, the levels of BUN and Cr were significantly increased in the CPR model group and Rhubarb pretreatment group [BUN (mmol/L): 15.53±3.90, 10.51±3.16 vs. 7.03±2.23, Cr (μmol/L): 137.20±12.23, 86.80±7.67 vs. 66.39±5.47, both P < 0.05]. Compared with the CPR model group, the levels of BUN and Cr were significantly decreased in the Rhubarb pretreatment group [BUN (mmol/L): 10.51±3.16 vs. 15.53±3.90, Cr (μmol/L): 86.80±7.67 vs. 137.20±12.23, both P < 0.05]. Immunohistochemical staining showed that the expression of NGAL and IL-18 mainly existed in glomerular and tubular cells in patina. Compared with the sham operation group, the positive expression areas of NGAL and IL-18 in kidney were significantly increased in the CPR model group and Rhubarb pretreatment group [NGAL (μm2</sup>): 208.26±7.58, 136.74±5.33 vs. 98.93±7.83, IL-18 (μm2</sup>): 256.48±4.64, 113.22±6.98 vs. 77.06±6.47, all P < 0.05]. Compared with the CPR model group, the positive expression areas of NGAL and IL-18 were significantly decreased in the Rhubarb pretreatment group [NGAL (μm2</sup>): 136.74±5.33 vs. 208.26±7.58, IL-18 (μm2</sup>): 113.22±6.98 vs. 256.48±4.64, both P < 0.05].</AbstractText>CA can lead to acute kidney injury (AKI). Rhubarb extract can reduce the expression of NGAL and IL-18 in kidney of rabbits after CPR, and protect the kidney after CPR.</AbstractText> |
20,068 | [Analysis of out-of-hospital emergency treatment for ventricular fibrillation between 2013 and 2016 in Shanghai]. | To investigate the epidemiological features of out-of-hospital patients with ventricular fibrillation (VF) in Shanghai and to analysis factors associated with outcomes, and to provide evidence for improving the success rate of VF.</AbstractText>The data of patients with VF admitted to Shanghai Medical Emergency Center from January 2013 to December 2016 were analyzed retrospectively. All the data were recorded including the clinical data, medical service time, return of spontaneous circulation (ROSC) at scene/en route, survival to hospital discharge. Factors that associated with successful resuscitation were analyzed by Logistic regression.</AbstractText>From 2013 to 2016, 21 096 patients with suspected cardiac arrest were admitted to the Shanghai Medical Emergency Center. After excluding ventricular tachycardia (13 cases) and ventricular asystole (20 995 cases), 88 patients with VF were enrolled, with 62 male and 26 female; the average age was (63.22±16.15) years old. While bystander cardiopulmonary resuscitation (CPR) was performed in only 21 cases (23.86%). Fifty-seven cases occurred during the day (08:00-20:00), while 31 cases occurred in the night. And the average emergency response time was (6.47±4.13) minutes; the average on-site time was (14.76±10.88) minutes; the average transport to hospital time was (5.95±4.00) minutes. There were no significant differences in response time, on-site time and transport to hospital time each year, and there were no significant differences in emergency medical service time between day and night either. From 2013 to 2016, prehospital successful resuscitation rate was decreased by years [95.65% (22/23), 87.50% (14/16), 83.33% (20/24) vs. 80.00% (20/25), respectively, χ2</sup> = 1.895, P = 0.595]. Survival to hospital discharge rate was increased by years [21.74% (5/23), 31.25% (5/16), 37.50% (9/24), 40.00% (10/25), respectively, χ 2</sup> = 2.862, P = 0.413]. The success rate of prehospital resuscitation for patients with 1, 2, ≥3 defibrillation was 35.23% (31/88), 23.08% (12/52), 89.19% (33/37), respectively (χ2</sup> = 42.811, P = 0.000). The on-site time in successful final resuscitation group was shorter than that in final resuscitation failure group (minutes: 10.85±8.83 vs. 16.79±11.36, t = 2.367, P = 0.020), the ROSC time in successful final resuscitation group was shorter than that of final resuscitation failure group (minutes: 3.24±3.17 vs. 7.43±6.64, t = 3.175, P = 0.002). It was shown by Logistic regression that long ROSC time was the risk factor for final resuscitation failure [odds ratio (OR) = 0.771, P = 0.024]. Gender, age, availability of witnesses CPR, call time, emergency response time, on-site time and transport to hospital time had no significant impact on the prehospital successful resuscitation and final successful resuscitation. In prehospital successful resuscitation group, there was significant difference in survival to hospital discharge rate among different defibrillation times group [48.39% (15/31), 58.33% (7/12) vs. 21.21% (7/33), χ2</sup> = 7.460, P = 0.024].</AbstractText>From 2013 to 2016, there were no significant changes in the emergency response time, prehospital successful resuscitation rate and survival to hospital discharge rate of patients with VF in Shanghai. Though, repeated defibrillation could significantly increased prehospital successful resuscitation rate, multiple defibrillation indicated decline of survival to hospital discharge rate in prehospital successful resuscitation group. Additionally, long on-site time and long ROSC time indicated poor prognosis.</AbstractText> |
20,069 | The prognostic impact of single extra-stimulus on programmed ventricular stimulation in Brugada patients without previous cardiac arrest: multi-centre study in Japan. | The prognostic value of programmed electrical stimulation (PES) in Brugada syndrome (BrS) remains controversial. One of the reasons for discrepant results may be due to the selection of stimulation protocol. We evaluated the prognostic value of a positive PES result (PES+) according to the inducible pacing sites and the number of extra-stimuli in BrS patients without previous cardiac arrest (CA).</AbstractText>We enrolled 224 consecutive BrS patients without previous CA (mean age 51 ± 14 years, 209 males), who underwent PES with the identical protocol. Clinical outcomes of development of CA were explored in the patients with and without PES+ according to sites and number of extra-stimuli. During a mean follow-up period of 76 months, 12 cardiac events (CE: sudden cardiac death or documented VF) occurred (8 with and 4 without PES+). The incidence of CE was not different in patients with and without PES+, those with PES+ from RVA (n = 72) or RVOT (n = 60), and those with and without PES+ by up to 2 extra-stimuli (n = 58). However, in patients that were PES+ by a single extra-stimulus (n = 8) the incidence of CE was significantly higher than in those without PES+ (8.8 vs. 0.6%/year, P < 0.0001). On univariate analysis, syncope, spontaneous type 1 ECG, and PES+ by a single extra-stimulus were associated with CE.</AbstractText>Details of the stimulation protocol may be important for risk assessment in BrS patients without previous CA. A single extra-stimulus may be useful in stratifying risk in patients with spontaneous type 1 ECG and syncope.</AbstractText> |
20,070 | Safety and efficiency of porous-tip contact-force catheter for drug-refractory symptomatic paroxysmal atrial fibrillation ablation: results from the SMART SF trial. | THERMOCOOL SMARTTOUCH® SF Catheter is a new contact-force (CF)-sensing catheter with 56-hole porous tip designed for improved cooling and reduced fluid delivery compared with a standard 6-hole open-irrigated catheter. The SMART SF study examined the periprocedural safety, acute effectiveness, and procedural efficiency of the catheter for drug-refractory symptomatic paroxysmal atrial fibrillation (PAF) ablation.</AbstractText>The prospective, open-label, non-randomized SMART-SF was conducted at 17 US sites. Circumferential pulmonary vein (PV) isolation was performed with confirmation of entrance block in all PVs. Stable ablation sites were identified using CARTO VISITAG™ Module. Primary adverse events (AEs; ≤1 week of index procedure), periprocedural AEs within 30 days of ablation procedure, acute effectiveness (confirmation of entrance block for targeted PVs), CF, and procedural parameters were assessed. Overall, 165 patients were enrolled (mean age, 62.7 years; male, 57.9%; white, 97%; left ventricular ejection fraction, 60.1 ± 7%; left atrium diameter, 38.8 ± 6 mm); 159 underwent radiofrequency ablation and comprised the safety cohort. Primary safety performance criteria were met: primary AE rate was 2.5% (4/159; cardiac tamponade [n = 2], thrombo-embolism [n = 1], transient ischaemic attack [n = 1]). All primary AEs resolved/improved within the 1-month follow-up period. Acute procedural effectiveness was attained in 96.2% (95% confidence interval: 92.0-98.6%) of patients. Procedure time, fluoroscopy time, and fluid delivered were observed in comparison to predecessor catheters.</AbstractText>In the SMART-SF trial, the predetermined safety performance goal was met, demonstrating the safety and acute effectiveness of the THERMOCOOL SMARTTOUCH® SF Catheter for PAF ablation.</AbstractText> |
20,071 | Broad antiarrhythmic effect of mexiletine in different arrhythmia models. | Experimental studies and clinical reports suggest antiarrhythmic properties of mexiletine in different arrhythmias. We aimed at investigating mexiletine in experimental models of atrial fibrillation (AF) as well as in long-QT- (LQTS) and short-QT-syndrome (SQTS).</AbstractText>In 15 isolated rabbit hearts, erythromycin (300 µM) was infused for simulation of long-QT-2-syndrome. In further 13 hearts, veratridine was administered to simulate long-QT-3-syndrome. Both drugs induced a significant QT-prolongation (erythromycin: +87 ms, P < 0.01; veratridine: +19 ms, P < 0.05) and increased dispersion of repolarization (erythromycin: +55 ms, P < 0.01; veratridine +31 ms, P < 0.01). Additional infusion of mexiletine (25 µM) resulted in a significant reduction of dispersion (erythromycin: -43 ms, P < 0.01; veratridine: -26 ms, P < 0.05). Reproducible induction of torsade de pointes was observed in 13 of 15 erythromycin-treated hearts (192 episodes) and 6 of 13 veratridine-treated hearts (36 episodes). Additional infusion of mexiletine significantly reduced ventricular tachycardia (VT) incidence. With mexiletine, only 3 of 15 erythromycin-treated hearts (27 episodes) and 1 of 13 veratridine-treated hearts (2 episodes) presented polymorphic VT. In additional 9 hearts, the IK-ATP-channel-opener pinacidil was employed to simulate SQTS and significantly abbreviated ventricular repolarization (QT-interval: -18 ms, P < 0.05) and enhanced induction of ventricular fibrillation (VF). Mexiletine reversed the effects of pinacidil, increase refractory period (+127 ms, P < 0.01) and significantly suppressed induction of VF. In further 13 hearts AF was induced by combined treatment with acetylcholine/isoproterenol. Mexiletine also increased atrial refractory period (+80 ms, P < 0.01) and thereby effectively suppressed atrial fibrillation.</AbstractText>Acute infusion of mexiletine significantly reduced the occurrence of polymorphic VT in the presence of pharmacologically simulated LQTS. Furthermore, mexiletine demonstrated potent antiarrhythmic properties in a model of SQTS and in AF.</AbstractText> |
20,072 | Triggered intracellular calcium waves in dog and human left atrial myocytes from normal and failing hearts. | Abnormal intracellular Ca2+ cycling contributes to triggered activity and arrhythmias in the heart. We investigated the properties and underlying mechanisms for systolic triggered Ca2+ waves in left atria from normal and failing dog hearts.</AbstractText>Intracellular Ca2+ cycling was studied using confocal microscopy during rapid pacing of atrial myocytes (36 °C) isolated from normal and failing canine hearts (ventricular tachypacing model). In normal atrial myocytes (NAMs), Ca2+ waves developed during rapid pacing at rates ≥ 3.3 Hz and immediately disappeared upon cessation of pacing despite high sarcoplasmic reticulum (SR) load. In heart failure atrial myocytes (HFAMs), triggered Ca2+ waves (TCWs) developed at a higher incidence at slower rates. Because of their timing, TCW development relies upon action potential (AP)-evoked Ca2+ entry. The distribution of Ca2+ wave latencies indicated two populations of waves, with early events representing TCWs and late events representing conventional spontaneous Ca2+ waves. Latency analysis also demonstrated that TCWs arise after junctional Ca2+ release has occurred and spread to non-junctional (cell core) SR. TCWs also occurred in intact dog atrium and in myocytes from humans and pigs. β-adrenergic stimulation increased Ca2+ release and abolished TCWs in NAMs but was ineffective in HFAMs making this a potentially effective adaptive mechanism in normals but potentially arrhythmogenic in HF. Block of Ca-calmodulin kinase II also abolished TCWs, suggesting a role in TCW formation. Pharmacological manoeuvres that increased Ca2+ release suppressed TCWs as did interventions that decreased Ca2+ release but these also severely reduced excitation-contraction coupling.</AbstractText>TCWs develop during the atrial AP and thus could affect AP duration, producing repolarization gradients and creating a substrate for reentry, particularly in HF where they develop at slower rates and a higher incidence. TCWs may represent a mechanism for the initiation of atrial fibrillation particularly in HF.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions please email: journals.permissions@oup.com.</CopyrightInformation> |
20,073 | Low-energy defibrillation with nanosecond electric shocks. | Reliable defibrillation with reduced energy deposition has long been the focus of defibrillation research. We studied the efficacy of single shocks of 300 ns duration in defibrillating rabbit hearts as well as the tissue damage they may cause.</AbstractText>New Zealand white rabbit hearts were Langendorff-perfused and two planar electrodes were placed on either side of the heart. Shocks of 300 ns duration and 0.3-3 kV amplitude were generated with a transmission line generator. Single nanosecond shocks consistently induced waves of electrical activation, with a stimulation threshold of 0.9 kV (over 3 cm) and consistent activation for shock amplitudes of 1.2 kV or higher (9/9 successful attempts). We induced fibrillation (35 episodes in 12 hearts) and found that single shock nanosecond-defibrillation could consistently be achieved, with a defibrillation threshold of 2.3-2.4 kV (over 3 cm), and consistent success at 3 kV (11/11 successful attempts). Shocks uniformly depolarized the tissue, and the threshold energy needed for nanosecond defibrillation was almost an order of magnitude lower than the energy needed for defibrillation with a monophasic 10 ms shock delivered with the same electrode configuration. For the parameters studied here, nanosecond defibrillation caused no baseline shift of the transmembrane potential (that could be indicative of electroporative damage), no changes in action potential duration, and only a brief change of diastolic interval, for one beat after the shock was delivered. Histological staining with tetrazolium chloride and propidium iodide showed that effective defibrillation was not associated with tissue death or with detectable electroporation anywhere in the heart (six hearts).</AbstractText>Nanosecond-defibrillation is a promising technology that may allow clinical defibrillation with profoundly reduced energies.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions please email: journals.permissions@oup.com.</CopyrightInformation> |
20,074 | Newly developed left ventricular apical thrombus under dabigatran treatment. | : Left ventricular (LV) thrombi are mostly formed in the aneurysmal or akinetic segment of the LV apex. Thromboembolism to the brain is usually fatal. There is not enough information available regarding the use of these new oral anticoagulant agents in LV thrombi. In this case, we present a 56-year-old male patient who was given dabigatran (150 mg, twice a day) for paroxysmal atrial fibrillation after experiencing anterior myocardial infarction. During the use of dabigatran, thrombus formation, which was not present earlier, was observed in the LV apical aneurysm. The dabigatran treatment discontinued and warfarin was initiated and, in the follow-ups, the thrombus was observed to shrink, and complete resolution was seen 6 weeks after treatment with warfarin. The patient did not experience any thromboembolic event. Our case is the first report showing that the treatment of dabigatran 150 mg may not prevent LV thrombus development. |
20,075 | Atrial myxomas causing severe left and right ventricular dysfunction. | Myxomas are the most common cardiac tumors, accounting for about 50% of benign primary cardiac tumors, with the majority located in the left atrium, and 80% of which originate in the interatrial septum. We report two cases with severe cachexia, neurological sequelae, and severe biventricle dysfunction secondary to atrial myxomas with marked early improvement after tumor excision. |
20,076 | Implantable cardioverter-defibrillator in the elderly: Predictors of appropriate interventions and mortality at 12-month follow-up. | The effectiveness of implantable cardioverter-defibrillator (ICD) in the elderly is uncertain, given their competing risk of nonarrhythmic death. Guidelines state that an ICD should be implanted if the expectation of survival is at least 1 year. However, survival is not easy to predict in elderly patients with severe cardiac disease.</AbstractText>To assess 12-month survival after ICD implantation in patients aged ≥75 years, to identify predictors of 12-month mortality, and to evaluate the incidence of ICD therapy during follow-up.</AbstractText>We retrospectively analyzed all clinical, instrumental, and survival data of patients ≥75 years old who received an ICD in our center from 2000 to 2013.</AbstractText>We included 127 patients (mean age 78 years). ICD was implanted for primary prevention in 61%. The 12-month survival rate was 87.4%. At both univariate and multivariate analyses, left ventricular ejection fraction (EF) ≤ 25%, and moderate to severe impaired renal function (IRF) independently predicted 12-month mortality that was as high as 45.5% in patients with both risk factors. During a median follow-up of 38 months, 30 patients (23.6%) received ≥1 appropriate ICD interventions, but only 3.1% of shocks occurred during the first year, and none in the subgroup of patients with EF ≤ 25% and IRF.</AbstractText>Twelve-month survival in elderly patients after ICD implantation is good and the indication for ICD should not be based on age alone. However, the subgroup with EF ≤ 25% and IRF showed a high 12-month nonarrhythmic mortality and did not benefit from ICD implantation.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,077 | Usefulness of the WCD in patients with suspected tachymyopathy. | The wearable cardioverter defibrillator (WCD) is used for temporary protection of patients deemed to be at high risk for sudden death. There is limited experience regarding the clinical development of patients with tachymyopathy. We aimed to evaluate the clinical development of tachymyopathy patients protected with a WCD in a single-center non-randomized patient cohort.</AbstractText>We fitted 130 consecutive patients deemed to be at high risk for ventricular tachyarrhythmias with the WCD. Of these, 20 patients (15%) presenting with newly diagnosed heart failure in the setting of rapidly conducted atrial fibrillation/flutter were suspected to suffer from tachymyopathy. The control group consisted of the remaining 110 patients with other indications for WCD therapy. LVEF increased by more than 10% in 13/20 (65%) tachymyopathy patients compared to 40/110 (36%) patients in the control population (p = 0.01). Similarly, BNP levels decreased in 15/20 (75%) tachymyopathy patients compared to 41/110 (37%) in the control group (p = 0.05). ICD implantation rates were lower in the tachymyopathy group (3/20) compared to the control population (40/110; p = 0.04). On further follow-up (mean 12 ± 8 months), patients with suspected tachymyopathy had no sustained ventricular arrhythmias. Compared to 5/110 patients in the control group, no tachymyopathy patient died.</AbstractText>Most of the patients with suspected tachymyopathy have a favorable clinical outcome. The WCD is useful for temporary protection while LV function recovers.</AbstractText> |
20,078 | Biomarkers of Atrial Fibrillation in Hypertension. | Atrial fibrillation (AF) is the most frequently encountered cardiac arrhythmia globally and substantially increases the risk for thromboembolic disease. Albeit, 20% of all cases of AF remain undiagnosed. On the other hand, hypertension amplifies the risk for both AF occurrences through hemodynamic and non-hemodynamic mechanisms and cerebrovascular ischemia. Under this prism, prompt diagnosis of undetected AF in hypertensive patients is of pivotal importance.</AbstractText>We conducted a review of the literature for studies with biomarkers that could be used in AF diagnosis as well as in predicting the transition of paroxysmal AF to sustained AF, especially in hypertensive patients.</AbstractText>Potential biomarkers for AF can be broadly categorized into electrophysiological, morphological and molecular markers that reflect the underlying mechanisms of adverse atrial remodeling. We focused on P-wave duration and dispersion as electrophysiological markers, and left atrial (LA) and LA appendage size, atrial fibrosis, left ventricular hypertrophy and aortic stiffness as structural biomarkers, respectively. The heterogeneous group of molecular biomarkers of AF encompasses products of the neurohormonal cascade, including NT-pro BNP, BNP, MR-pro ANP, polymorphisms of the ACE and convertases such as corin and furin. In addition, soluble biomarkers of inflammation (i.e. CRP, IL-6) and fibrosis (i.e. TGF-1 and matrix metalloproteinases) were assessed for predicting AF.</AbstractText>The reviewed individual biomarkers might be a valuable addition to current diagnostic tools but the ideal candidate is expected to combine multiple indices of atrial remodeling in order to effectively detect both AF and adverse characteristics of high risk patients with hypertension.</AbstractText>Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.</CopyrightInformation> |
20,079 | Influence of atrial contraction dynamics on cardiac function. | In recent years, there has been a move from monoventricular or biventricular models of the heart, to more complex models that incorporate the electromechanical function in all 4 chambers. However, the biophysical foundation is still underdeveloped, with most work in atrial cellular models having focused on electrophysiological properties. Here, we present a biophysical model of human atrial contraction at body temperature and use it to study the effects of atrial contraction on whole organ function and a study of the effects of remodelling due to atrial fibrillation on atrial and ventricular function. |
20,080 | Non-invasive assessment of left ventricular filling pressure. | Dyspnoea is a presenting symptom for patients with heart failure. It is often due to elevated left ventricular (LV) filling pressure but can be due to pulmonary disease or other non-cardiac reasons. While physical examination is useful, it has its limitations. Accordingly, non-invasive imaging has an important role in the diagnostic evaluation of patients with known or suspected heart failure. Echocardiography is usually the first test obtained and is used to determine LV volumes, ejection fraction and mass as well as right ventricular size and function, left and right atrial volumes, valvular lesions, and pulmonary artery pressures. Additionally, LV filling pressure can be estimated. A recent algorithm was published that depends on clinical, two-dimensional data and Doppler signals. The algorithm is accurate in patients with depressed and normal ejection fraction. There are other measurements that can be obtained as LV strain and diastolic strain rate and left atrial strain. These indices provide valuable insight into LV relaxation and filling pressure as well as left atrial function. Assessment of LV filling pressure has been evaluated most extensively in patients in sinus rhythm. However, it is also possible to assess LV filling and draw inferences about LV filling pressure in patients in atrial fibrillation, in patients with mitral valve disease and in patients with left ventricular assist devices. Left ventricular filling has been assessed by other imaging modalities, including cardiac computed tomography and cardiac magnetic resonance. While these other imaging modalities may be needed in some cases, echocardiography has the highest feasibility and validation, and the most practical application. |
20,081 | Management of Arrhythmias in Athletes: Atrial Fibrillation, Premature Ventricular Contractions, and Ventricular Tachycardia. | Management of atrial fibrillation, premature ventricular contractions, and ventricular tachycardia without underlying cardiac disease or arrhythmogenic conditions differs in athletes from the general population. Athletes tend to be younger, healthier individuals with few comorbidities. Therapies that work well in the general population may not be appropriate or preferable for athletes. Management strategies include deconditioning, pharmacologic therapy, such as rate control with β-blockers or non-dihydropyridine calcium channel blockers and rhythm control with class I or class III antiarrhythmic drugs, and catheter ablation. Deconditioning is not preferred by athletes because of lost playing time. Pharmacologic therapy is well tolerated among most individuals, but is not as favorable in athletes. Rate control medications can reduce performance and β-blockers, in particular, are prohibited in many sports. Antiarrhythmic drugs are preferred over rate control with athletes, but many, especially younger athletes, may not like the idea of long-term medical therapy. Catheter ablation has been proven to be safe and efficacious, may eliminate the need for long-term medical therapy, and is supported by the major societies (AHA, ACC, ESC). |
20,082 | Arrhythmias in Type 2 Diabetes Mellitus. | Chronic hyperglycaemia of Type 2 diabetes mellitus causes long term damage to heart resulting in coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF), and sudden death from arrhythmias.</AbstractText>To study the prevalence of different types of arrhythmias in T2DM, particularly in association with Cardiac Autonomic Neuropathy (CAN).</AbstractText>A cross-sectional study including 100 patients of Type 2 Diabetes Mellitus (T2DM) presenting with cardiac arrhythmias, was done at our hospital over 2 years. Detailed history along with physical examination and tests for CAN were done. Routine investigations along with echocardiography, stress test, Holter monitoring were done.</AbstractText>Sinus Tachycardia (ST) was the commonest arrhythmia, found in 32% of patients. 20% had Complete Heart Block (CHB), 15% had Sinus Bradycardia (SB), and 15% had Atrial Fibrillation (AF). Ventricular Premature Complex (VPC) was found in 10% and 3% had Atrial Premature Complex (APC). 3% had first degree AV block, whereas 1% had Paroxysmal Supra Ventricular Tachycardia (PSVT), and another 1% had Ventricular Tachycardia (VT). Poorly controlled diabetes and co-morbidities was associated with higher incidence of arrhythmias. 62% of patients had prolonged QTc, majority of which had CAN. Most of the patients responded to standard therapy.</AbstractText> |
20,083 | Antiarrhythmics in Cardiac Arrest: A Systematic Review and Meta-Analysis. | It is widely accepted that antiarrhythmics play a role in cardiopulmonary resuscitation (CPR) universally, but the absolute benefit of antiarrhythmic use and the drug of choice in advanced life support remains controversial.</AbstractText>To perform a thorough, in-depth review and analysis of current literature to assess the efficacy of antiarrhythmics in advanced life support.</AbstractText>Two authors systematically searched through multiple bibliographic databases including CINAHL, SCOPUS, PubMed, Web of Science, Medline(Ovid) and the Cochrane Clinical Trials Registry. To be included studies had to compare an antiarrhythmic to either a control group, placebo or another antiarrhythmic in adult cardiac arrests. These studies were independently screened for outcomes in cardiac arrest assessing the effect of antiarrhythmics on return of spontaneous circulation (ROSC), survival and neurological outcomes. Data was extracted independently, compared for homogeneity and level of evidence was evaluated using the Cochrane Collaboration's tool for assessing the risk of bias. The Mantel-Haenszel (M-H) random effects model was used and heterogeneity was assessed using the I2</sup> statistic.</AbstractText>The search of the literature yielded 30 studies, including 39,914 patients. Eight antiarrhythmic agents were identified. Amiodarone and lidocaine, the two most commonly used agents, showed no significant effect on any outcome either against placebo or each other. Small low quality studies showed benefits in isolated outcomes with esmolol and bretylium against placebo. The only significant benefit of one antiarrhythmic over another was demonstrated with nifekalant over lidocaine for survival to admission (p=0.003). On sensitivity analysis of a small number of high quality level one RCTs, both amiodarone and lidocaine had a significant increase in survival to admission, with no effect on survival to discharge.</AbstractText>This systematic review and meta-analysis suggests that, based on current literature and data, there has been no conclusive evidence that any antiarrhythmic agents improve rates of ROSC, survival to admission, survival to discharge or neurological outcomes. Given the side effects of some of these agents, we recommend further research into their utility in current cardiopulmonary resuscitation guidelines.</AbstractText>Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,084 | Presence of cardiomyocytes exhibiting Purkinje-type morphology and prominent connexin45 immunoreactivity in the myocardial sleeves of cardiac veins. | Pulmonary vein (PV) myocardium is a known source of atrial fibrillation. A debated question is whether myocardial extensions into caval veins and coronary sinus (CS) have similar properties. No studies have documented specific pacemaker and/or conducting properties of human extracardiac myocardium.</AbstractText>The purpose of this study was to characterize the histology and immunohistochemical features of myocardial sleeves in the wall of cardiac veins.</AbstractText>Sections of 32 human hearts were investigated. Specimens of PVs, superior caval vein (SVC), CS, sinoatrial and atrioventricular nodes, and left ventricle were stained with Best's Carmine for selective staining of intracellular glycogen. Anti-connexin45 (Cx45)- and Cx43-specific antibodies were used to determine the conduction properties of extracardiac myocardium.</AbstractText>Myocardial sleeve was found in the wall of PVs of 15 of 16 hearts, 21 of 22 SVCs, and 8 of 8 CSs. Bundles of glycogen-positive cardiomyocytes exhibiting pale cytoplasm and peripheral myofibrils were observed in the venous sleeves. Strong Cx45 and weak Cx43 labeling was detected in the extracardiac myocardium. Similar staining pattern was observed for the pacemaker and conduction system, whereas ventricular myocardium exhibited prominent Cx43 and no Cx45 immunoreactivity.</AbstractText>Myocardial fibers of PVs, SVC, and CS exhibit morphology similar to that of Purkinje fibers and are enriched in glycogen. We provide data for the first time on prominent positive staining for Cx45 in the extracardiac myocardium, indicating its potential pacemaker and/or conducting nature.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,085 | Echocardiographic estimation of left ventricular and pulmonary pressures in patients with heart failure and preserved ejection fraction: a study utilizing simultaneous echocardiography and invasive measurements. | Although echocardiography is generally used for the diagnosis of heart failure with preserved ejection fraction (HFpEF), invasive measurements of filling pressures are the gold standard. Studies simultaneously performing echocardiography and invasive measurements in HFpEF are sparse.</AbstractText>Invasive haemodynamic and echocardiographic measurements were simultaneously performed in 98 patients with heart failure New York Heart Association class ≥II, left ventricular ejection fraction (LVEF) ≥45%, and suspected pulmonary hypertension on a previous echocardiogram. Multivariable linear regression analyses were used to establish echocardiographic predictors of pulmonary artery wedge pressure (PAWP), left ventricular end-diastolic pressure (LVEDP), and mean pulmonary arterial pressure (mPAP). Mean age of the study patients was 74 ± 9 years, 68% were female, mean LVEF was 57 ± 5%, and 30% had atrial fibrillation at the time of measurement. Mean PAWP, LVEDP and mPAP were 17.2 ± 6.2, 16.7 ± 5.8 and 30.9 ± 10.2 mmHg, respectively. Isovolumetric relaxation time (IVRT) and left atrial reservoir strain could moderately estimate PAWP (r = 0.656; P < 0.001). LVEDP was only modestly predicted by IVRT and right ventricular wall thickness (r = 0.548; P < 0.001). Surprisingly, a low correlation was found between E/e'mean</sub> and PAWP (r = 0.240; P = 0.019), E/e'mean</sub> and LVEDP (r = 0.081; P = 0.453). Correlation coefficients were similar in patients with and without atrial fibrillation.</AbstractText>In patients with HFpEF, echocardiographic measurements, including the E/e' ratio, have a poor to moderate predictive value for the estimation of invasively acquired LVEDP and PAWP. This limitation should be taken into account for the diagnosis and evaluation of patients with HFpEF.</AbstractText>© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.</CopyrightInformation> |
20,086 | The Effects of SEA0400 on Ca<sup>2+</sup> Transient Amplitude and Proarrhythmia Depend on the Na<sup>+</sup>/Ca<sup>2+</sup> Exchanger Expression Level in Murine Models. | <b>Background/Objective:</b> The cardiac Na<sup>+</sup>/Ca<sup>2+</sup> exchanger (NCX) has been identified as a promising target to counter arrhythmia in previous studies investigating the benefit of NCX inhibition. However, the consequences of NCX inhibition have not been investigated in the setting of altered NCX expression and function, which is essential, since major cardiac diseases (heart failure/atrial fibrillation) exhibit NCX upregulation. Thus, we here investigated the effects of the NCX inhibitor SEA0400 on the Ca<sup>2+</sup> transient amplitude and on proarrhythmia in homozygous NCX overexpressor (OE) and heterozygous NCX knockout (hetKO) mice compared to corresponding wild-types (WT<sub>OE</sub>/WT<sub>hetKO</sub>). <b>Methods/Results:</b> Ca<sup>2+</sup> transients of field-stimulated isolated ventricular cardiomyocytes were recorded with fluo-4-AM or indo-1-AM. SEA0400 (1 μM) significantly reduced NCX forward mode function in all mouse lines. SEA0400 (1 μM) significantly increased the amplitude of field-stimulated Ca<sup>2+</sup> transients in WT<sub>OE</sub>, WT<sub>hetKO</sub>, and hetKO, but not in OE (% of basal; OE = 98.7 ± 5.0; WT<sub>OE</sub> = 137.8 ± 5.2<sup>*</sup>; WT<sub>hetKO</sub> = 126.3 ± 6.0<sup>*</sup>; hetKO = 140.6 ± 12.8<sup>*</sup>; <sup>*</sup><i>p</i> < 0.05 vs. basal). SEA0400 (1 μM) significantly reduced the number of proarrhythmic spontaneous Ca<sup>2+</sup> transients (sCR) in OE, but increased it in WT<sub>OE</sub>, WT<sub>hetKO</sub> and hetKO (sCR per cell; basal/+SEA0400; OE = 12.5/3.7; WT<sub>OE</sub> = 0.2/2.4; WT<sub>hetKO</sub> = 1.3/8.8; hetKO = 0.2/5.5) and induced Ca<sup>2+</sup> overload with subsequent cell death in hetKO. <b>Conclusion:</b> The effects of SEA0400 on Ca<sup>2+</sup> transient amplitude and the occurrence of spontaneous Ca<sup>2+</sup> transients as a proxy measure for inotropy and cellular proarrhythmia depend on the NCX expression level. The antiarrhythmic effect of SEA0400 in conditions of increased NCX expression promotes the therapeutic concept of NCX inhibition in heart failure/atrial fibrillation. Conversely, in conditions of reduced NCX expression, SEA0400 suppressed the NCX function below a critical level leading to adverse Ca<sup>2+</sup> accumulation as reflected by an increase in Ca<sup>2+</sup> transient amplitude, proarrhythmia and cell death. Thus, the remaining NCX function under inhibition may be a critical factor determining the inotropic and antiarrhythmic efficacy of SEA0400. |
20,087 | Nonalcoholic fatty liver disease is associated with an increased risk of heart block in hospitalized patients with type 2 diabetes mellitus. | Recent studies suggested that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiac tachyarrhythmias (mainly atrial fibrillation) in patients with and without type 2 diabetes mellitus. The aim of this study was to examine whether an association also exists between NAFLD and heart block. We have retrospectively evaluated a hospital-based cohort of 751 patients with type 2 diabetes discharged from our Division of Diabetes and Endocrinology during years 2007-2014. Standard electrocardiograms were performed on all patients. Diagnosis of NAFLD was based on ultrasonography, whereas the severity of advanced hepatic fibrosis was based on the fibrosis (FIB)-4 score and other non-invasive fibrosis markers. Overall, 524 (69.8%) patients had NAFLD and 202 (26.9%) had heart block (defined as at least one block among first-degree atrio-ventricular block, second-degree block, third-degree block, left bundle branch block, right bundle branch block, left anterior hemi-block or left posterior hemi-block) on electrocardiograms. Patients with NAFLD had a remarkably higher prevalence of any persistent heart block than those without NAFLD (31.3% vs. 16.7%, p<0.001); this prevalence was particularly increased among those with higher FIB-4 score. NAFLD was associated with a threefold increased risk of prevalent heart block (adjusted-odds ratio 3.04, 95% CI 1.81-5.10), independently of age, sex, hypertension, prior ischemic heart disease, hemoglobin A1c, microvascular complication status, use of medications and other potentially confounding factors. In conclusion, this is the largest cross-sectional study to show that NAFLD and its severity are independently associated with an increased risk of prevalent heart block in hospitalized patients with type 2 diabetes. |
20,088 | Heart Toxicity Related to Herbs and Dietary Supplements: Online Table of Case Reports. Part 4 of 5. | The purpose of this review was to create an online research summary table of heart toxicity case reports related to dietary supplements (DS; includes herbs).</AbstractText>Documented PubMed case reports of DS appearing to contribute to heart-related problems were used to create a "Toxic Table" that summarized the research (1966 to April, 2016, and cross-referencing). Keywords included "herb," "dietary supplement," and cardiac terms. Case reports were excluded if they were herb combinations (some exceptions), Chinese herb mixtures, teas of mixed herb contents, mushrooms, poisonous plants, self-harm (e.g. suicide), excess dose (except vitamins/minerals), drugs or illegal drugs, drug-herbal interactions, and confounders of drugs or diseases. The spectrum of heart toxicities included hypertension, hypotension, hypokalemia, bradycardia, tachycardia, arrhythmia, ventricular fibrillation, heart attack, cardiac arrest, heart failure, and death.</AbstractText>Heart related problems were associated with approximately seven herbs: Four traditional Chinese medicine herbs - Don quai (Angelica sinensis), Jin bu huan (Lycopodium serratum), Thundergod vine or lei gong teng (Tripterygium wilfordii Hook F), and Ting kung teng (Erycibe henryi prain); one an Ayruvedic herb - Aswagandha, (Withania somnifera); and two North American herbs - blue cohosh (Caulophyllum thalictroides), and Yohimbe (Pausinystalia johimbe). Aconitum and Ephedra species are no longer sold in the United States. The DS included, but are not limited to five DS - bitter orange, caffeine, certain energy drinks, nitric oxide products, and a calming product. Six additional DS are no longer sold. Licorice was the food related to heart problems.</AbstractText>The online "Toxic Table" forewarns clinicians, consumers and the DS industry by listing DS with case reports related to heart toxicity. It may also contribute to Phase IV post marketing surveillance to diminish adverse events that Government officials use to regulate DS.</AbstractText> |
20,089 | Renin-angiotensin system inhibition is associated with reduced risk of left atrial appendage thrombosis formation in patients with atrial fibrillation. | Inhibition of the renin-angiotensin axis can reduce the likelihood of atrial fibrillation (AF). However, the effects of angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) on thrombogenicity in AF remain incompletely elucidated. Thisretrospective case-control study was conducted to evaluate whether the use of ACEI or ARB could reduce the incidence of left atrial appendage thrombus (LAAT) and spontaneous echocardiographic contrast (SEC) in patients with AF.</AbstractText>A total of 199 AF patients who received both transesophageal echocardiogram (TEE) and transthoracic echocardiogram (TTE) successively on the same day from 2012 to 2016 were enrolled. Left atrial dimension, maximal left atrial volume (LAVmax), left ventricular end-diastolic dimension, left ventricular ejection fraction, and the ratio of the early transmitral flow velocity and the early mitral annular velocity (E/e') were determined. Longitudinal LA strain was evaluated using two-dimensional speckle tracking imaging at each LA segment. Peak systolic strain was calculated by averaging total segments. LAAT, LAA emptying flow velocity (LAAeV) and SEC were evaluated by TEE. Risk factors for LAAT and usage of ACEIs or ARBs were recorded.</AbstractText>The incidence of LAAT was 27.6%. Among the patients with renin-angiotensin system (RAS) inhibitors, 20.5% were demonstrated to have LAAT, compared with 33.3% in the nonuser group (p = 0.044). LA peak systolic strain and LAAeV were significantly increased in patients with RAS inhibitors compared to the nonuser group (p = 0.002, p = 0.047, respectively). Patients with LAAT had higher CHA2DS2-VASc scores and evident SEC compared with those without LAAT (p = 0.000, p = 0.000, respectively). Usage of ACEIs/ARBs and antiplatelet drugs were frequent in patients with LAAT than in those without LAAT (p = 0.044, p = 0.000, respectively). Even after controlling for LAAT-related risk factors (age, body mass index, AF type, hypertension, diabetes mellitus, prior stroke or transient ischemic attack, drinking history and usage of antiplatelet drugs and LAVmax), use of RAS inhibitors remained significantly associated with a lower risk of LAAT (OR = 0.222; 95% CI 0.084-0.585, p = 0.002).</AbstractText>This study shows that RAS inhibitors may be effective in reducing the risk of LAAT in patients with AF through atrial reverse remodeling.</AbstractText> |
20,090 | A case study of likely wild-type cardiac transthyretin amyloidosis causing rapid deterioration. | We present the case of an 88-year-old gentleman who presented to hospital septic with bilateral leg cellulitis, pulmonary oedema and hypotension. He had no history of heart disease but had had bilateral carpal tunnel releases. His condition deteriorated with refractory hypotension in spite of fluid filling, inotropic and vasopressor support. His echocardiogram showed an infiltrative cardiomyopathy with a speckled myocardium, severe concentric left and right ventricular increased wall thickness, diastolic dysfunction, biatrial dilatation and restrictive physiology in keeping with cardiac amyloidosis. He developed atrial fibrillation and worsening respiratory failure due to fluid overload and was intubated and ventilated but continued to decline and passed away. The degree of heart failure in the absence of ischaemia, the patient's advanced age, echocardiographic findings and past history of carpal tunnel syndrome in a male are strongly indicative of a diagnosis of wild-type cardiac transthyretin amyloidosis. We discuss the key features and intensive care management of this disease. |
20,091 | Meta-analysis of the efficacies of amiodarone and nifekalant in shock-resistant ventricular fibrillation and pulseless ventricular tachycardia. | Amiodarone (AMD) and nifekalant (NIF) are used in the treatment of ventricular fibrillation or tachycardia; however, only few studies have been conducted on their efficacies. Therefore, a meta-analysis was conducted. Relevant sources were identified from PubMed, Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi. The outcomes were short-term and long-term survival in patients with shock-resistant ventricular fibrillation /pulseless ventricular tachycardia. Thirty-three studies were analysed. The results showed that, compared to the control treatment, AMD did not improve short-term survival (odds ratio (OR): 1.25, 95% confidence interval (CI): 0.91-1.71) or long-term survival (OR: 1.00, 95% CI: 0.63-1.57). However, compared to the control treatment, NIF significantly improved short-term survival (OR: 3.23, 95% CI: 2.21-4.72) and long-term survival (OR: 1.88, 95% CI: 1.36-2.59). No significant difference was observed in short-term survival (OR: 0.85, 95% CI: 0.63-1.15) or long-term survival (OR: 1.25, 95% CI: 0.67-2.31) between AMD- and NIF-treated patients. The results suggest that NIF is beneficial for short-term and long-term survival in shock-resistant ventricular fibrillation/pulseless ventricular tachycardia; however, the efficacy of AMD in either outcome is not clear. |
20,092 | Specific indications and clinical outcome in patients with subcutaneous implantable cardioverter-defibrillator (ICD) - A nationwide multicentre registry. | Subcutaneous implantable cardioverter-defibrillators (S-ICD) are an innovative and less invasive alternative to transvenous ICD (TV-ICD) in selected patients. We aimed to investigate the underlying diseases and the specific indications for implanting S-ICD in clinical practice, as well as the prevalence of shock delivery and complications.</AbstractText>From December 2012, data of 236 patients (30,5% female; age 48,6±16,8years) were gathered from 12 centres in Austria. Follow-up data over a period of 1,7±1,1years were available for 231 patients (in total 359,2 patient-years). Predominant underlying diseases were ischemic cardiomyopathy (iCMP; 32,0%), idiopathic ventricular fibrillation (22,6%) and dilated cardiomyopathy (dCMP; 17,3%). The most frequent indications for implantation were sudden cardiac death survival (27,4%), primary prevention for iCMP (23,9%) and for dCMP (12,8%), and previous explantation of TV-ICD (12,4%). Appropriate shocks were documented in 16 patients (6,9%), iCMP being the predominant underlying disease. Arrhythmia conversion was successful in all patients, efficacy of the first shock was 96%. Inappropriate shock rate was 5,2%, predominantly caused by oversensing of T wave or artefacts. A device upgrade to an ICD system with pacing function was necessary in <1%. Clinical complications needing surgical revision occurred in 8 patients (3,5%).</AbstractText>S-ICD were mostly implanted for primary prevention, one fourth of our cases were sudden death survivors. Clinical and functional complication rate was relatively low. In conclusion, S-ICD is a safe and efficient alternative in a larger population of ICD candidates, when no cardiac pacing is needed. EC-number: C-136-17.</AbstractText>Copyright © 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,093 | Double sequential defibrillation for refractory ventricular fibrillation. | A 54-year-old suffered from an out-of-hospital cardiac arrest. Compressions were started within minutes and the patient was in refractory ventricular fibrillation despite multiple asynchronized shocks and maximal doses of antiarrhythmic agents. Double sequential defibrillation was attempted with successful Return Of Spontaneous Circulation (ROSC) after a total of 61min of cardiac arrest. The patient was discharged home neurologically intact. Double sequential defibrillation could be a simple effective approach to patients with refractory ventricular fibrillation. |
20,094 | E/e' ratio and outcome prediction in hypertrophic cardiomyopathy: the influence of outflow tract obstruction. | Diastolic dysfunction is thought to be an important pathophysiologic component of hypertrophic cardiomyopathy (HCM). However, there are conflicting data on the potential value of the mitral E/e' ratio. We examined whether left ventricular outflow tract (LVOT) obstruction influences the value of E/e' in predicting outcomes in HCM.</AbstractText>Patients who met diagnostic criteria for HCM were enrolled. Diastolic function was assessed with complete two-dimensional and Doppler echocardiography. A composite clinical outcome including new onset atrial fibrillation, sustained ventricular tachycardia/fibrillation, heart failure, transplantation, and death was examined over a mean follow-up period of 4.2 years. Among 604 patients, 206 patients had an E/e' level ≥20. Patients with higher septal E/e' level were older, with more severe NYHA class, and more severe LVOT obstruction. Higher E/e' was associated with worse event-free survival in non-obstructive group and total HCM cohort. In addition, E/e' and LVOT pressure gradient were highly correlated in non-obstructive and total HCM, but not in labile or obstructive group. During follow-up period, 95 patients underwent myectomy. Post-op E/e' correlated significantly with LVOT pressure gradient (R = 0.306, P = 0.004). In these patients, post-op E/e' was associated with worse event-free survival (log-rank P = 0.030).</AbstractText>Assessment of E/e' is useful for risk stratification in HCM patients. Nevertheless, the predictive power is confounded by dynamic LVOT obstruction. Higher E/e' predicts worse clinical outcomes in non-obstructive HCM and in labile/obstructive after myectomy.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
20,095 | Outcome of Stable Patients With Acute Myocardial Infarction and Coronary Artery Bypass Surgery Within 48 Hours: A Single-Center, Retrospective Experience. | The optimal timing of coronary artery bypass grafting (CABG) in clinically stable patients with acute myocardial infarction who are unsuitable for percutaneous coronary intervention is unclear. We report our experience with early CABG in these patients.</AbstractText>Between January 2001 and May 2015, 766 patients with ST-segment-elevation myocardial infarction (STEMI, n=305) or non-STEMI (NSTEMI, n=461) not including cardiogenic shock underwent CABG within 48 hours at our department. STEMI patients were younger than non-STEMI patients (age 65 years [range: 58-72] versus 70 years [range: 62-75], P</i><0.001) with a lower EuroSCORE II (4.12 [range: 2.75-5.81] versus 4.58 [range: 2.80-7.74], P</i>=0.009). STEMI patients had undergone preoperative percutaneous coronary intervention more often (20.3% versus 7.8%, P</i><0.001). Time to surgery was shorter in STEMI compared with non-STEMI patients (5.0 hours [range: 3.2-8.8] versus 11.7 hours [range: 6.4-22.0], P</i><0.001). No significant differences concerning arterial graft use (93.8% versus 94.8%, P</i>=0.540) or complete revascularization (87.5% versus 83.4%, P</i>=0.121) were observed. The rate of strokes did not differ between the groups (2.0% versus 3.9%, P</i>=0.134). Thirty-day mortality was lower in STEMI patients (2.7% versus 6.6% P</i>=0.018), especially when CABG was performed within 6 hours (1.8% versus 7.1%, P</i>=0.041). Survival of STEMI and non-STEMI patients was 94% versus 88% after 1 year (P</i><0.001), 87% versus 73% after 5 years (P</i><0.001), and 74% versus 57% after 10 years (P</i><0.001). Independent predictors of 30-day and long-term mortality included preoperatively increased lactate values, age, atrial fibrillation, and reduced left ventricular function.</AbstractText>Stable STEMI patients showed a lower rate of perioperative complications and better survival compared with non-STEMI patients when CABG was performed within 48 hours.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,096 | Comparison of different oral anticoagulant regimens in patients with atrial fibrillation undergoing ablation or cardioversion. | INTRODUCTION    Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative to vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF). OBJECTIVES    The aim of the study was to assess the incidence of left atrial appendage (LAA) thrombus and dense spontaneous echo contrast (SEC), as well as to compare the clinical characteristics of patients with AF treated with different anticoagulant regimens. PATIENTS AND METHODS    We studied 1033 consecutive patients with AF, who underwent transesophageal echocardiography (TEE) before AF ablation or cardioversion. We excluded 174 patients without any prior oral anticoagulation or who underwent bridging with heparin before TEE. RESULTS    In the study group of 859 patients (median age, 61 years; men, 66%), 437 patients (50.9%) received VKAs; 191 (22.2%), dabigatran; 230 (26.8%), rivaroxaban; and 1 patient (0.1%), apixaban. There were no differences in baseline characteristics or the incidence of LAA thrombus (VKAs, 6.9%; NOACs, 5.5%; P = 0.40) and dense SEC (VKAs, 5.3%; NOACs, 3.3%; P = 0.18) between patients on VKAs and those on NOACs. Compared with patients treated with dabigatran, those on rivaroxaban more often had paroxysmal AF, higher ejection fraction, LAA emptying velocity, and platelet count, as well as lower left ventricular end‑diastolic dimension and hematocrit. The frequency of LAA thrombus in patients receiving dabigatran and those receiving rivaroxaban was comparable (6.8% vs 4.4%; P = 0.29), while dense SEC occurred more often in patients treated with dabigatran (5.2% vs 1.7%; P = 0.06). In a logistic regression analysis, none of the oral anticoagulation regimens predicted LAA thrombus in TEE, whereas maximal LAA emptying velocity was the only parameter independently associated with the presence of thrombus. CONCLUSIONS    In the studied group of patients with AF, the choice of anticoagulation did not depend on thromboembolic or bleeding risk. |
20,097 | Outcomes of persistent pulmonary hypertension following transcatheter aortic valve replacement. | To determine the prevalence and factors associated with persistent pulmonary hypertension (PH) following transcatheter aortic valve replacement (TAVR) and its relationship with long-term mortality.</AbstractText>Consecutive patients who underwent TAVR from July 2011 through January 2016 were studied. The prevalence of baseline PH (mean pulmonary artery pressure ≥25 mm Hg on right heart catheterisation) and the prevalence and the predictors of persistent≥moderate PH (pulmonary artery systolic pressure (PASP)>45 mm Hg on 1 month post-TAVR transthoracic Doppler echocardiography) were collected. Cox models quantified the effect of persistent PH on subsequent mortality while adjusting for confounders.</AbstractText>Of the 407 TAVR patients, 273 (67%) had PH at baseline. Of these, 102 (25%) had persistent≥moderate PH. Mortality at 2 years in patients with no baseline PH versus those with PH improvement (follow-up PASP≤45 mm Hg) versus those with persistent≥moderate PH was 15.4%, 16.6% and 31.3%, respectively (p=0.049). After adjusting for Society of Thoracic Surgeons Predicted Risk of Mortality and baseline right ventricular function (using tricuspid annular plane systolic excursion), persistent≥moderate PH remained associated with all-cause mortality (HR=1.82, 95% CI 1.06 to 3.12, p=0.03). Baseline characteristics associated with increased likelihood of persistent≥moderate PH were ≥moderate tricuspid regurgitation, ≥moderate mitral regurgitation, atrial fibrillation/flutter, early (E) to late (A) ventricular filling velocities (E/A ratio) and left atrial volume index.</AbstractText>Persistency of even moderate or greater PH at 1 month post-TAVR is common and associated with higher all-cause mortality.</AbstractText>© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.</CopyrightInformation> |
20,098 | Clinical factors associated with the development of atrial fibrillation in the year following STEMI treated by primary PCI. | Advanced age, poor left ventricular function, and congestive heart failure are known predictors of atrial fibrillation (AF) in acute myocardial infarction (AMI) patients. Recent advances in AMI treatment may have changed the occurrence of new-onset AF. Thus, we investigated the factors associated with the development of new-onset AF in ST elevation myocardial infarction (STEMI) patients.</AbstractText>This study included 527 STEMI patients [mean age, 60.6±12.8 years; 102 (19.4%) women] who underwent primary percutaneous coronary intervention (PCI) in the previous 7 years. New-onset AF was evaluated following STEMI treated by primary PCI. Patients who developed AF during this follow-up period were compared with those who did not develop AF to identify factors that were associated with the development of AF.</AbstractText>New-onset AF was documented in 81 patients (15.4%) at 1 year after STEMI. Patients with new-onset AF (n=81) tended to be older (p<0.001); were more often female (p=0.009); had more congestive heart failure (p=0.015); had less use of beta-blockers (p=0.001); had more often used antiarrhythmic drugs (p<0.001); experienced cardiogenic shock more frequently (p=0.038); had lower left ventricular ejection fraction (p=0.024); and had higher E velocity (p<0.001), E/e' (p=0.011), and left atrial volume index (LAVI; p=0.029) than the 446 patients with no AF. Multivariate regression analysis revealed that cardiogenic shock, LAVI, and age were predictors of new-onset AF in STEMI patients (OR 2.823, 1.254, and 1.124; p=0.005, <0.001, and 0.028, respectively).</AbstractText>Cardiogenic shock was a new predictor of new-onset AF in STEMI patients.</AbstractText>Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.</CopyrightInformation> |
20,099 | Ibutilide Effectiveness and Safety in the Cardioversion of Atrial Fibrillation and Flutter in the Community Emergency Department. | Little is known about the use of ibutilide for cardioversion in atrial fibrillation and flutter outside of clinical trials. We seek to describe patient characteristics, ibutilide administration patterns, cardioversion rates, and adverse outcomes in the community emergency department (ED) setting. We also evaluate potential predictors of cardioversion success.</AbstractText>Using a retrospective cohort of adults who received ibutilide in 21 community EDs between January 2009 and June 2015, we gathered demographic and clinical variables from electronic health records and structured manual chart review. We calculated rates of cardioversion and frequency of ventricular tachycardia within 4 hours and estimated adjusted odds ratios (aOR) in a multivariate regression model for potential predictors of cardioversion.</AbstractText>Among 361 patients, the median age was 61 years (interquartile range 53 to 71 years) and most had recent-onset atrial fibrillation and flutter (98.1%). Five percent of the cohort had a history of heart failure. The initial QTc interval was prolonged (>480 ms) in 29.4% of patients, and 3.1% were hypokalemic (<3.5 mEq/L). The mean ibutilide dose was 1.5 mg (SD 0.5 mg) and the rate of ibutilide-related cardioversion within 4 hours was 54.8% (95% confidence interval [CI] 49.6% to 60.1%), 50.5% for atrial fibrillation and 75.0% for atrial flutter. Two patients experienced ventricular tachycardia (0.6%), both during their second ibutilide infusion. Age (in decades) (aOR 1.3; 95% CI 1.1 to 1.5), atrial flutter (versus atrial fibrillation) (aOR 2.7; 95% CI 1.4 to 5.1), and no history of atrial fibrillation and flutter (aOR 2.0; 95% CI 1.2 to 3.1) were associated with cardioversion.</AbstractText>The effectiveness and safety of ibutilide in this community ED setting were consistent with clinical trial results despite less stringent patient selection criteria.</AbstractText>Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
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