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20,500 | Clinical implications of hypothermic ventricular fibrillation versus beating-heart technique during cardiopulmonary bypass for pulmonary valve replacement in patients with repaired tetralogy of Fallot. | This study aimed to compare the effects of hypothermic ventricular fibrillation and beating-heart techniques during cardiopulmonary bypass (CPB) on postoperative outcomes after simple pulmonary valve replacement in patients with repaired tetralogy of Fallot (TOF).</AbstractText>We retrospectively reviewed the data of 47 patients with repaired tetralogy of Fallot at a single institution, who received pulmonary valve replacement under the ventricular fibrillation or beating-heart technique without cardioplegic cardiac arrest during CPB between January 2005 and April 2015.</AbstractText>The patients were divided into fibrillation (n = 32) and beating-heart (n = 15) groups. On comparing these groups, the fibrillation group had a larger sinotubular junction (27.1 ± 4.6 vs 22.1 ± 2.4 mm), had a longer operation duration (396 ± 108 vs 345 ± 57 min), required more postoperative transfusions (2.1 ± 2.6 vs 5.0 ± 6.3 units) and had a higher vasoactive-inotropic score at intensive care unit admission (8.0 vs 10, all P < 0.05). Echocardiographic data indicated that the systolic internal diameter of the left ventricle was larger in the fibrillation group than in the beating-heart group immediately after surgery and at the 1-year follow-up. Major adverse cardiac events occurred in 3 cases, all from the fibrillation group. Among 7 patients from the fibrillation group with transoesophageal echocardiography data during CPB, 6 had fully opened aortic valves during fibrillation, causing flooding into the left ventricle and left ventricle distension.</AbstractText>The postoperative outcomes are worse with the ventricular fibrillation technique than with the beating-heart technique during CPB for pulmonary valve replacement in patients with repaired tetralogy of Fallot.</AbstractText>© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.</CopyrightInformation> |
20,501 | [Ventricular arrhythmias in ion channel diseases]. | In patients with ion channel disease the predominant arrhythmias are polymorphic ventricular tachycardias (VT), torsade de pointes tachycardia and ventricular fibrillation (VF). In only extremely rare cases is very rapid monomorphic ventricular tachycardia observed. This is why implantable cardioverter-defibrillators (ICDs) should always be programmed for treatment of VF only with high detection rates to avoid inappropriate discharges. In idiopathic VF and catecholaminergic polymorphic ventricular tachycardia (CPVT), no baseline electrocardiographic abnormalities can be detected, whereas in Brugada syndrome, long QT syndrome, early repolarisation syndrome and Anderson-Tawil syndrome alterations of the baseline ECG are very important to identify patients at risk. |
20,502 | Correlation of Ventricular Arrhythmogenesis with Neuronal Remodeling of Cardiac Postganglionic Parasympathetic Neurons in the Late Stage of Heart Failure after Myocardial Infarction. | <b>Introduction:</b> Ventricular arrhythmia is a major cause of sudden cardiac death in patients with chronic heart failure (CHF). Our recent study demonstrates that N-type Ca<sup>2+</sup> currents in intracardiac ganglionic neurons are reduced in the late stage of CHF rats. Rat intracardiac ganglia are divided into the atrioventricular ganglion (AVG) and sinoatrial ganglion. Only AVG nerve terminals innervate the ventricular myocardium. In this study, we tested the correlation of electrical remodeling in AVG neurons with ventricular arrhythmogenesis in CHF rats. <b>Methods and Results:</b> CHF was induced in male Sprague-Dawley rats by surgical ligation of the left coronary artery. The data from 24-h continuous radiotelemetry ECG recording in conscious rats showed that ventricular tachycardia/fibrillation (VT/VF) occurred in 3 and 14-week CHF rats but not 8-week CHF rats. Additionally, as an index for vagal control of ventricular function, changes of left ventricular systolic pressure (LVSP) and the maximum rate of left ventricular pressure rise (LV dP/dt<sub>max</sub>) in response to vagal efferent nerve stimulation were blunted in 14-week CHF rats but not 3 or 8-week CHF rats. Results from whole-cell patch clamp recording demonstrated that N-type Ca<sup>2+</sup> currents in AVG neurons began to decrease in 8-week CHF rats, and that there was also a significant decrease in 14-week CHF rats. Correlation analysis revealed that N-type Ca<sup>2+</sup> currents in AVG neurons negatively correlated with the cumulative duration of VT/VF in 14-week CHF rats, whereas there was no correlation between N-type Ca<sup>2+</sup> currents in AVG neurons and the cumulative duration of VT/VF in 3-week CHF. <b>Conclusion:</b> Malignant ventricular arrhythmias mainly occur in the early and late stages of CHF. Electrical remodeling of AVG neurons highly correlates with the occurrence of ventricular arrhythmias in the late stage of CHF. |
20,503 | The role of genetics in primary ventricular fibrillation, inherited channelopathies and cardiomyopathies. | Sudden cardiac death (SCD) has a strong familial component; however, our understanding of its genetic basis varies significantly according to the underlying causes. When coronary artery disease is involved, the predisposing genetic background is complex and despite some interesting findings it remains largely unknown. Quite different is the case of monogenic structural and non-structural heart diseases, in which a number of disease-causing genes have been established and are being used in clinical practice. As SCD can be the first clinical manifestation of inherited syndromes, in order to ascertain the cause of death, it is extremely important to include molecular autopsy among the standard post-mortem examinations. Indeed, molecular screening of the major disease-causing genes in the deceased person is often the only way to achieve a post-mortem diagnosis in channelopathies, which may prove crucial for the identification and management of at risk family members. Overall, these data, together with the inclusion in current guidelines of molecular screening for diagnosis and/or risk stratification of specific inherited cardiac diseases, exemplify how research on the genetic basis of SCD may be deeply translational, while the transition of genetic testing from the research to the diagnostic setting is already improving every-day clinical practice. |
20,504 | <i>C-GRApH</i>: A Validated Scoring System for Early Stratification of Neurologic Outcome After Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management. | Out-of-hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post-OHCA remains difficult in patients receiving targeted temperature management.</AbstractText>Retrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32-34°C) for 24 hours at a tertiary-care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3-5). Patient demographics, pre-OHCA diagnoses, and initial laboratory studies post-resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system (C-GRApH</i>). The C-GRApH</i> score ranges 0 to 5 using equally weighted variables: (C</i>): coronary artery disease, known pre-OHCA; (G</i>): glucose ≥200 mg/dL; (R</i>): rhythm of arrest not ventricular tachycardia/fibrillation; (A</i>): age >45; (pH</i>): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary-care health system (n=272) from 2012 to 2014. The c-statistic for predicting neurologic outcome was 0.82 (0.74-0.90, P</i><0.001) in the development cohort and 0.81 (0.76-0.87, P</i><0.001) in the validation cohort. When subdivided by C-GRApH</i> score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0-1, n=60), 22% versus 19% for medium (2-3, n=307), and 0% versus 2% for high (4-5, n=99) C-GRApH</i> scores in the development and validation cohorts, respectively.</AbstractText>C-GRApH</i> stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32-34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable (C-GRApH</i> ≤1) and poor (C-GRApH</i> ≥4) prognoses.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,505 | Drug-induced fatal arrhythmias: Acquired long QT and Brugada syndromes. | Since the early 1990s, the concept of primary "inherited" arrhythmia syndromes or ion channelopathies has evolved rapidly as a result of revolutionary progresses made in molecular genetics. Alterations in genes coding for membrane proteins such as ion channels or their associated proteins responsible for the generation of cardiac action potentials (AP) have been shown to cause specific malfunctions which eventually lead to cardiac arrhythmias. These arrhythmic disorders include congenital long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, short QT syndrome, progressive cardiac conduction disease, etc. Among these, long QT and Brugada syndromes are the most extensively studied, and drugs cause a phenocopy of these two diseases. To date, more than 10 different genes have been reported to be responsible for each syndrome. More recently, it was recognized that long QT syndrome can be latent, even in the presence of an unequivocally pathogenic mutation (silent mutation carrier). Co-existence of other pathological conditions in these silent mutation carriers may trigger a malignant form of ventricular arrhythmia, the so called torsade de pointes (TdP) that is most commonly brought about by drugs. In analogy to the drug-induced long QT syndrome, Brugada type 1 ECG can also be induced or unmasked by a wide variety of drugs and pathological conditions; so physicians may encounter patients with a latent form of Brugada syndrome. Of particular note, Brugada syndrome is frequently associated with atrial fibrillation whose therapeutic agents such as Vaughan Williams class IC drugs can unmask the dormant and asymptomatic Brugada syndrome. This review describes two types of drug-induced arrhythmias: the long QT and Brugada syndromes. |
20,506 | Mechanism of atrial functional mitral regurgitation in patients with atrial fibrillation: A study using three-dimensional transesophageal echocardiography. | Functional mitral regurgitation (MR) can occur in patients with atrial fibrillation (AF) despite having preserved left ventricular (LV) systolic function. This MR is known as atrial functional MR. The aim of this study was to clarify the mechanism of atrial functional MR using real-time three-dimensional transesophageal echocardiography (3DTEE).</AbstractText>Sixty patients underwent transthoracic echocardiography and 3DTEE: 16 patients with AF and significant non-organic MR and preserved LV ejection fraction (>50%) constituted the AF-MR group, 20 patients with AF and no significant MR formed the AF-NSMR group, and 24 normal subjects comprised the control group.</AbstractText>The left atrial volume index was significantly larger in the AF-MR group (95±41ml/m2</sup>) than in the AF-NSMR group (38±13ml/m2</sup>, p<0.05) or the control group (21±7ml/m2</sup>, p<0.05). The 3D annular circumference was significantly longer in the AF-MR group than in the AF-NSMR group. The annular-anterior leaflet coaptation angle was smaller in the AF-MR group than in the AF-NSMR group (11±6° vs. 18±9°, p<0.05). The annular-posterior leaflet coaptation angle was comparable between the two AF groups (26±12° vs. 28±10°), whereas the annular-posterior leaflet tip angle was larger in the AF-MR group than in the AF-NSMR group (59±13° vs. 44±11°, p<0.05). The posterior leaflet bending toward LV cavity was therefore significantly larger in the AF-MR group than in the AF-NSMR group (32±10° vs. 18±15°, p<0.05).</AbstractText>In patients with AF and significant functional MR occurring despite their preserved LV systolic function, the left atrium and mitral annulus were dilated and the anterior leaflet was flattened along the mitral annular plane, whereas the posterior leaflet was bent toward the LV cavity.</AbstractText>Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.</CopyrightInformation> |
20,507 | Energy Drinks and atrial fibrillation in young adults. | The present paper evaluates the association between Energy Drinks (EDs) and occurrence of atrial fibrillation (AF) in young people. Data from three clinical cases of AF after EDs consumption are reported. All patients presented with palpitations, nausea and anxiety. ECG showed AF with high ventricular response (135-170 bpm range frequency). Anamnestic record reported a high consumption of EDs during the previous 8 h from the onset of AF. In one case ED was associated with a moderate quantity of alcohol. Patients were successfully cardioverted both spontaneously and after pharmacological treatment. After cardioversion: the ECG and echocardiogram appeared normal in all patients; the toxicological tests and the laboratory analyses resulted negative. Our experience suggests that larger consumption of EDs, especially when combined with alcoholic beverages, could act as a trigger in the development of AF in young patients. This action may be caused by the synergic effect of caffeine and other substances present in EDs. Following the increasing consumption of EDs in young people, we suggest a careful attention to cardiac complications. |
20,508 | Genetic variants of interleukin-18 are associated with reduced risk of atrial fibrillation in a population from Northeast China. | Atrial fibrillation (AF) affects approximately 1-2% of general population. Chronic inflammation plays an important role in AF development and interleukin-18 (IL-18) is a pro-inflammatory cytokine. This study aimed to assess the association of single nucleotide polymorphisms (SNPs) of IL-18 for with AF risk. Blood samples were taken from 243 AF patients and 160 non-AF individuals from a Chinese population and subjected to genotyping for six IL-18 SNPs using the MassArray system. Association of individual SNPs with AF risk was analyzed using SAS version 9.1. The results showed that the left atrial diameter was increased and the left ventricular ejection fraction was decreased in AF patients compared to controls. IL-18 SNPs were associated with reduced risk of AF even after adjusting for various confounding factors. Specifically, rs187238 GC genotype and C allele, rs360719 AG genotype and G allele, and rs549908 GT genotype and G allele were associated with decreased risk of AF. In conclusion, our findings indicate that rs187238, rs360719, and rs549908 in IL-18 are associated with reduced risk of AF in this cohort of patients. |
20,509 | Slow ventricular tachycardia in a 91-year-old man with implantable cardioverter-defibrillator and acute respiratory failure. | Slow ventricular tachycardia (VT) in patients with devices such as an implantable cardioverter - defibrillator (ICD) is more common than in the rest of the population. The incidence in elderly patients with an ICD remains largely unknown. In younger patients, slow VT is generally asymptomatic or associated with limited clinical relevance. It may be efficiently and safely terminated by anti-tachycardia pacing. We present a case of slow VT in a 91-year-old man with ICD with type 1 acute respiratory failure and drowsiness. Very elderly patients who have poor cardiac reserve and minor deterioration in cardiac function can face serious consequences such as ventricular fibrillation, cardiac arrest, and sudden cardiac death. The persistent ventricular rhythm may have a deleterious effect on their haemodynamic status, with potential aggravation of symptoms of heart failure and further impairment of ventricular function. |
20,510 | Automated external defibrillator and operator performance in out-of-hospital cardiac arrest. | An increasing number of failing automated external defibrillators (AEDs) is reported: AEDs not giving a shock or other malfunction. We assessed to what extent AEDs are 'failing' and whether this had a device-related or operator-related cause.</AbstractText>We studied analysis periods from AEDs used between January 2012 and December 2014. For each analysis period we assessed the correctness of the (no)-shock advice (sensitivity/specificity) and reasons for an incorrect (no)-shock advice. If no shock was delivered after a shock advice, we assessed the reason for no-shock delivery.</AbstractText>We analyzed 1114 AED recordings with 3310 analysis periods (1091 shock advices; 2219 no-shock advices). Sensitivity for coarse ventricular fibrillation was 99% and specificity for non-shockable rhythm detection 98%. The AED gave an incorrect shock advice in 4% (44/1091) of all shock advices, due to device-related (n=15) and operator-related errors (n=28) (one unknown). Of these 44 shock advices, only 2 shocks caused a rhythm change. One percent (26/2219) of all no-shock advices was incorrect due to device-related (n=20) and operator-related errors (n=6). In 5% (59/1091) of all shock advices, no shock was delivered: operator failed to deliver shock (n=33), AED was removed (n=17), operator pushed 'off' button (n=8) and other (n=1). Of the 1073 analysis periods with a shockable rhythm, 67 (6%) did not receive an AED shock.</AbstractText>Errors associated with AED use are rare (4%) and when occurring are in 72% caused by the operator or circumstances of use. Fully automatic AEDs may prevent the majority of these errors.</AbstractText>Copyright © 2017 The Author(s). Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,511 | Stretch-activated two-pore-domain (K<sub>2P</sub>) potassium channels in the heart: Focus on atrial fibrillation and heart failure. | Two-pore-domain potassium (K<sub>2P</sub>) channels modulate cellular excitability. The significance of stretch-activated cardiac K<sub>2P</sub> channels (K<sub>2P</sub>2.1, TREK-1, KCNK2; K<sub>2P</sub>4.1, TRAAK, KCNK4; K<sub>2P</sub>10.1, TREK-2, KCNK10) in heart disease has not been elucidated in detail. The aim of this work was to assess expression and remodeling of mechanosensitive K<sub>2P</sub> channels in atrial fibrillation (AF) and heart failure (HF) patients in comparison to murine models. Cardiac K<sub>2P</sub> channel levels were quantified in atrial (A) and ventricular (V) tissue obtained from patients undergoing open heart surgery. In addition, control mice and mouse models of AF (cAMP-response element modulator (CREM)-IbΔC-X transgenic animals) or HF (cardiac dysfunction induced by transverse aortic constriction, TAC) were employed. Human and murine KCNK2 displayed highest mRNA abundance among mechanosensitive members of the K<sub>2P</sub> channel family (V > A). Disease-associated K<sub>2P</sub>2.1 remodeling was studied in detail. In patients with impaired left ventricular function, atrial KCNK2 (K<sub>2P</sub>2.1) mRNA and protein expression was significantly reduced. In AF subjects, downregulation of atrial and ventricular KCNK2 (K<sub>2P</sub>2.1) mRNA and protein levels was observed. AF-associated suppression of atrial Kcnk2 (K<sub>2P</sub>2.1) mRNA and protein was recapitulated in CREM-transgenic mice. Ventricular Kcnk2 expression was not significantly altered in mouse models of disease. In conclusion, mechanosensitive K<sub>2P</sub>2.1 and K<sub>2P</sub>10.1 K<sup>+</sup> channels are expressed throughout the heart. HF- and AF-associated downregulation of KCNK2 (K<sub>2P</sub>2.1) mRNA and protein levels suggest a mechanistic contribution to cardiac arrhythmogenesis. |
20,512 | Left ventricular mural thrombus and dual coronary embolization associated with hyperthyroid cardiomyopathy and atrial fibrillation: a case report. | The majority of acute myocardial infarction (AMI) events are caused by thrombotic occlusion of the coronary artery, secondary to atherosclerotic plaque erosion or rupture. However, coronary embolism (CE), while rare, is being increasingly recognized as an important cause of AMI. We present the case of a patient with multi-site coronary artery embolization associated with hyperthyroid-related cardiomyopathy and atrial fibrillation.</AbstractText>A 49-year-old female with a history of hyperthyroidism and atrial fibrillation (AF) was admitted to our hospital presenting with right upper limb pain and swelling. Initial transthoracic echocardiography demonstrated left ventricular apical mural thrombi and hyperthyroidism-induced cardiomyopathy. On the eighth day after admission, the patient developed sudden onset of severe chest pain and evidence of acute myocardial infarction (AMI). Emergency coronary angiography revealed multi-site coronary embolization of the left anterior descending artery and a large diagonal branch. Despite emergency thrombo-aspiration and balloon angioplasty, the patient went into ventricular fibrillation, from which she did not recover.</AbstractText>Although rare, a fatal case of left ventricular thrombus and dual-vessel coronary embolism associated with hyperthyroid cardiomyopathy and atrial fibrillation is reported.</AbstractText> |
20,513 | Nonpegylated liposomal doxorubicin combination regimen in patients with diffuse large B-cell lymphoma and cardiac comorbidity. Results of the HEART01 phase II trial conducted by the Fondazione Italiana Linfomi. | The purpose of this phase 2, multicenter study was to determine the activity and safety of nonpegylated liposomal doxorubicin as part of "R-COMP" combination in patients with diffuse large B-cell lymphoma and coexisting cardiac disorders. The study was conducted using a Bayesian continuing assessment method using complete remission rate and rate of cardiac events as study endpoints. Between November 2009 and October 2011, 50 evaluable patients were enrolled (median age, 76 years). Median baseline left ventricular ejection fraction (LVEF) was 60%. Ischemic cardiopathy was the most frequent preexisting cardiac disorder (35%), followed by atrial fibrillation (15%), left ventricular hypertrophy (13%), and baseline LVEF <50% (12%). Based on the intent to treat analysis, overall response rate was 72%, including 28 patients in complete remission (complete remission rate, 56%), and 8 in partial remission (16%). At the end of treatment, grades 3 to 4 cardiac events were observed in 6 patients. No significant modifications from baseline values of LVEF were observed during treatment and follow-up. Nonpegylated liposomal doxorubicin instead of doxorubicin in the R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen is a feasible option for patients with diffuse large B-cell lymphoma presenting with concomitant cardiac disorders. |
20,514 | Arrhythmia burden and related outcomes in Eisenmenger syndrome. | Patients with Eisenmenger syndrome have a shorter lifespan than the general population. A significant proportion develop arrhythmia and some, sudden death.</AbstractText>The aims of this study were to characterize the frequency, type and effects of arrhythmias in adult patients with Eisenmenger's syndrome and to identify risk factors for arrhythmias.</AbstractText>This retrospective study included patients aged ≥ 18 years of age with Eisenmenger's syndrome from three institutions. Arrhythmias were noted from electrocardiograms and Holter study reviews.</AbstractText>A total of 167 patients, 96 females, 63 males (gender not available in 9 patients) were included in this study. The mean age was 38 ± 9 years (range: 18-63 years) with a majority in NYHA functional class II or III (57% and 32% respectively). Twenty-eight patients (17%) had significant tachyarrhythmia: paroxysmal supraventricular tachycardia (8 patients, 29%), atrial fibrillation (6 patients, 21%), atrial fibrillation and flutter (2 patients, 7%), nonsustained ventricular tachycardia (6 patients, 21%) and sustained ventricular tachycardia (6 patients, 21%). Among the entire study group, 26 patients (16%) were currently on antiarrhythmic therapy and 77 patients (49%) were on advanced therapies for pulmonary hypertension. Down syndrome was present in 78 patients (46%). There were 21 (13%) documented deaths, of which 8 (5%) were sudden death. Patients with arrhythmia were older [P = .01] and were more likely to have atrioventricular valvar regurgitation [Odds ratio: 4.33]. Advanced pulmonary hypertension therapy was associated with decreased all-cause mortality in logistic regression analysis [odds ratio: 0.31], while antiarrhythmic therapy was associated with sudden death [odds ratio: 6.24].</AbstractText>Arrhythmias are common among patients with Eisenmenger syndrome occurring in around 1 in 5 individuals and are associated with all-cause mortality and sudden death.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,515 | Discovery of a new mutation in the desmin gene in a young patient with cardiomyopathy and muscular weakness. | A 25-year-old woman with a five years history of syncope, mild left ventricular hypertrophy and moderately enlarged atria, was diagnosed with third degree atrioventricular heart block alternating with atrioventricular heart block 2:1, and received a dual chamber pacemaker. After three years of evolution, she developed atrial fibrillation, marked biatrial enlargement, severely depressed longitudinal myocardial velocities, associated with mild girdle weakness and slight increase in creatine kinase level. The diagnosis of restrictive cardiomyopathy with mild skeletal myopathy imposed the screening for a common etiology. Skeletal muscle biopsy revealed the morphological picture of myofibrillar myopathy with sarcoplasmic aggregates, immunoreactive for desmin and other ectopic proteins on immunohistochemistry, appearing as granulofilamentous material at ultrastructural level. Western blot analysis confirmed the desmin overexpression. Genetic testing identified a heterozygous missense variant DES rs869025381, c.1297C>A, p.(Pro433Thr), not previously reported. This is not only the first confirmed Romanian patient with myofibrillar myopathy with clinical features of severe restrictive cardiomyopathy associated with mild skeletal myopathy, but also a case which adds up to the known mutational spectrum in desminopathy. |
20,516 | Amyloidosis - a rare cause of refractory heart failure in a young female. | Cardiac amyloidosis may occur in any type of systemic amyloidosis. The clinical picture is often characterized by restrictive cardiomyopathy. We report the case of a 41-year-old female patient admitted to the Department of Cardiology with clinical signs of right heart failure: congested jugular veins, hepatomegaly, peripheral edema, ascites associated with atrial fibrillation, low values of arterial blood pressure and oliguria. Echocardiographic findings were helpful for the diagnosis of cardiac amyloidosis: enlarged atrial cavities, normal size ventricles, thickened ventricular septum and posterior left ventricle wall with normal left ventricular ejection fraction, mitral and tricuspid regurgitation. Two-dimensional echocardiography revealed additional features: thickened papillary muscles and a specific "granular sparkling" appearance of the thickened cardiac walls - probably due to the amyloid deposit. Gingival biopsy showing amorphous eosinophilic material located in the vessel walls and the specific dichroism and "apple-green" birefringence under polarized light on Congo red stained slides completed the diagnosis of systemic amyloidosis. We recommend cardiologists to take into account a possible cardiac amyloidosis in a patient with unexplained refractory heart failure and a typical pattern of restrictive cardiomyopathy revealed by echocardiographic examination. We also emphasize the fact that the complete diagnosis cannot be set without a biopsy that should reveal the presence of amyloid. Although endomyocardial biopsy, completed with histochemical and immunohistochemical stains, is a valuable diagnostic method, in cases with advanced cardiac failure, the best site for this biopsy may be the gingiva. |
20,517 | Synergistic Effect of Dofetilide and Mexiletine on Prevention of Atrial Fibrillation. | Although atrial fibrillation (AF) is the most common abnormal heart rhythm and its prevalence continues to rise, there is a marked paucity of effective and safe antiarrhythmic drugs for AF. This study was done to test whether combined use of dofetilide and mexiletine exhibits not only a synergistic effect on AF suppression but also a safer profile in drug-induced ventricular proarrhythmias.</AbstractText>The effects of dofetilide plus mexiletine on atrial effective refractory period (ERP), AF inducibility, QT, and QT-related ventricular arrhythmias were studied using the isolated arterially perfused rabbit atrial and ventricular wedge preparations. Dofetilide or mexiletine alone mildly to moderately prolonged atrial ERP, but their combined use produced a markedly rate-dependent increase in atrial ERP. Dofetilide (3 nmol/L) plus mexiletine (10 μmol/L) increased the ERP by 28.2% from 72.2±5.7 to 92.8±5.9 ms (n=9, P</i><0.01) at a pacing rate of 0.5 Hz and by 94.5% from 91.7±5.2 to 178.3±12.0 ms (n=9, P</i><0.01) at 3.3 Hz. Dofetilide plus mexiletine strongly suppressed AF inducibility. On the other hand, dofetilide at 10 nmol/L produced marked QT and Tp-e</sub> prolongation, steeper QT-BCL and Tp-e</sub>-BCL slopes, and induced early afterdepolarizations and torsade de pointes in the ventricular wedges. Mexiletine at 10 μmol/L reduced dofetilide-induced QT and Tp-e</sub> prolongation, QT-BCL and Tp-e</sub>-BCL slopes, and abolished early afterdepolarizations and torsade de pointes.</AbstractText>In rabbits, combined use of dofetilide and mexiletine not only synergistically increases atrial ERP and effectively suppresses AF inducibility, but also markedly reduces QT liability and torsade de pointes risk posed by dofetilide alone.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,518 | The Girona Territori Cardioprotegit Project: Performance Evaluation of Public Defibrillators. | In recent years, public access defibrillation programs have exponentially increased the availability of automatic external defibrillators (AED) in public spaces but there are no data on their performance in our setting. We conducted a descriptive analysis of the performance of AED since the launch of a public defibrillation program in our region.</AbstractText>A retrospective analysis was conducted of electrocardiographic tracings and the performance of AED in a public defibrillation program from June 2011 to June 2015 in the province of Girona, Spain.</AbstractText>There were 231 AED activations. Full information was available on 188 activations, of which 82% corresponded to mobile devices and 18% to permanent devices. Asystole was the most prevalent rhythm (42%), while ventricular fibrillation accounted for 23%. The specificity of the device in identifying a shockable rhythm was 100%, but there were 8 false negatives (sensitivity 83%). There were 47 shockable rhythms, with a spontaneous circulation recovery rate of 49% (23 cases). There were no accidents related to the use of the device.</AbstractText>Nearly half of the recorded rhythms were asystole. The AED analyzed showed excellent safety and specificity, with moderate sensitivity. Half the patients with a shockable rhythm were successfully treated by the AED.</AbstractText>Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.</CopyrightInformation> |
20,519 | Management of untreatable ventricular arrhythmias during pharmacologic challenges with sodium channel blockers for suspected Brugada syndrome. | Pharmacologic challenge with sodium channel blockers is part of the diagnostic workout in patients with suspected Brugada syndrome. The test is overall considered safe but both ajmaline and flecainide detain well known pro-arrhythmic properties. Moreover, the treatment of patients with life-threatening arrhythmias during these diagnostic procedures is not well defined. Current consensus guidelines suggest to adopt cautious protocols interrupting the sodium channel blockers as soon as any ECG alteration appears. Nevertheless, the risk of life-threatening arrhythmias persists, even adopting a safe and cautious protocol and in absence of major arrhythmic risk factors. The authors revise the main published case studies of sodium channel blockers challenge in adults and in children, and summarize three cases of untreatable ventricular arrhythmias discussing their management. In particular, the role of advanced cardiopulmonary resuscitation with extra-corporeal membrane oxygenation is stressed as it can reveal to be the only reliable lifesaving facility in prolonged cardiac arrest. |
20,520 | Dabigatran vs. warfarin in relation to the presence of left ventricular hypertrophy in patients with atrial fibrillation- the Randomized Evaluation of Long-term anticoagulation therapY (RE-LY) study. | We tested the hypothesis that left ventricular hypertrophy (LVH) interferes with the antithrombotic effects of dabigatran and warfarin in patients with atrial fibrillation (AF).</AbstractText>This is a post-hoc analysis of the Randomized Evaluation of Long-term anticoagulation therapY (RE-LY) Study. We defined LVH by electrocardiography (ECG) and included patients with AF on the ECG tracing at entry. Hazard ratios (HR) for each dabigatran dose vs. warfarin were calculated in relation to LVH. LVH was present in 2353 (22.7%) out of 10 372 patients. In patients without LVH, the rates of primary outcome were 1.59%/year with warfarin, 1.60% with dabigatran 110 mg (HR vs. warfarin 1.01, 95% confidence interval (CI) 0.75-1.36) and 1.08% with dabigatran 150 mg (HR vs. warfarin 0.68, 95% CI 0.49-0.95). In patients with LVH, the rates of primary outcome were 3.21%/year with warfarin, 1.69% with dabigatran 110 mg (HR vs. warfarin 0.52, 95% CI 0.32-0.84) and 1.55% with 150 mg (HR vs. warfarin 0.48, 95% CI 0.29-0.78). The interaction between LVH status and dabigatran 110 mg vs. warfarin was significant for the primary outcome (P = 0.021) and stroke (P = 0.016). LVH was associated with a higher event rate with warfarin, not with dabigatran. In the warfarin group, the time in therapeutic range was significantly lower in the presence than in the absence of LVH.</AbstractText>LVH was associated with a lower antithrombotic efficacy of warfarin, but not of dabigatran, in patients with AF. Consequently, the relative benefit of the lower dose of dabigatran compared to warfarin was enhanced in patients with LVH. The higher dose of dabigatran was superior to warfarin regardless of LVH status.</AbstractText>http:www.clinicaltrials.gov. Unique identifier: NCT00262600.</AbstractText>© The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology.</CopyrightInformation> |
20,521 | Attitudes and preferences for the clinical management of hypertension and hypertension-related cerebrovascular disease in the general practice: results of the Italian hypertension and brain survey. | The aim of this survey was to evaluate attitudes and preferences for the clinical management of hypertension and hypertension-related cerebrovascular diseases (CVD) in Italy.</AbstractText>A predefined 16-item survey questionnaire was anonymously administered to a large community sample of general practitioners (GPs), trained by specialized physicians (SPs), who have been included in an educational program between January and November 2015.</AbstractText>A total of 591 physicians, among whom 48 (8%) training SPs and 543 (92%) trained GPs, provided 12,258 valid answers to the survey questionnaire. Left ventricular hypertrophy was considered the most frequent marker of hypertension-related organ damage, whereas atrial fibrillation and carotid atherosclerosis were considered relatively not frequent (10-20%). The most appropriate blood pressure (BP) targets to be achieved in hypertensive patients with CVD were <140/90 mmHg for SPs and <135/85 mmHg for GPs. To achieve these goals, ACE inhibitors were considered the most effective strategies by GPs, whereas SPs expressed a preference for ARBs, both in monotherapies and in combination therapies with beta-blockers.</AbstractText>This survey demonstrates that Italian physicians considered left ventricular hypertrophy frequently associated to CVD and that drugs inhibiting the renin-angiotensin system the most appropriate therapy to manage hypertension and hypertension-related CVD.</AbstractText> |
20,522 | Late Presentation of Aortic Aneurysm and Dissection Following Cardiac Catheterization. | We report a 63-year-old female with hypertension, hyperlipidemia, and prior pacemaker insertion for atrial fibrillation with symptomatic bradycardia, who was admitted with substernal chest pressure and diaphoresis. Her electrocardiogram revealed atrial fibrillation with demand ventricular pacing and her cardiac biomarkers were negative for acute coronary syndrome. Echocardiogram revealed normal left ventricular systolic function and normal aortic root diameter. Coronary angiography revealed 60-70% obtuse marginal lesion, otherwise mild disease. She was treated medically and discharged in stable condition. She was readmitted 1 month later with recurring chest pain, and shortness of breath which started shortly after her most recent discharge. Blood pressure was 152/93 mm Hg, and heart rate was 105 bpm. BNP was elevated at 1,400 pg/mL, and other cardiac biomarkers were negative. She was treated with diuretics, which resulted in decrease of her blood pressure to 81/51 mm Hg. Repeat echocardiogram revealed severely dilated aortic root, measuring 6.7 cm, with aortic dissection flap and moderate to severe aortic regurgitation. CT angiogram revealed aortic dissection extending proximally to the aortic root above the coronary ostia and distally to the left subclavian artery takeoff. She underwent surgery; she, however, could not be weaned off from cardiopulmonary bypass and died in the operating room. This case illustrates the importance of having a high index of suspicion for iatrogenic aortic dissection following cardiac catheterization as a cause of recurrence of cardiac symptoms, as early detection may help avert a catastrophic outcome, as we report in our patient. |
20,523 | Heart rate and outcome in heart failure with reduced ejection fraction: Differences between atrial fibrillation and sinus rhythm-A CIBIS II analysis. | Heart rate has been associated with prognosis in patients with heart failure with reduced ejection fraction (HFREF) and sinus rhythm; whether this also holds true in patients with atrial fibrillation (AF) is unknown.</AbstractText>To evaluate cardiac rhythm and baseline heart rate and the influence of outcome in patients with HFREF enrolled in the Cardiac Insufficiency Bisoprolol Study II.</AbstractText>In total, 2539 patients were stratified according to their baseline heart rhythm (AF or sinus rhythm) and into quartiles of heart rate (≤70 bpm, 71-78 bpm, 79-90 bpm, and >90 bpm). The primary outcome was all-cause mortality. Mean follow-up was 1.3 years.</AbstractText>Mean age was 61 years, mean left ventricular ejection fraction was 28%, and 80% were male. A total of 521 (21%) patients had AF at baseline. The risk associated with all-cause mortality for each 5 bpm increase in heart rate in patients with sinus rhythm (hazard ratio [HR]: 1.06, 95% confidence interval [CI]: 1.01-1.11, P = 0.012) was significantly different from those with AF (HR: 1.00, 95% CI: 0.94-1.07, P = 0.90, P for interaction = 0.041). The risk associated with higher heart rate in sinus rhythm was primarily attributable to excess risk in the highest quartile (HR: 1.64, 95% CI: 1.18-2.30, P = 0.003). Allocation to bisoprolol did not modify the interaction between heart rate, rhythm and outcome.</AbstractText>In HFREF patients with AF, a higher heart rate is not associated with increased event rates in contrast to HFREF patients with sinus rhythm.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,524 | When Cardioversion May Be Complicated. | In recent years cardioversion of atrial fibrillation has become a routine procedure, enabling symptomatic functional improvement in most cases. However, some patients develop complications after cardioversion. Identifying these individuals is an important step toward improving patient outcome.</AbstractText>To characterize those patients who may not benefit from cardioversion or who may develop complications following cardioversion.</AbstractText>We retrospectively analyzed 186 episodes of cardioversion in 163 patients with atrial fibrillation who were admitted to our cardiology department between 2008 and 2013 based on their clinical and echocardiographic data. Patients were divided into two groups: those with uncomplicated cardioversion, and those who developed complications after cardioversion.</AbstractText>Of the 186 episodes, cardioversion was done in 112 men (60%) and 74 women (40%), P < 0.00001. Complications after cardioversion occurred in 25 patients (13%). These patients were generally older (72 vs. 65 years, P < 0.01), were more often diabetic (52% vs. 27%, P = 0.005), had undergone emergency cardioversion (64% vs. 40%, P = 0.01), had left ventricular hypertrophy (left ventricular mass 260 vs. 218 g, P = 0.01), had larger left atrium (left atrial volume 128 vs. 102 ml, P < 0.009), and more often died from complications of cardioversion (48% vs. 16%). They had significant mitral regurgitation (20% vs. 4%, P = 0.03) and higher pulmonary artery pressure (50 vs. 42 mm Hg, P < 0.02).</AbstractText>People with complications after cardioversion tend to be older, are more often diabetic and more often have severe mitral regurgitation. In these patients, the decision to perform cardioversion should consider the possibility of complications.</AbstractText> |
20,525 | Prevalence of early repolarization pattern in patients with lone atrial fibrillation. | The objective of this study was to test the association of early repolarization pattern (ER) with lone atrial fibrillation (AF).</AbstractText>Electrocardiograms (ECGs) were analyzed in blinded fashion in a case-control study of 182 patients with lone AF and 182 controls without AF.</AbstractText>Patients with lone AF and controls had similar frequencies of ER pattern (15% vs. 19%, p=0.40). In patients <50years of age, there was also no difference in the percentage of patients with ER in the AF and control groups (17% vs. 19%, p=0.60). ER pattern was more common in patients with ECG voltage criteria of left ventricular hypertrophy (LVH), with ER present in 57% of patients with elevated Sokolow-Lyon voltage compared to 14% of those without (p<0.0001).</AbstractText>No association could be identified between the ER pattern and lone AF in young and middle-aged patients. In this age group, ER is substantially more common in patients with elevated Sokolow-Lyon voltage criteria.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,526 | Impact of a Perioperative Prophylaxis Guideline on Post-Cardiothoracic Surgery Atrial Fibrillation. | National practice guidelines do not provide clear recommendations on combination pharmacological regimens to reduce cardiothoracic surgery (CTS) postoperative atrial fibrillation (POAF).</AbstractText>This study examines if there is a reduction in POAF rates after implementing a perioperative prophylaxis guideline that includes amiodarone, β-blockers, and high-intensity statins.</AbstractText>Data were retrospectively collected on 400 adults (200 patients pre-guideline implementation and 200 patients post-guideline implementation) with a CHA2</sub>DS2</sub>-VASc (Congestive Heart Failure, Hypertension, Age, Diabetes Mellitus, and Vascular Disease) score of at least 3 points after CTS. Data were collected on the incidence of POAF lasting more than 5 minutes and secondary outcomes, including the length of hospitalization, guideline adherence rate, adverse events, and timeliness of POAF treatment.</AbstractText>Guideline implementation increased prophylactic amiodarone ( P < 0.0001), statin ( P = 0.029), and high-intensity statin ( P = 0.002) use without changing β-blocker use (64.5% vs 67.0%, P = 0.673) and reduced POAF (39.5% vs 52.0%, P = 0.016) and ventricular tachycardia (15.5% vs 24.5%, P = 0.034) compared with preguideline rates. Length of hospitalization and other postoperative adverse events, including stroke and mortality, were not statistically different. Subgroup analyses of patients who were adherent to both the amiodarone and β-blocker recommendations (28% of the total) or to all 3 recommended therapies (24% of the total) had significant decreases in POAF ( P = 0.001; P < 0.001), length of hospitalization ( P = 0.023; P = 0.049), length of intensive care unit stay ( P = 0.045; P = 0.040), and ventricular tachycardia ( P = 0.008; P = 0.017) compared with preguideline patients, respectively.</AbstractText>A perioperative guideline of amiodarone, β-blockers, and high-intensity statins reduced POAF, but better benefits may result from enhanced adherence.</AbstractText> |
20,527 | Effectiveness of enzyme replacement therapy in Fabry disease: Long term experience in Argentina. | Evidence regarding long term effectiveness of enzyme replacement therapy (ERT) in Fabry disease (FD) is needed. The aim of this study was to analyze in a cohort of FD patients in Argentina, the long term effectiveness of ERT on renal, cardiac and cerebrovascular parameters.</AbstractText>Patients with genetically proven FD were included from GADYTEF (Argentinean group for the treatment of FD) between 2001 and 2014. Renal, cardiac, and cerebral outcomes were prospectively studied in patients treated with ERT. Additionally, the occurrence of major cardiac complications, stroke, end-stage renal disease and death was analyzed during follow up.</AbstractText>During the follow-up 8 major complications occurred in 5 patients (n</i> = 2 deaths, n</i> = 4 cases of end stage renal disease and n</i> = 1 atrial fibrillation), 4 of them males and only 1 female who suffered an atrial fibrillation. Sudden death or stroke did not occur. Four (40%) of 10 males with baseline left ventricular hypertrophy (LVH) reduced left ventricular mass index (LVMI) from 163.1 ± 64.7 to 123.4 ± 49.8 g/m2</sup>, 2 stabilized LVMI and 4 increased LVMI from157.9 ± 32.3 to 261.6 ± 48.6 g/m2</sup>. Estimated glomerular filtration was stable in 30 patients (17 males and 13 females).</AbstractText>We observed a few major complications during the follow up. Future studies are necessary to show the effectiveness of ERT in affected patients.</AbstractText> |
20,528 | Non-Alcoholic Fatty Liver Disease Association with Cardiac Arrhythmias. | Non-alcoholic fatty liver disease (NAFLD) has become a public health burden all over the world. A significant percentage of the patients with NAFLD have a co-existing metabolic syndrome that is a risk factor for cardiovascular disease. Clinical as well as epidemiological research shows that NAFLD is not simply related to liver-related morbidity and mortality but is also associated with an elevated risk of coronary heart disease (CHD), irregularities of cardiac function as well as cardiac structure, valvular heart disease, and arrhythmias. Animal studies suggest that NAFLD by itself exacerbates systemic/hepatic insulin resistance, leads to atherogenic dyslipidemia and generates a number of pro-inflammatory, pro-coagulant and profibrogenic mediators which play an essential role in the pathophysiology of cardiac abnormalities including arrhythmias. Hence, it is suggested that the patients with NAFLD may derive benefit from intensive monitoring and treatment methods to reduce the risk of CHD along with other cardiac/arrhythmic complications. The intent of this clinical review is to sum up the quickly increasing body of evidence that provides support for a robust relationship between NAFLD and cardiac arrhythmias and to present the putative biological mechanisms underlying this correlation. |
20,529 | Multiscale ordinal network analysis of human cardiac dynamics. | In this study, we propose a new information theoretic measure to quantify the complexity of biological systems based on time-series data. We demonstrate the potential of our method using two distinct applications to human cardiac dynamics. Firstly, we show that the method clearly discriminates between segments of electrocardiogram records characterized by normal sinus rhythm, ventricular tachycardia and ventricular fibrillation. Secondly, we investigate the multiscale complexity of cardiac dynamics with respect to age in healthy individuals using interbeat interval time series and compare our findings with a previous study which established a link between age and fractal-like long-range correlations. The method we use is an extension of the symbolic mapping procedure originally proposed for permutation entropy. We build a Markov chain of the dynamics based on order patterns in the time series which we call an ordinal network, and from this model compute an intuitive entropic measure of transitional complexity. A discussion of the model parameter space in terms of traditional time delay embedding provides a theoretical basis for our multiscale approach. As an ancillary discussion, we address the practical issue of node aliasing and how this effects ordinal network models of continuous systems from discrete time sampled data, such as interbeat interval time series.This article is part of the themed issue 'Mathematical methods in medicine: neuroscience, cardiology and pathology'. |
20,530 | Alogliptin, a Dipeptidyl Peptidase-4 Inhibitor, Alleviates Atrial Remodeling and Improves Mitochondrial Function and Biogenesis in Diabetic Rabbits. | There is increasing evidence implicating atrial mitochondrial dysfunction in the pathogenesis of atrial fibrillation. In this study, we explored whether alogliptin, a dipeptidyl peptidase-4 inhibitor, can prevent mitochondrial dysfunction and atrial remodeling in a diabetic rabbit model.</AbstractText>A total of 90 rabbits were randomized into 3 groups as follows: control group (n=30), alloxan-induced diabetes mellitus group (n=30), and alogliptin-treated (12.5 mg/kg per day for 8 weeks) diabetes mellitus group (n=30). Echocardiographic and hemodynamic assessments were performed in vivo. The serum concentrations of glucagon-like peptide-1, insulin, and inflammatory and oxidative stress markers were measured. Electrophysiological properties of Langendorff-perfused rabbit hearts were assessed. Mitochondrial morphology, respiratory function, membrane potential, and reactive oxygen species generation rate were assessed. The protein expression of transforming growth factor β1, nuclear factor κB p65, and mitochondrial biogenesis-related proteins were measured by Western blot analysis. Diabetic rabbits exhibited left ventricular hypertrophy and left atrial dilation without obvious hemodynamic abnormalities, and all of these changes were attenuated by alogliptin. Compared with the control group, higher atrial fibrillation inducibility in the diabetes mellitus group was observed, and markedly reduced by alogliptin. Alogliptin decreased mitochondrial reactive oxygen species production rate, prevented mitochondrial membrane depolarization, and alleviated mitochondrial swelling in diabetic rabbits. It also improved mitochondrial biogenesis by peroxisome proliferator-activated receptor-γ coactivator 1α/nuclear respiratory factor-1/mitochondrial transcription factor A signaling regulated by adiponectin/AMP-activated protein kinase.</AbstractText>Dipeptidyl peptidase-4 inhibitors can prevent atrial fibrillation by reversing electrophysiological abnormalities, improving mitochondrial function, and promoting mitochondrial biogenesis.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,531 | COOL AMI EU pilot trial: a multicentre, prospective, randomised controlled trial to assess cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction. | We aimed to investigate the rapid induction of therapeutic hypothermia using the ZOLL Proteus Intravascular Temperature Management System in patients with anterior ST-elevation myocardial infarction (STEMI) without cardiac arrest.</AbstractText>A total of 50 patients were randomised; 22 patients (88%; 95% confidence interval [CI]: 69-97%) in the hypothermia group and 23 patients (92%; 95% CI: 74-99) in the control group completed cardiac magnetic resonance imaging at four to six days and 30-day follow-up. Intravascular temperature at coronary guidewire crossing after 20.5 minutes of endovascular cooling decreased to 33.6°C (range 31.9-35.5°C). There was a 17-minute (95% CI: 4.6-29.8 min) cooling-related delay to reperfusion. In "per protocol" analysis, median infarct size/left ventricular mass was 16.7% in the hypothermia group versus 23.8% in the control group (absolute reduction 7.1%, relative reduction 30%; p=0.31) and median left ventricular ejection fraction (LVEF) was 42% in the hypothermia group and 40% in the control group (absolute reduction 2.4%, relative reduction 6%; p=0.36). Except for self-terminating paroxysmal atrial fibrillation (32% versus 8%; p=0.074), there was no excess of adverse events in the hypothermia group.</AbstractText>We rapidly and safely cooled patients with anterior STEMI to 33.6°C at the time of coronary guidewire crossing. This is ≥1.1°C lower than in previous cooling studies. Except for self-terminating atrial fibrillation, there was no excess of adverse events and no clinically important cooling-related delay to reperfusion. A statistically non-significant numerical 7.1% absolute and 30% relative reduction in infarct size warrants a pivotal trial powered for efficacy.</AbstractText> |
20,532 | Atrial antitachycardia pacing and atrial remodeling: A substudy of the international, randomized MINERVA trial. | Atrial tachycardia (AT) and atrial fibrillation (AF) are common in pacemaker patients and are associated with bad prognoses.</AbstractText>The purpose of this study was to evaluate atrial antitachycardia pacing impact on AT/AF-induced atrial remodeling, measured by early recurrence of AT/AF (ERAF) and by change in left atrial diameter (LAD), and to evaluate the impact of AT/AF duration on ERAF incidence.</AbstractText>Pacemaker patients were randomized to dual-chamber pacing (Control DDDR: 385 patients), managed ventricular pacing (MVP: 398 patients), or atrial antitachycardia pacing plus MVP (DDDRP+MVP: 383 patients). LAD change, estimated by echocardiography, was considered significant if the relative difference between baseline and 24-month measurements was >10%.</AbstractText>At median follow-up of 34 months, ERAF incidence was significantly lower in the DDDRP+MVP arm for all AT/AF durations, in particular, ERAF followed AT/AF longer than 3 hours in 53% cases in Control DDDR, in 51% cases in MVP, and in 39% cases in DDDRP+MVP (P <.001 vs other groups). ERAF incidence showed a U-shaped pattern when evaluated as a function of previous AT/AF duration, decreasing for durations from 5 minutes to 12 hours and increasing for longer durations. Among patients with significant LAD change, the proportion of patients with a reduction in LAD was 35% in Control DDDR, 37% in MVP, and 70% in DDDRP+MVP (P <.05 vs other groups).</AbstractText>Our data suggest that atrial electrical remodeling becomes important after about 12 hours of continuous arrhythmia. Compared to DDDR or MVP, DDDRP+MVP reduces ERAF and favors LAD reduction, suggesting that atrial antitachycardia pacing may reverse electrical and mechanical remodeling.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,533 | [Congenital heart disease in adolescents and adults: Management in a general cardiology department in Senegal]. | Congenital heart diseases in adults include malformations treated in childhood that decompensate secondarily and those asymptomatic at birth, appear later. This study aims to identify congenital heart diseases in adults in general cardiology department of Senegal and to assess clinical presentations, treatment and outcomes.</AbstractText>We conducted a cross-sectional and descriptive study based on the records of patients aged at least 16 years and followed for congenital heart disease in the cardiology department of the General Hospital of Grand-Yoff in Dakar between May 2003 and March 2015. Diagnosis of heart disease was based on echocardiography.</AbstractText>We have registered 50 dossiers of patients equivalent to a prevalence of 0.75%, with a female predominance (64%). The average age of patients was 36.2±18.4 years (16-79 years), and mean age of diagnosis was 29.76±22.58 years. Dyspnea was the main sign (60%). Main malformations were the atrial septal defect (38%), pulmonary stenosis (14%), the ventricular septal defect (12%) and patent ductus arteriosus (10%). According to the classification of Bethesda, heart disease was simple complexity (42%), intermediate (58%) or severe (10%). The treatment was medical in 43 patients and 7 patients had surgical repair. Main complications were infective endocarditis (10%), atrial fibrillation (12%), heart failure (24%) and pulmonary arterial hypertension (50%).</AbstractText>Congenital heart diseases in adults seem underestimated in our countries. Surgical repair is rare. It is necessary to ensure a good management of the transition between pediatric and adult age.</AbstractText>Copyright © 2017 Elsevier Masson SAS. All rights reserved.</CopyrightInformation> |
20,534 | Impact of chronic obstructive pulmonary disease on in-hospital morbidity and mortality in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention. | Patients with chronic obstructive pulmonary disease (COPD) presenting with ST-segment elevation myocardial infarction (STEMI) are less likely to beneficiate of primary percutaneous coronary intervention (pPCI), and have poorer prognosis. We aimed to evaluate the impact of COPD on the in-hospital outcomes of pPCI-treated STEMI patients.</AbstractText>Data were collected from 418 STEMI patients treated by pPCI. Inotropics and diuretics usage, cardiogenic shock, asystole, kidney dysfunction, and left ventricular ejection fraction were used as markers of hemodynamic complications. Atrial and ventricular fibrillation, conduction disorders, and antiarrhythmics usage were used as markers of arrhythmic complications. In-hospital mortality was evaluated. The associations between these parameters and COPD were assessed.</AbstractText>COPD was present in 7.42% of STEMI patients. COPD patients were older (p=0.02) and less likely to receive beta-blockers (OR 0.29; 95%CI 0.13-0.64; p<0.01). They had higher Killip class on admission (p<0.001), received more often inotropics (p<0.001) and diuretics (p<0.01), and presented more often atrial (p=0.01) and ventricular fibrillation (p=0.02). Unadjusted in-hospital mortality was higher in COPD patients (OR 4.18, 95%CI 1.55-11.30, p<0.01). After adjustment for potentially confounding factors except beta-blockers, COPD remained an independent predictor of in-hospital mortality (p=0.02). After further adjustment with beta-blocker therapy, no excess mortality was noted in COPD patients.</AbstractText>Despite being treated by pPCI, COPD patients with STEMI are more likely to develop hemodynamic and arrhythmic complications, and have higher in-hospital mortality. This appears to be due to lower beta-blockers usage in COPD patients. Increasing beta-blockers usage in COPD patients with STEMI may improve survival.</AbstractText>Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
20,535 | Synchronization as a mechanism for low-energy anti-fibrillation pacing. | Low-energy anti-fibrillation pacing (LEAP) has been suggested as an alternative treatment in symptomatic fibrillation patients. It significantly lowers the energy required compared with standard 1-shock defibrillation.</AbstractText>In this study, we investigated the mechanism of arrhythmia termination by LEAP and systematically analyzed the influence of shock period and timing on the success rate of LEAP.</AbstractText>We induced atrial and ventricular fibrillation in isolated canine hearts and applied LEAP and standard 1-shock defibrillation to terminate the arrhythmia. We simulated the arrhythmia and LEAP using a 2-dimensional bidomain human atrial model.</AbstractText>The ex vivo experiments showed successful termination of atrial fibrillation and ventricular fibrillation using LEAP, with an average 88% and 81% energy reduction, respectively, and both experiments and simulations verified that synchronization from virtual electrodes is the key mechanism for termination of arrhythmia by LEAP using modified Kuramoto phase plots and fraction of tissue excited (FTE) plots. We also observed in simulations that LEAP is more effective when the shock period is close to the dominant period and the first shock is delivered when FTE is decreasing.</AbstractText>Our results support synchronization as the mechanism for arrhythmia termination by LEAP, and its effectiveness can be improved by adjusting shock period and timing.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,536 | Electrical Substrate Elimination in 135 Consecutive Patients With Brugada Syndrome. | There is emerging evidence that localization and elimination of abnormal electric activity in the epicardial right ventricular outflow tract may be beneficial in patients with Brugada syndrome.</AbstractText>A total of 135 symptomatic Brugada syndrome patients having implantable cardiac defibrillator were enrolled: 63 (group 1) having documented ventricular tachycardia (VT)/ventricular fibrillation (VF) and Brugada syndrome-related symptoms, and 72 (group 2) having inducible VT/VF without ECG documentation at the time of symptoms. About 27 patients of group 1 experienced multiple implantable cardiac defibrillator shocks for recurrent VT/VF episodes. Three-dimensional maps before and after ajmaline determined the arrhythmogenic electrophysiological substrate (AES) as characterized by prolonged fragmented ventricular potentials. Primary end point was identification and elimination of AES leading to ECG pattern normalization and VT/VF noninducibility. Extensive areas of AES were found in the right ventricle epicardium, which were wider in group 1 (P</i>=0.007). AES increased after ajmaline in both groups (P</i><0.001) and was larger in men (P</i>=0.008). The increase of type-1 ST-segment elevation correlated with AES expansion (r</i>=0.682, P</i><0.001). Radiofrequency ablation eliminated AES leading to ECG normalization and VT/VF noninducibility in all patients. During a median follow-up of 10 months, the ECG remained normal even after ajmaline in all except 2 patients who underwent a repeated effective procedure for recurrent VF.</AbstractText>In Brugada syndrome, AES is commonly located in the right ventricle epicardium and ajmaline exposes its extent and distribution, which is correlated with the degree of coved ST-elevation. AES elimination by radiofrequency ablation results in ECG normalization and VT/VF noninducibility. Substrate-based ablation is effective in potentially eliminating the arrhythmic consequences of this genetic disease.</AbstractText>URL: https://clinicaltrials.gov. Unique identifier: NCT02641431.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,537 | Efficacy of an Anatomical Approach in Radiofrequency Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating From the Left Ventricular Outflow Tract. | When anatomic obstacles preclude radiofrequency catheter ablation of idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT), an alternative approach from the anatomically opposite side (endocardial versus epicardial or above versus below the aortic valve) may be considered (anatomic ablation). The purpose of this study was to investigate the efficacy of an anatomic ablation in idiopathic LVOT VAs.</AbstractText>We studied 229 consecutive patients with idiopathic LVOT VAs. Radiofrequency ablation from the first suitable site was successful in 190 patients, and in the remaining 39 patients, it was unsuccessful or had to be abandoned because of anatomic obstacles. In 22 of these 39 patients, an anatomic ablation was successful, and the VA origins were located in the intramural LVOT in 17 patients, basal left ventricular summit in 4, and LVOT septum near the His bundle in 1. The anatomic ablation was highly successful for idiopathic VAs originating from the intramural LVOT (>75%) and lateral LVOT, whereas it was unlikely to be successful for idiopathic VAs originating from the basal left ventricular summit (25%) and sepal LVOT.</AbstractText>When a standard catheter ablation targeting the best electrophysiological measure of idiopathic LVOT VAs was unsuccessful or had to be abandoned because of anatomic obstacles, an anatomic ablation was moderately successful. These idiopathic LVOT VAs with a successful anatomic ablation commonly arose from the intramural LVOT among the left coronary cusp, aortomitral continuity, and epicardium, occasionally the basal left ventricular summit, and rarely the LVOT septum near the His bundle.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,538 | Determinants of decline of renal function in treated hypertensive patients: the Campania Salute Network. | Hypertension is a leading cause of chronic kidney disease (CKD) and a decrease in glomerular filtration rate (GFR) is associated with a higher prevalence of hypertension and an increased proportion of suboptimal blood pressure (BP) control.</AbstractText>To investigate characteristics associated with GFR decline, we selected 4539 hypertensive patients from the Campania Salute Network (mean age 53 ± 11 years) with at least 3 years of follow-up (FU) and no more than Stage III CKD. GFR was calculated at baseline and at the last available visit using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. GFR decline was defined as a ≥30% decrease from initial GFR for patients in Stage III CKD or by a composite ≥30% decrease from baseline and a final value of <60 for those < with Stage III or higher CKD.</AbstractText>At a mean FU of 7.5 years, 432 patients (10%) presented with GFR decline. Those patients were older, more likely to be diabetic, with lower GFR and ejection fraction, higher systolic and lower diastolic BP and higher left ventricular (LV) mass and relative wall thickness at baseline; during FU, patients with GFR decline exhibited higher systolic BP, took more drugs and developed more atrial fibrillation (all P < 0.02). The probability of GFR decline was independently associated with older age, prevalent diabetes, baseline lower GFR, higher systolic BP during FU, FU duration, increased LV mass and incident AF with no impact from antihypertensive and antiplatelet medications.</AbstractText>During antihypertensive therapy, kidney function declines in patients with initially lower GFR, increased LV mass and suboptimal BP control during FU.</AbstractText>© The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.</CopyrightInformation> |
20,539 | Early versus late percutaneous revascularization in patients hospitalized with non ST-segment elevation myocardial infarction: The atherosclerosis risk in communities surveillance study. | Current guidelines recommend early invasive intervention (<24 hr) for high risk patients with non-ST-segment elevation myocardial infarction (NSTEMI). A delayed invasive strategy (24-72 hr) is considered reasonable for low risk patients. The real-world effectiveness of this strategy is unknown.</AbstractText>The ARIC Study has conducted hospital surveillance of acute myocardial infarction (MI) since 1987. NSTEMI was classified using a validated algorithm. We limited our study to patients undergoing early (<24 hr of the event onset), or late (≥24 hr) percutaneous coronary intervention (PCI). Patients were stratified into low (TIMI score 2-4), and high risk (TIMI score 5-7, or presence of cardiogenic shock, ventricular fibrillation, or cardiac arrest). Associations between early versus late PCI and mortality were analyzed using multivariable logistic regression adjusted for demographics, hospitalization year, TIMI score, and comorbidities.</AbstractText>From 1987 to 2012, 6,746 patients were hospitalized with NSTEMI and underwent PCI. Most were white (79%), male (68%), with mean age 61 years. The 28-day and 1-year mortality were 2% and 5%, respectively. Most revascularizations (65%) were late. After accounting for potential confounders, early PCI was associated with a 58% reduced 28-day mortality (OR = 0.42; 95% CI: 0.21-0.84) for the entire population, and 57% reduced mortality (OR = 0.43; 95% CI: 0.21-0.88) for high risk patients. By 1-year of follow up, there was no significant difference in mortality with respect to early vs. late PCI.</AbstractText>In hospitalized NSTEMI patients with high risk of clinical events, early PCI is associated with improved 28-day survival.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,540 | [Cryptogenic stroke in a young patient with heart disease and kidney failure]. | Fabry's disease is an infrequent metabolic pathology linked to the X chromosome which causes a wide variety of signs and symptoms.</AbstractText>A 39-year-old male who was admitted to our stroke unit with right-side hemiparesis (1 + 0) and dysarthria (1). The score on the National Institute of Health Stroke Scale was 2. The patient presented angiokeratomas in both thighs. A computerised axial tomography scan of the head showed left thalamic acute infarction. The duplex scan of the supra-aortic trunks was normal, and the transcranial Doppler reflected a generalised increase in the pulsatility indices. Transthoracic echocardiography showed left ventricular hypertrophy and left atrial dilatation. He was discharged five days later, with antiaggregating medication but asymptomatic. The prolonged Holter-electrocardiogram recording showed paroxysmal atrial fibrillation. One notable value in the urine analysis was microalbuminuria of 281 mg/L. In view of the multi-organic involvement and the family history, a study for Fabry's disease was performed. Activity of the enzyme alpha-galactosidase A was diminished, and the presence of a mutation in the GLA gene was found. The patient's brother, who suffered from kidney failure and atrial fibrillation, was positive for this mutation. The patient is on treatment with agalsidase beta.</AbstractText>Fabry's disease must be suspected in young males with heart disease, stroke or peripheral neuropathy, skin lesions, kidney failure and a history of cases in the family. Hormone replacement therapy must be established at an early stage, as it can improve the prognosis.</AbstractText> |
20,541 | Metformin prevents ischaemic ventricular fibrillation in metabolically normal pigs. | <AbstractText Label="AIMS/HYPOTHESIS">Metformin is the drug most often used to treat type 2 diabetes. Evidence suggests that metformin may reduce mortality of individuals with type 2 diabetes, but the mechanism of such an effect is unknown and outcomes of metformin treatment in people without diabetes have not been determined. If metformin favourably affected mortality of non-diabetic individuals, it might have even broader therapeutic utility. We evaluated the effect of metformin on myocardial energetics and ischaemic ventricular fibrillation (VF) in metabolically normal pigs.</AbstractText>Domestic farm pigs were treated with metformin (30 mg kg-1</sup> day-1</sup> orally for 2-3 weeks; n = 36) or received no treatment (n = 37). Under anaesthesia, pigs underwent up to 90 min low-flow regional myocardial ischaemia followed by 45 min of reperfusion. Pigs were monitored for arrhythmia, monophasic action potential morphology, haemodynamics and myocardial substrate utilisation, AMP-activated protein kinase (AMPK) phosphorylation activity and ATP concentration.</AbstractText>Death due to VF occurred in 12% of pigs treated with metformin compared with 50% of untreated controls (p = 0.03). The anti-fibrillatory effect of metformin was associated with attenuation of action potential shortening in ischaemic myocardium (p = 0.02) and attenuation of the difference in action potential duration between ischaemic and non-ischaemic regions (p < 0.001) compared with untreated controls. Metformin had no effect on myocardial contractile function, oxygen consumption, or glucose or lactate utilisation. During ischaemia, however, metformin treatment amplified the activation of AMPK and preserved ATP concentration in myocardium compared with untreated controls (each p < 0.05).</AbstractText><AbstractText Label="CONCLUSIONS/INTERPRETATION">Chronic treatment of metabolically normal pigs with metformin at a clinically relevant dose reduces mortality from ischaemic VF. This protection is associated with preservation of myocardial energetics during ischaemia. Maintenance of myocardial ATP concentration during ischaemia is likely to prevent action potential shortening, heterogeneity of repolarisation, and propensity for lethal arrhythmia. The findings suggest that metformin might be protective in non-diabetic individuals with coronary heart disease.</AbstractText> |
20,542 | Brugada Syndrome:Risk Stratification And Management. | The Brugada syndrome (BrS) is an arrhythmogenic disease associated with an increased risk of ventricular fibrillation and sudden cardiac death. The risk stratification and management of BrS patients, particularly of asymptomatic ones, still remains challenging. A previous history of aborted sudden cardiac death or arrhythmic syncope in the presence of spontaneous type 1 ECG pattern of BrS phenotype appear to be the most reliable predictors of future arrhythmic events. Several other ECG parameters have been proposed for risk stratification. Among these ECG markers, QRS-fragmentation appears very promising. Although the value of electrophysiological study still remains controversial, it appears to add important information on risk stratification, particularly when incorporated in multiparametric scores in combination with other known risk factors. The present review article provides an update on the pathophysiology, risk stratification and management of patients with BrS. |
20,543 | Amiodarone-Induced Third Degree Atrioventricular Block and Extreme QT Prolongation Generating Torsade Des Pointes in Paroxysmal Atrial Fibrillation. | Amiodarone is still the most potent antiarrhythmic drug in the prevention of life threatening ventricular arrhythmias and demonstrates a very low incidence of torsade de pointes. An unusual case of an 81-year-old woman who developed serious abnormalities of the conduction system of the heart and torsade des pointes during intravenous infusion of amiodarone for the treatment of paroxysmal atrial fibrillation is described. To the best of our knowledge, this is the first case showing an association of intravenous amiodarone-induced third degree atrioventricular block and extreme QT interval prolongation generating torsade des pointes in a patient with paroxysmal atrial fibrillation who required an implantable cardioverter-defibrillator. Currently, amiodarone is still one of the few remaining treatment options for the medical therapeutic management of serious ventricular arrhythmias and to reduce the incidence of atrial fibrillation without increasing mortality or sudden cardiac death rates in heart failure patients like our elderly present patient. Nevertheless, we have to keep in mind that intravenous amiodarone may generate serious abnormalities of the conduction system of the heart and lethal ventricular arrhythmias in certain patients. |
20,544 | Idiopathic Paroxysmal Atrio-Ventricular Block. What is The Mechanism? | Idiopathic paroxysmal atrioventricular (AV) block poses a true diagnostic challenge. What is clear about this entity is the confusion about its definition and consequently about its etiology. According to certain sources, the diagnosis of this block requires the lack of a structural cardiac pathology that justifies the observed manifestations and an absence of electrocardiographic disorders prior to an episode. The clinical presentation of idiopathic paroxysmal AV block does not differ from that of another cardiogenic syncope or of a vasovagal syncope with a significant cardioinhibitory component. With respect to the mechanism that explains this block, it has been postulated that patients with low basal adenosine levels exhibit hyperaffinity of the A2 receptors of the AV node. Variations in plasma adenosine levels may favor episodes of paroxysmal AV block. The diagnosis of this block is complex and can require years to determine. Routine electrophysiological examination of these patients is not cost effective due to the low sensitivity and specificity of this approach. Numerous groups have supported the use of an implantable loop recorder to substantiate AV block paroxysms and assess their clinical correlations. Permanent stimulation devices are utilized to reduce syncopal recurrence. |
20,545 | Novel Ventricular Repolarization Indices in Patients with Coronary Slow Flow. | <b>Background:</b> Coronary slow flow (CSF) phenomenon is described angiographically as delayed progression of the injected contrast agents through the coronary arteries. Aim of this study was to analyze ventricular repolarization in CSF patients by using Tpeak-Tend interval, Tpeak-Tend/QT ratio, Tpeak-Tend/QTc ratio and other repolarization parameters since these parameters are used as predictors for ventricular arrhythmogenesis. <b>Materials and Methods:</b> We have retrospectively analyzed diagnostic coronary angiography results of 160 patients between 2010 and 2014. Patients were divided into two groups according to coronary flow results. CSF group consisted of 33 female, 82 male patients with mean age 51,9±11,5 years. Control group included patients with normal coronary flow; 13 female, 32 male with mean age 50,8±11,7 years. In all patients, ventricular repolarization parameters as well as other associated electrocardiographic intervals were measured on the twelve-lead surface electrocardiogram. <b>Results:</b> The ventricular repolarization parameters: QTmax interval, QTmin interval, QTc, QTI, QTcI, JTmax interval, JTmin interval, JTdispersion and JTIndex were not significantly different between the groups. However followings parameters differed significantly between patients and controls; QRS (92,8±11,5 msn versus 78,3±16,713,40 msn, respectively; p=0.001), T wave (89±20,2 msn vs. 73,3±13,3 msn respectively, p=0.001), QT dispersion (26,8±17,5 msn vs. 13,5±20,4 msn respectively, p=0.002), JTcorrected (331,6±39,8%; vs. 350,1±39,7% respectively; p=0.01). Furthermore; Tpeak-Tend duration (89±20,2 msn vs. 73,3±13,9 msn respectively; p=0.001), T wave (204±34,9 msn vs. 189,2±24,8 msn respectively; p=0.003), Tpeak-Tend/QT ratio (0,22±0,05 msn vs. 0,19±0,03 msn respectively, p=0.001) were significantly higher in patients compared to controls. Tpeak-Tend/QTc ratio was also significantly higher in the CSF group compared to the controls. (0,21±0,05 msn vs. 0,17±0,03 msn respectively, p =0.001). <b>Conclusion:</b> Ventricular repolarization parameters are prolonged in patients with CSF. |
20,546 | Ventricular and Supraventricular Ectopy in Subjects With Early Repolarization. | Early repolarization (ER) is a common electrocardiographic (ECG) finding that is associated with an increased risk of idiopathic ventricular fibrillation and sudden cardiac death. This study investigated whether the presence of ER is a predictor of ventricular and supraventricular ectopy as a marker for electrical instability. Standard 12-lead electrocardiograms of the first follow-up in the population-based Study of Health in Pomerania (SHIP-1) (n = 3,300, age 20 to 79 years) were analyzed to identify subjects with an ER pattern. Ventricular and supraventricular ectopy was assessed via portable tele-ECG cards recording 2 electrocardiograms daily over the course of 4 weeks. Data of 1,630 subjects (n = 83,833 ECG card recordings, average 51.4 per subject) were analyzed for ventricular and supraventricular ectopy using a standardized automated algorithm. Associations of ER and several forms of arrhythmias were assessed using a 2-sided Fisher's exact test or t test, where appropriate. Overall, prevalence of ER in the SHIP-1 population was 4.8%. Presence of ER was not associated with the occurrence of ventricular and supraventricular arrhythmias (p ≥0.05 for all analyses). Furthermore, subgroup analyzes for ER localization (inferior) and ST-segment morphology (horizontal/descending) did not show any association with arrhythmic events. In conclusion, presence of the ER pattern is not associated with an increased occurrence of ventricular or supraventricular arrhythmias as assessed by serial ECG card recordings in this large population-based sample. |
20,547 | Trends in Management and Mortality in Adults Hospitalized With Cardiac Arrest in the United States. | We sought to examine temporal trends in management (ie, use of extracorporeal membrane oxygenation [ECMO], therapeutic hypothermia [TH], coronary angiogram, and percutaneous coronary intervention [PCI]) and in-hospital mortality in adults hospitalized with cardiac arrest.</AbstractText>Utilizing the Nationwide Inpatient Sample, medical history, clinical management, and in-hospital mortality were assessed in 942 495 hospitalizations in adults with cardiac arrest (identified through International Classification of Diseases-9</i> codes) from 2006 to 2012.</AbstractText>From 2006 to 2012, there was an overall rise in the use of coronary angiogram (12.8%, 13.0%, 14.7%, 15.0%, 14.3%, 14.7%, and 15.8%), PCI (7.5%, 7.1%, 8.4%, 8.1%, 8.1%, 8.4%, and 8.9%), TH (0.2%, 0.3%, 0.6%, 1.2%, 1.9%, 2.8%, and 3.0%), and ECMO (0.1%, 0.1%, 0.1%, 0.2%, 0.2%, 0.3%, and 0.4%; P</i> < .001 for all). In-hospital mortality significantly decreased over the 7-year study period (65.5%, 63.4%, 59.3%, 57.9%, 57.0%, 56.0%, and 56.3% from 2006 to 2012). In multivariable analysis, a 31% decrease in mortality was accompanied by a concomitant 24% and 27% increase in coronary angiogram and PCI, respectively, during the study period. Therapeutic hypothermia and ECMO were associated with an approximate 11-fold and 7-fold increase, respectively, from 2006 to 2012. The strongest predictors of use of ECMO, TH, coronary angiogram, and PCI were younger age and the presence of coronary artery disease.</AbstractText>During 2006 to 2012, a decline in mortality was accompanied by a steady rise in the use of ECMO, TH, coronary angiogram, and PCI in adults hospitalized with cardiac arrest. Patients of younger age and with coronary artery disease were more likely to receive these advanced therapies.</AbstractText> |
20,548 | Impact of pre-existing or new-onset atrial fibrillation on 30-day clinical outcomes following transcatheter aortic valve replacement: Results from the BRAVO 3 randomized trial. | Prior studies have suggested that patients with atrial fibrillation (AF) undergoing transcatheter aortic valve replacement (TAVR) are at higher risk for adverse cardiovascular events. Whether procedural bivalirudin compared with unfractionated heparin (UFH) has a beneficial effect on early outcomes in these patients is unknown. We examined for the effect of baseline or new-onset AF within 30 days of TAVR and explored for the effect of bivalirudin versus UFH by AF status, on 30-day outcomes from the BRAVO 3 trial.</AbstractText>The BRAVO-3 trial multicenter randomized trial included 802 patients undergoing transfemoral TAVR randomized to bivalirudin or UFH. We compared AF and no-AF groups and examined for 30-day Bleeding Academic Research Consortium type ≥3b bleeding, major vascular complications and all ischemic endpoints. Adjusted outcomes were analyzed using logistic regression methods.</AbstractText>Of the study population, 41.4% (n = 332) patients had baseline or new-onset AF within 30 days of TAVR, whereas 58.6% (n = 470) had no AF. Patients with AF had greater prevalence of renal dysfunction, lower left ventricular ejection fraction, and higher euroSCORE I compared with their counterparts without AF. Among AF and no-AF patients, there were no significant baseline differences between bivalirudin and UFH groups. At 30 days the incidence of death (6.0 vs. 4.5%, P = 0.324) and stroke (3.9 vs. 2.6%, P = 0.274) was similar in AF vs. no-AF patients. However, new-onset AF (n = 38) was associated with significantly greater crude risk of 30-day stroke compared with no AF (HR 4.49, 95% CI 1.37-14.67). Regardless of AF status, there were no differences in 30-day death (P-int = 0.652) or stroke (P-int = 0.066) by anticoagulation type.</AbstractText>Prior or new-onset AF is noted in more than one-third of patients undergoing transfemoral TAVR. Despite greater baseline comorbidities than non-AF patients, AF was not associated with significantly higher risk of adjusted 30-day outcomes. In the BRAVO 3 trial, early outcomes were similar regardless of anticoagulant strategy in each group.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,549 | Anticoagulation Control in Patients With Ventricular Assist Devices. | Anticoagulation control has been associated with risk of thromboembolism and hemorrhage. Herein, we explore the relationship between anticoagulation control achieved in left ventricular assist device (LVAD) patients and evaluate the association with risk of thromboembolism and hemorrhage. Patients (19 years old or older) with a continuous flow LVAD placed from 2006 to 2012. Percent time spent in target range (PTTR) for international normalized ratio (INR) was estimated with target range of 2.0-3.0. Proportion of time spent in target range was categorized into PTTR > 60%, PTTR ≥ 50 < 60%, and PTTR < 50%. The relationship between PTTR and thromboembolism and hemorrhage was assessed. One hundred fifteen participants contributed 624.5 months of follow-up time. Only 20% of patients achieved anticoagulation control (PTTR > 60% for INR range of 2-3). After adjusting for chronic kidney disease, history of diabetes, history of atrial fibrillation, and age at implant, compared with patients with PTTR < 50%, the relative risk of thromboembolism in patients with PTTR ≥ 60% (hazard ratio [HR]: 0.37; 95% confidence interval [CI]: 0.14-0.96; p = 0.042) was significantly lower, but not for patients with a PTTR of ≥ 50 < 60% (HR: 0.21; 95% CI: 0.02-1.82; p = 0.16). The relative risk for hemorrhage was also significantly lower among patients with a PTTR ≥ 60% (HR: 0.45; 95% CI: 0.21-0.98; p = 0.045), but not among those with PTTR of ≥ 50 < 60% (HR: 0.47; 95% CI: 0.14-1.56; p = 0.22). This current study demonstrates that LVAD patients remain in the INR target range an average of 42.9% of the time. To our knowledge, this is the first report with regard to anticoagulation control as assessed by PTTR and its association with thromboembolism, hemorrhage, or death among patients with ventricular assist devices (VADs). |
20,550 | Practice guideline summary: Reducing brain injury following cardiopulmonary resuscitation: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. | To assess the evidence and make evidence-based recommendations for acute interventions to reduce brain injury in adult patients who are comatose after successful cardiopulmonary resuscitation.</AbstractText>Published literature from 1966 to August 29, 2016, was reviewed with evidence-based classification of relevant articles.</AbstractText>For patients who are comatose in whom the initial cardiac rhythm is either pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) after out-of-hospital cardiac arrest (OHCA), therapeutic hypothermia (TH; 32-34°C for 24 hours) is highly likely to be effective in improving functional neurologic outcome and survival compared with non-TH and should be offered (Level A). For patients who are comatose in whom the initial cardiac rhythm is either VT/VF or asystole/pulseless electrical activity (PEA) after OHCA, targeted temperature management (36°C for 24 hours, followed by 8 hours of rewarming to 37°C, and temperature maintenance below 37.5°C until 72 hours) is likely as effective as TH and is an acceptable alternative (Level B). For patients who are comatose with an initial rhythm of PEA/asystole, TH possibly improves survival and functional neurologic outcome at discharge vs standard care and may be offered (Level C). Prehospital cooling as an adjunct to TH is highly likely to be ineffective in further improving neurologic outcome and survival and should not be offered (Level A). Other pharmacologic and nonpharmacologic strategies (applied with or without concomitant TH) are also reviewed.</AbstractText>© 2017 American Academy of Neurology.</CopyrightInformation> |
20,551 | Coronary artery bypass surgery within 48 hours after cardiac arrest due to acute myocardial infarction. | Cardiac arrest (CA) in patients with acute myocardial infarction is associated with a poor prognosis. Due to the additional trauma, risk of stroke and lack of data, coronary artery bypass grafting (CABG) is a controversial revascularization strategy for patients who cannot be treated percutaneously. Against this background, we investigated the outcome of patients from our department with acute myocardial infarction undergoing CABG after CA.</AbstractText>Between January 2001 and January 2015, 129 patients with preoperative CA due to acute myocardial infarction underwent CABG at our institution within 48 h after the CA had occurred. Predictors of in-hospital and long-term mortality were analysed. Neurological outcome according to cerebral performance category scale was investigated.</AbstractText>Sixty CA (47%) events occurred out-of-hospital. Ventricular fibrillation was the major underlying arrhythmia ( n  = 92, 71%). The mean age was 65 ± 10 years. Eighty-four patients (65%) were diagnosed with ST-elevation myocardial infarction and 108 patients (84%) had 3-vessel coronary artery disease. Forty-three cases (33%) underwent percutaneous transluminal angioplasty. The median time to CABG was 4 (range 0.2-4) h. Complete revascularization was achieved in 106 patients (83%). The stroke rate was 9% ( n  = 11) and hypoxic brain damage occurred in 16 patients (12%). Nine subjects (7%) needed extracorporeal life support. Four intraoperative deaths (3%) occurred; the 30-day mortality rate was 23% ( n  = 30); the mortality rate during follow-up was 30% ( n  = 27). A total of 79% ( n  = 70) of patients discharged alive showed good neurological outcome according to the cerebral performance category scale.</AbstractText>Despite the reluctance to expose patients with CA to early CABG, our data indicate that the operative strategy may not be as unfavourable as suspected.</AbstractText>© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.</CopyrightInformation> |
20,552 | Substrate-dependent risk stratification for implantable cardioverter defibrillator therapies using cardiac magnetic resonance imaging: The importance of T1 mapping in nonischemic patients. | The role of implantable cardioverter defibrillators (ICDs) in nonischemic cardiomyopathy is unclear and better risk-stratification is required. We sought to determine if T1 mapping predicts appropriate defibrillator therapy in patients with nonischemic cardiomyopathy. We studied a mixed cohort of ischemic and nonischemic patients to determine whether different cardiac magnetic resonance (CMR) applications (T1 mapping, late gadolinium enhancement, and Grayzone) were selectively predictive of therapies for the different arrhythmic substrates.</AbstractText>We undertook a prospective longitudinal study of consecutive patients receiving defibrillators in a tertiary cardiac center. Participants underwent CMR myocardial tissue characterization using T1 mapping and conventional CMR scar assessment before device implantation. QRS duration and fragmentation on the surface electrocardiogram were also assessed. The primary endpoint was appropriate defibrillator therapy. One-hundred thirty patients were followed up for a median of 31 months (IQR ± 9 months). In nonischemic patients, T1_native</sup> was the sole predictor of the primary endpoint (hazard ratio [HR] 1.12 per 10 millisecond increment in value [95% confidence interval [CI] 1.04-1.21; P ≤ 0.01]). In ischemic patients, Grayzone_2SD-3SD</sup> was the strongest predictor of appropriate therapy (HR 1.34 per 1% left ventricular increment in value [95% CI 1.03-1.76; P = 0.03]). QRS fragmentation correlated well with myocardial scar core (receiver operating characteristic area under the curve [ROC AUC] 0.64; P = 0.02) but poorly with T1_native</sup> (ROC AUC 0.4) and did not predict appropriate therapy.</AbstractText>In the medium-long term, T1_native</sup> mapping was the only independent predictor of therapy in nonischemic patients, whereas Grayzone was a better predictor in ischemic patients. These findings suggest a potential role for T1_native</sup> mapping in the selection of patients for ICDs in a nonischemic population.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,553 | Longstanding persistent accelerated idioatrial rhythm: Benign sinus node-like rhythm or insidious rhythm? | Detailed description of longstanding persistent accelerated idioatrial rhythm (AIAR) is lacking. This observational study investigated the clinical manifestations, electrophysiological characteristics, diagnosis, treatment, and prognosis of this unusual arrhythmia.</AbstractText>Fifteen patients (11 males; average age 25.9 ± 15.7 years) suspected with longstanding persistent AIAR were enrolled in our study. All patients had electrocardiogram (ECG), 24-hour Holter monitoring, isoproterenol provocation test, echocardiogram, and exercise treadmill test. Electrophysiological study (EPS) and catheter ablation were performed if necessary. The above noninvasive tests would be repeated during follow-up. Among the patients, 10 were asymptomatic; 5 had concomitant paroxysmal atrial tachycardia. Two asymptomatic patients had impaired left ventricular function. AIAR was observed throughout 24-hour Holter monitoring, showing chronotropic profile similar to sinus rhythm (SR). Such AIAR exhibited competitive property with SR when provoked by isoproterenol or during treadmill test. Twelve patients had EPS and 8 of them had successful ablation to eliminate AIAR. During a medium follow-up of 3.7 years, all patients were in well clinical course and preserved left ventricular dysfunction, and 3 patients spontaneously reverted to SR at 10-year follow-up.</AbstractText>Longstanding persistent AIAR is an unusual entity of atrial arrhythmias and in most situations a benign rhythm requiring no treatment. The clinical course will be worsened when AIAR develops rapid focal firing, is associated with focal atrial tachycardias or results in tachycardia-mediated cardiomyopathy, but can be resolved via catheter ablation.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,554 | Comparison of Quantitative Characteristics of Early Post-resuscitation EEG Between Asphyxial and Ventricular Fibrillation Cardiac Arrest in Rats. | Quantitative electroencephalogram (EEG) analysis has shown promising results in studying brain injury and functional recovery after cardiac arrest (CA). However, whether the quantitative characteristics of EEG, as potential indicators of neurological prognosis, are influenced by CA causes is unknown. The purpose of this study was designed to compare the quantitative characteristics of early post-resuscitation EEG between asphyxial CA (ACA) and ventricular fibrillation CA (VFCA) in rats.</AbstractText>Thirty-two Sprague-Dawley rats of both sexes were randomized into either ACA or VFCA group. Cardiopulmonary resuscitation was initiated after 5-min untreated CA. Characteristics of early post-resuscitation EEG were compared, and the relationships between quantitative EEG features and neurological outcomes were investigated.</AbstractText>Compared with VFCA, serum level of S100B, neurological deficit score and brain histopathologic damage score were dramatically higher in the ACA group. Quantitative measures of EEG, including onset time of EEG burst, time to normal trace, burst suppression ratio, and information quantity, were significantly lower for CA caused by asphyxia and correlated with the 96-h neurological outcome and survival.</AbstractText>Characteristics of earlier post-resuscitation EEG differed between cardiac and respiratory causes. Quantitative measures of EEG not only predicted neurological outcome and survival, but also have the potential to stratify CA with different causes.</AbstractText> |
20,555 | Epidemiology of ventricular tachyarrhythmia : Any changes in the past decades? | Ventricular tachyarrhythmias include potentially lethal episodes of sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) as well as hemodynamically tolerated ventricular ectopic activity. Sustained VT or VF may develop in the setting of acute myocardial infarction or as clinical sequelae of advanced cardiomyopathy. The incidence of these serious arrhythmias is estimated from retrospective and observational studies and registries of sudden cardiac arrest and sudden cardiac death. Over the past few decades, there has been a gradual decline in the incidence of life-threatening ventricular tachyarrhythmias which has been largely driven by upstream treatments for and prevention of coronary artery disease and its sequelae. In addition primary prevention implantable cardioverter-defibrillators (ICDs) have improved survival in patients at risk for malignant ventricular arrhythmias and sudden cardiac death. Improved understanding, and improved diagnostic and imaging methods have elucidated many of the previously classified "idiopathic" ventricular arrhythmias as inherited arrhythmic syndromes and occult cardiomyopathies. In addition, improved sensitivity and duration of ECG monitoring has allowed increased detection of ventricular ectopic activity. |
20,556 | Usefulness of Preoperative Transforming Growth Factor-Beta to Predict New Onset Atrial Fibrillation After Surgical Ventricular Septal Myectomy in Patients With Obstructive Hypertrophic Cardiomyopathy. | Postoperative atrial fibrillation (AF) occurs frequently after cardiac surgery and contributes significantly to mortality. Transforming growth factor-beta (TGF-β) is associated with postoperative AF after coronary artery bypass grafting and valve surgery. We performed a prospective study to evaluate the role of TGF-β as a predictor of AF after myectomy. A total of 109 consecutive obstructive hypertrophic cardiomyopathy patients without previous AF who underwent myectomy were identified. We measured plasma TGF-β levels before surgery, monitored heart rhythm until discharge, and followed patients for a mean of 36 ± 10 months. AF was documented in 19 patients (17%). AF patients were older (50 ± 10 vs 43 ± 15 years, p = 0.037). Patients who developed AF had higher plasma TGF-β levels (1,695 ± 2,011 vs 1,099 ± 2,494 pg/ml, p = 0.011), more major adverse cardiac events (32% vs 7%, p = 0.006), and more strokes (16% vs 0%, p = 0.005) than patients who did not. TGF-β level ≥358 pg/ml predicted AF with sensitivity and specificity of 58% and 77% (p = 0.011), respectively. Higher TGF-β levels were associated with pulmonary hypertension (25% vs 8%, p = 0.033). In multivariable regression analysis, age (odds ratio 1.05, 95% confidence interval 1.00 to 1.11, p = 0.041) and TGF-β levels (odds ratio 2.42, 95% confidence interval 1.30 to 4.50, p = 0.005) predicted AF independently. In conclusion, elevated preoperative TGF-β value is an independent predictor of postoperative AF in hypertrophic cardiomyopathy patients after surgical ventricular septal myectomy. |
20,557 | Two hearts synchronized each other with a DDD pacemaker. | : We describe the case of a patient with dyspnea and heterotopic cardiac transplant, ventricular fibrillation from the native heart and sinus rhythm from the transplanted one. The two hearts were synchronized with a pacemaker. Electric external cardioversion and a different type of pacemaker stimulation were successfully performed, with improving symptoms. |
20,558 | [Malignant bileaflet mitral valve prolapse syndrome in otherwise idiopathic ventricular fibrillation]. | A 32-year-old, otherwise healthy woman was admitted after successful out-of-hospital resuscitation due to ventricular fibrillation. Established cardiac, pulmonary, metabolic, and toxicological causes were excluded. However, persisting (biphasic) negative T waves in the inferior ECG leads and premature ventricular contractions (PVC) were noted. PVC morphology indicated a focus alternating between the posterior papillary muscle/the left posterior fascicle and the left ventricular outflow tract region/anterior papillary muscle. Echocardiography revealed a bileaflet mitral prolapse with mild mitral valve regurgitation. This case is a typical presentation of the recently described malignant bileaflet mitral valve prolapse syndrome. The patient was discharged without overt neurological deficit after implantation of a cardioverter-defibrillator. |
20,559 | Performance of AHEAD Score in an Asian Cohort of Acute Heart Failure With Either Preserved or Reduced Left Ventricular Systolic Function. | AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score has been related to clinical outcomes of acute heart failure. However, the prognostic value of the AHEAD score in acute heart failure patients with either reduced or preserved left ventricular ejection fraction (HFrEF and HFpEF) remain to be elucidated.</AbstractText>The study population consisted of 2143 patients (age 77±12 years, 68% men, 38% HFrEF) hospitalized primarily for acute heart failure with a median follow-up of 23.75 months. The performance of the AHEAD score (atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 μmol/L, and diabetes mellitus) was evaluated by Cox's regression analysis for predicting cardiovascular and all-cause mortality. The mean AHEAD scores were 2.7±1.2 in the total study population, 2.6±1.3 in the HFrEF group, and 2.7±1.1 in the HFpEF group. After accounting for sex, sodium, uric acid, and medications, the AHEAD score remained significantly associated with all-cause and cardiovascular mortality (hazard ratio and 95% CI: 1.49, 1.38-1.60 and 1.48, 1.33-1.64), respectively. The associations of AHEAD score with mortality remained significant in the subgroups of HFrEF (1.63, 1.47-1.82) and HFpEF (1.34, 1.22-1.48). Moreover, when we calculated a new AHEAD-U score by considering uric acid (>8.6 mg/dL) in addition to the AHEAD score, the net reclassification was improved by 19.7% and 20.1% for predicting all-cause and cardiovascular mortality, respectively.</AbstractText>The AHEAD score was useful in predicting long-term mortality in the Asian acute heart failure cohort with either HFrEF or HFpEF. The new AHEAD-U score may further improve risk stratification.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,560 | Prevalence of Cardiac Arrhythmias in Hypothyroid and Euthyroid Patients. | The thyroid functions as a regulator of cardiac function and rhythm through genomic and nongenomic actions of triiodothyronine (T3) in cardiac myocytes. Atrial fibrillation is a common complication of thyrotoxicosis. Hypothyroidism is not considered a risk factor for arrhythmias despite well-known EKG changes in this condition. This case control study was conducted to analyze the differences, if any, in the prevalence of cardiac arrhythmias between hypothyroid patients and euthyroid controls. Three hundred and four consecutive patients admitted at our medical center for a period of one year were included in the study. The study population was divided into 2 groups (age, gender and race matched): patients with hypothyroidism and euthyroid subjects as a control group. Major arrhythmia data were obtained from telemetry recordings and from known past medical history. There were 152 subjects in each arm of the study. The mean age was 61.9 years. Mean TSH in hypothyroid group was 40.4 mIU/l (95% CI 33.3-47.5) (range 10.09-304, SE 3.62) and in euthyroid group was 0.89 mIU/l (95% CI 0.82-0.96). Chi-square analysis revealed a higher prevalence of ventricular tachycardia (p=0.04) and any ventricular arrhythmia in the hypothyroid group (p=0.007). This relatively large case control study revealed a statistically higher prevalence of ventricular arrhythmias in hypothyroidism. Our study has thrown light on the prevalence of arrhythmias in hypothyroidism and the observation of increased ventricular arrhythmias necessitates future large scale prospective studies to better define the risk of such ventricular arrhythmias and the effects of thyroid supplementation on this risk. |
20,561 | Stellate ganglion blockade and bilateral cardiac sympathetic denervation in patients with life-threatening ventricular arrhythmias. | Autonomic modulation is being increasingly employed as a strategy to treat ventricular arrhythmias refractory to beta-blockers, antiarrhythmic drugs, and catheter-based ablation procedures. We report 6 patients with refractory ventricular tachycardia (VT) or ventricular fibrillation (VF) treated with stellate ganglion blockade (SGB) and/or bilateral cardiac sympathetic denervation (CSD). Our case series emphasizes the concept that the cardiac sympathetic nerves are important targets in the management of ventricular arrhythmias. SGB and CSD can be effective in suppressing VT/VF and can be offered to patients with refractory ventricular arrhythmias as an adjunct to conventional therapy. |
20,562 | Beyond the Electrocardiogram: Mutations in Cardiac Ion Channel Genes Underlie Nonarrhythmic Phenotypes. | Cardiac ion channelopathies are an important cause of sudden death in the young and include long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, idiopathic ventricular fibrillation, and short QT syndrome. Genes that encode ion channels have been implicated in all of these conditions, leading to the widespread implementation of genetic testing for suspected channelopathies. Over the past half-century, researchers have also identified systemic pathologies that extend beyond the arrhythmic phenotype in patients with ion channel gene mutations, including deafness, epilepsy, cardiomyopathy, periodic paralysis, and congenital heart disease. A coexisting phenotype, such as cardiomyopathy, can influence evaluation and management. However, prior to recent molecular advances, our understanding and recognition of these overlapping phenotypes were poor. This review highlights the systemic and structural heart manifestations of the cardiac ion channelopathies, including their phenotypic spectrum and molecular basis. |
20,563 | Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure. | The relationship between mortality and heart rate remains unclear for patients with heart failure with reduced ejection fraction in either sinus rhythm or atrial fibrillation (AF).</AbstractText>This analysis explored the prognostic importance of heart rate in patients with heart failure with reduced ejection fraction in randomized controlled trials comparing beta-blockers and placebo.</AbstractText>The Beta-Blockers in Heart Failure Collaborative Group performed a meta-analysis of harmonized individual patient data from 11 double-blind randomized controlled trials. The primary outcome was all-cause mortality, analyzed with Cox proportional hazard ratios (HR) modeling heart rate measured at baseline and approximately 6 months post-randomization.</AbstractText>A higher heart rate at baseline was associated with greater all-cause mortality for patients in sinus rhythm (n = 14,166; adjusted HR: 1.11 per 10 beats/min; 95% confidence interval [CI]: 1.07 to 1.15; p < 0.0001) but not in AF (n = 3,034; HR: 1.03 per 10 beats/min; 95% CI: 0.97 to 1.08; p = 0.38). Beta-blockers reduced ventricular rate by 12 beats/min in both sinus rhythm and AF. Mortality was lower for patients in sinus rhythm randomized to beta-blockers (HR: 0.73 vs. placebo; 95% CI: 0.67 to 0.79; p < 0.001), regardless of baseline heart rate (interaction p = 0.35). Beta-blockers had no effect on mortality in patients with AF (HR: 0.96, 95% CI: 0.81 to 1.12; p = 0.58) at any heart rate (interaction p = 0.48). A lower achieved resting heart rate, irrespective of treatment, was associated with better prognosis only for patients in sinus rhythm (HR: 1.16 per 10 beats/min increase, 95% CI: 1.11 to 1.22; p < 0.0001).</AbstractText>Regardless of pre-treatment heart rate, beta-blockers reduce mortality in patients with heart failure with reduced ejection fraction in sinus rhythm. Achieving a lower heart rate is associated with better prognosis, but only for those in sinus rhythm.</AbstractText>Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,564 | Treatment of pulmonary sinus cusp-derived ventricular arrhythmia with reversed U-curve catheter ablation. | The origin of pulmonary sinus cusp (PSC)-derived ventricular arrhythmia (VA) is a highly specialized anatomical structure; therefore, insertion of the radiofrequency ablation catheter tip to the target site to ensure safe ablation is a major challenge for clinicians.</AbstractText>To summarize ablation methods, and provide valuable experience for the treatment of PSC-derived VA with ablation.</AbstractText>A retrospective analysis and summary of the clinical data of 15 patients undergoing catheter ablation for PSC-derived VA in Cardiac Intervention Therapy Center, The Second Xiangya Hospital of Central South University between January 2013 and July 2015 was conducted.</AbstractText>For the 15 patients, the PSC-derived VA originated from the lower regions of the pulmonary sinuses, leading from the right, left, and anterior sinuses of the PSC in 4, 6, and 5 patients, respectively. Nine patients with PSC-derived VAs originating from the right and anterior sinuses underwent successful reversed U-curve catheter ablation, while the other six cases with arrhythmias originating from the left sinus underwent successful ablation with the conventional method (nonreversed U-curve catheter ablation). All the patients were followed-up for 6-31 months, and no cases of recurrence or complications occurred.</AbstractText>Reversed U-curve catheter ablation is suitable for VAs originating from the right and anterior PSCs, while conventional ablation can also be used for those originating from the left PSCs.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,565 | Three-dimensional Transesophageal Echocardiography Demonstration of Left Atrial Appendage Echocontrast Regression after 6 Months Therapy with Dabigatran and not with Warfarin. | While warfarin therapy is efficacious in treating left atrial (LA) thrombus formation in patients with nonvalvular atrial fibrillation (AF), it does not affect red cell aggregation <i>in vitro</i> or LA spontaneous echo-contrast in patients. In this patient with left ventricular (LV) dysfunction secondary to AF, we observed the disappearance of dense echo-contrast in the atrial appendage after therapy with dabigatran and not with well-controlled warfarin. This allowed us to analyze accurately the appendage with three-dimensional (3D) transesophageal echocardiography (TEE) excluding thrombi and to perform electrical cardioversion to obtain a significant improvement of LV function. This case demonstrates the capability of dabigatran and not of warfarin in reducing the intense spontaneous echocontrast in atrial appendage and the ability of 3D TEE in analyzing accurately the appendage, excluding thrombi to safely perform cardioversion. |
20,566 | Fatal cardiac glycoside poisoning due to mistaking foxglove for comfrey. | Accidental ingestion of foxglove (Digitalis purpurea) can cause significant cardiac toxicity. We report a patient who ingested foxglove mistaking it for comfrey and developed refractory ventricular arrhythmias. The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).</AbstractText>A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L). Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL. The patient developed ventricular fibrillation while waiting for Digibind infusion. Resuscitation was performed and an emergent VA-ECMO was set up. A total of eight vials of Digibind were given over the next 16 hours. She temporarily regained consciousness, but remained hemodynamically unstable and subsequently developed lower limb ischemia and multiple organ failure, and she expired on hospital day seven. A botanist confirmed that the plant was foxglove.</AbstractText>The diagnosis of cardiac glycoside plant poisoning can be difficult in the absence of an accurate exposure history. In facilities where DSFab is unavailable or insufficient, early VA-ECMO might be considered in severely cardiotoxic patients unresponsive to conventional therapy.</AbstractText> |
20,567 | An unexpected presentation of sick sinus syndrome: Isolated ventricular asystole. | Sick sinus syndrome is a disorder of sinus node function characterized by various dysrhythmias such as sinus bradycardia or pause, paroxysmal regular or irregular atrial tachycardia, tachycardiabradycardia attacks or atrial fibrillation with slow ventricular response. Ventricular asystole with preserved atrial electrical activity is a rarely seen presenting rhythm in the ED and an extremely rare cause of syncope. A 67-year-old male having a syncope attack was admitted to the emergency department. His Glasgow coma scale score was 15 on admission. He became unconscious during his observation in the emergency department, and cardiopulmonary resuscitation was initiated because he was seen to be apneic; his arterial pulse was impalpable, and ventricular asystole with preserved atrial electrical activity was seen on the monitor. He regained consciousness and normal sinus rhythm was seen on the monitor after 2min of cardiopulmonary resuscitation. Then, an alternating rhythm with short periods of bradycardia and tachycardia suggesting sick sinus syndrome was developed. A dual-chamber pacemaker was placed, and he was discharged after 2days of in patient follow-up. His symptoms have not recurred after placement of the pacemaker device. When sudden changes in vital parameters and/or consciousness develop during observation of a patient with sick sinus syndrome, although it is not a common circumstance, accompanying high degree atrioventricular block and simultaneous ventricular asystole should be considered, and cardiopulmonary resuscitation should be initiated immediately because cardiopulmonary arrest is inevitable when ventricular asystole develops even if the atrial electrical activity is maintained. |
20,568 | Profiling cardiac arrhythmia and heart failure patients in India: The Pan-arrhythmia and Heart Failure Observational Study. | The PANARrhythMia and Heart Failure Registry (PANARM HF) characterized demographic, clinical and interventional therapy indication profiles of cardiac arrhythmia (CA) and heart failure (HF) patients in India.</AbstractText>Consulting Physicians (CP) who medically manage CA and HF patients enrolled patients with one or more of the following: syncope, pre-syncope, dyspnea, palpitation, fatigue and LV dysfunction. The CPs were trained by interventional cardiologists (IC) to identify CA/HF patients indicated for implantable device/radiofrequency ablation (RFA). 59 CP's, 16 IC's & 2205 patients from 12 cities participated. Demographic, clinical, device/RFA indication and referral-consultation profiles were created. IC's provided device/RFA recommendations based on these profiles.</AbstractText>The CA/HF distribution of patients was: HF - 58%, bradyarrhythmia - 15%, atrial fibrillation - 15%, other supraventricular tachyarrhythmia - 10% and ventricular tachycardia/fibrillation - 4.5%. 62% of the CA/HF population was male and 45% were below age 60. Coronary artery disease (52%), hypertension (44%), diabetes (30%) & myocardial infarction (20%) were prominent. 1011 (46%) of the CA/HF population were potential device/RFA candidates according to the IC's. However, only 700 (69%) of these patients were referred to the IC by the CP. Of referred patients, only 177 (25%) consulted the IC and were recommended therapy. Thus, 824 (83%) of patients indicated for interventional therapy were not advised therapy or did not opt for it.</AbstractText>The India PANARM HF study provides new information and insights into the demographic, clinical, interventional therapy, referral and consultation pattern profiles of CA/HF patients in India.</AbstractText>Copyright © 2016. Published by Elsevier B.V.</CopyrightInformation> |
20,569 | Subcutaneous cardioverter defibrillator has longer time to therapy but is less cardiotoxic than transvenous cardioverter defibrillator. Study carried out in a preclinical porcine model. | Totally subcutaneous implantable cardioverter defibrillator (S-ICD) delivers higher shock energy and can have longer time to therapy compared to transvenous implantable cardioverter defibrillator (T-ICD). Aim of the study was to compare time to therapy and to investigate cardiac, cerebral and systemic injuries of S-ICD and T-ICD shocks delivered after ventricular fibrillation (VF) induction.</AbstractText>Fourteen pigs were randomly implanted with a S-ICD (n = 7) or a T-ICD (n = 7). Five VF episodes were induced in each pig. For each VF episode, up to two shocks could be delivered by the T-ICD or the S-ICD to terminate the arrhythmia. Cardiac, systemic, and cerebral toxicity were monitored. Mean time to therapy was longer in the S-ICD group compared to the T-ICD group (19[18; 23] s vs. 9 [7; 10] s; P = 0.001, respectively). High-sensitivity troponin T levels were significantly higher in the T-ICD group from 1 to 24 h after the procedure (P ≤ 0.02). Creatine phosphokinase activity levels were significantly higher in the S-ICD group, at 3, 6, and 24 h after the procedure (P ≤ 0.05). Lactate levels were not significantly different between groups. S100 protein level was similar in both groups at 1 h after the procedure and then decreased in the T-ICD group compared to the S-ICD group (P = 0.04).</AbstractText>Time to therapy in S-ICD was twice as long as for T-ICD, but didn't induce relevant brain injury. Conversely, S-ICD shocks were less cardiotoxic than T-ICD shocks.</AbstractText> |
20,570 | Takotsubo cardiomyopathy in amiodarone-induced hyperthyroidism. | Takotsubo cardiomyopathy (TC) is an atypical, severe but reversible form of acute heart insufficiency. It typically presents with left ventricular failure, transient apical and mid-segments hypokinesis, absence of significant coronary stenosis and new electrographic abnormalities and/or elevation in serum cardiac enzymes. Although TC ('broken heart syndrome') has classically been associated with emotional trauma, evidence suggests that other precipitants might exist, including iatrogenic and thyroid-mediated forms. Thyroid disease is a relatively common comorbidity in TC patients. We report a case of TC in a postmenopausal female with no history of emotional trauma or other potential precipitant factors who was diagnosed with amiodarone-induced hyperthyroidism during her hospital stay. Though some case reports of thyroid-related TC exist, we are not aware of any other reported case of TC precipitated by amiodarone-induced hyperthyroidism.</AbstractText>TC is a relatively new, rare, transient, severe, but reversible cardiovascular condition that is characterized by an acute left ventricular cardiac failure, which can clinically, analytically and electrocardiographically mimic an acute myocardial infarction.Many precipitant factors have been described in TC, being the most classical and emotional trauma. However, thyroid dysfunction is also a significant condition frequently found in patients with TC.A hypercatecholaminergic state leading to cardiomyocyte damage has been established as the main fact of TC physiopathology. Hyperthyroidism induces an upregulation of β-adrenergic receptors.Both hyperthyroidism and hypothyroidism have been related with TC development. Most reported cases of TC involving thyroid dysfunction correspond to hyperthyroidism due to Graves-Basedow disease, but there are also descriptions with severe hypothyroidism, radioiodine treatment or thyroid surgery.Amiodarone is a class III antiarrhythmic agent widely used, and it is a well-known cause of thyroid dysfunction, which can present either with hypothyroidism or hyperthyroidism, as approximately 40 percent of the amiodarone molecule is composed of iodine.In this case, a type II amiodarone-induced hyperthyroidism was the precipitant factor of a TC in a patient with a pre-existing atrial fibrillation. Given the high prevalence of atrial fibrillation and the wide use of amiodarone, the risk of this iatrogenic effect should be taken into account.</AbstractText> |
20,571 | Patient characteristics associated with false arrhythmia alarms in intensive care. | A high rate of false arrhythmia alarms in the intensive care unit (ICU) leads to alarm fatigue, the condition of desensitization and potentially inappropriate silencing of alarms due to frequent invalid and nonactionable alarms, often referred to as false alarms.</AbstractText>The aim of this study was to identify patient characteristics, such as gender, age, body mass index, and diagnosis associated with frequent false arrhythmia alarms in the ICU.</AbstractText>This descriptive, observational study prospectively enrolled patients who were consecutively admitted to one of five adult ICUs (77 beds) at an urban medical center over a period of 31 days in 2013. All monitor alarms and continuous waveforms were stored on a secure server. Nurse scientists with expertise in cardiac monitoring used a standardized protocol to annotate six clinically important types of arrhythmia alarms (asystole, pause, ventricular fibrillation, ventricular tachycardia, accelerated ventricular rhythm, and ventricular bradycardia) as true or false. Total monitoring time for each patient was measured, and the number of false alarms per hour was calculated for these six alarm types. Medical records were examined to acquire data on patient characteristics.</AbstractText>A total of 461 unique patients (mean age =60±17 years) were enrolled, generating a total of 2,558,760 alarms, including all levels of arrhythmia, parameter, and technical alarms. There were 48,404 hours of patient monitoring time, and an average overall alarm rate of 52 alarms/hour. Investigators annotated 12,671 arrhythmia alarms; 11,345 (89.5%) were determined to be false. Two hundred and fifty patients (54%) generated at least one of the six annotated alarm types. Two patients generated 6,940 arrhythmia alarms (55%). The number of false alarms per monitored hour for patients' annotated arrhythmia alarms ranged from 0.0 to 7.7, and the duration of these false alarms per hour ranged from 0.0 to 158.8 seconds. Patient characteristics were compared in relation to 1) the number and 2) the duration of false arrhythmia alarms per 24-hour period, using nonparametric statistics to minimize the influence of outliers. Among the significant associations were the following: age ≥60 years (P</i>=0.013; P</i>=0.034), confused mental status (P</i><0.001 for both comparisons), cardiovascular diagnoses (P</i><0.001 for both comparisons), electrocardiographic (ECG) features, such as wide ECG waveforms that correspond to ventricular depolarization known as QRS complex due to bundle branch block (BBB) (P</i>=0.003; P</i>=0.004) or ventricular paced rhythm (P</i>=0.002 for both comparisons), respiratory diagnoses (P</i>=0.004 for both comparisons), and support with mechanical ventilation, including those with primary diagnoses other than respiratory ones (P</i><0.001 for both comparisons).</AbstractText>Patients likely to trigger a higher number of false arrhythmia alarms may be those with older age, confusion, cardiovascular diagnoses, and ECG features that indicate BBB or ventricular pacing, respiratory diagnoses, and mechanical ventilatory support. Algorithm improvements could focus on better noise reduction (eg, motion artifact with confused state) and distinguishing BBB and paced rhythms from ventricular arrhythmias. Increasing awareness of patient conditions that apparently trigger a higher rate of false arrhythmia alarms may be useful for reducing unnecessary noise and improving alarm management.</AbstractText> |
20,572 | Syncope in Primary Prevention Implantable Cardioverter Defibrillator Implantation. | Syncope prognosis varies widely: 1 year mortality may range from 0% in the case of vasovagal events up to 30% in the presence of heart disease.</AbstractText>To assess the outcomes and prognosis of patients with implantable cardiac defibrillator (ICD) and indication of primary prevention and compare patients presenting with or without prior syncope.</AbstractText>We reviewed the charts of 75 patients who underwent ICD implantation with the indication of primary prevention and history of syncope and compared them to a control group of 80 patients without prior syncope. We assessed the number of ventricular tachycardia (VT), ventricular fibrillation (VF), shock, anti-tachycardia pacing (ATP), and death in each group during the follow-up.</AbstractText>Mean follow-up was 893 days (810-976, 95% confidence interval) (no difference between groups). Patients with prior syncope had a higher ejection fraction (EF) (35.5 ± 12.6 vs. 31.4 ± 8.76, P = 0.02), more episodes of VT (21.3% vs. 3.8%, P = 0.001) and VF (8% vs. 0%, P = 0.01) and also received more electric shocks (18.7% vs. 3.8%, P = 0.004) and ATP (17.3% vs. 6.2%, P = 0.031). There were no differences in inappropriate shocks (6.7% vs. 5%, P = 0.74), in cardiovascular mortality (cumulative 5 year estimate 29.9% vs. 32.2% P = 0.97) and any death (cumulative 5 year estimate 38.1% vs. 48.9% P = 0.18) during the follow-up.</AbstractText>Syncopal patients before ICD implantation seem to have more episodes of VT/VF and shock or ATP. No mortality differences were observed.</AbstractText> |
20,573 | Postoperative Atrial Fibrillation Following Coronary Artery Bypass Graft Surgery Predicts Long-Term Atrial Fibrillation and Stroke. | Atrial fibrillation (AF) is a common complication of coronary artery bypass graft (CABG) surgery, occurring in 20%-40% of patients, mostly during the first week after surgery. It is associated with increased morbidity and mortality, but data are limited.</AbstractText>To assess the correlation between new-onset in-hospital AF following CABG and long-term AF, cerebrovascular accident (CVA), or death.</AbstractText>We conducted an analysis of 161 consecutive patients who underwent isolated CABG surgery in a tertiary center during the period 2002-2003.</AbstractText>Patients' mean age was 72 years, and the majority were males (77%). Approximately half of the patients experienced prior myocardial infarction, and 14% had left ventricular ejection fraction < 40%. Postoperative AF (POAF) occurred in 27% of the patients. Patients were older and had larger left atrium diameter. POAF was strongly correlated with late AF (OR 4.34, 95%CI 1.44-13.1, P = 0.01) during a mean follow-up of 8.5 years. It was also correlated with long-term stroke but was not associated with long-term mortality.</AbstractText>POAF is a common complication of CABG surgery, which is correlated with late AF and stroke. Patients with POAF should be closely monitored to facilitate early administration of anticoagulant therapy in a high risk population upon recurrence of AF.</AbstractText> |
20,574 | Evaluation of processed borax as antidote for aconite poisoning. | Aconite root is very poisonous; causes cardiac arrhythmias, ventricular fibrillation and ventricular tachycardia. There is no specific antidote for aconite poisoning. In Ayurveda, dehydrated borax is mentioned for management of aconite poisoning.</AbstractText>The investigation evaluated antidotal effect of processed borax against acute and sub-acute toxicity, cardiac toxicity and neuro-muscular toxicity caused by raw aconite.</AbstractText>For acute protection Study, single dose of toxicant (35mg/kg) and test drug (22.5mg/kg and 112.5mg/kg) was administered orally, and then 24h survival of animals was observed. The schedule was continued for 30 days in sub-acute protection Study with daily doses of toxicant (6.25mg/kg), test drug (22.5mg/kg and 112.5mg/kg) and vehicle. Hematological and biochemical tests of blood and serum, histopathology of vital organs were carried out. The cardiac activity Study was continued for 30 days with daily doses of toxicant (6.25mg/kg), test drug (22.5mg/kg), processed borax solution (22.5mg/kg) and vehicle; ECG was taken after 1h of drug administration on 1TB</sup>, 15th and on 30th day. For neuro-muscular activity Study, the leech dorsal muscle response to 2.5µg of acetylcholine followed by response of toxicant at 25µg and 50µg doses and then response of test drug at 25µg dose were recorded.</AbstractText>Protection index indicates that treated borax gave protection to 50% rats exposed to the lethal dose of toxicant in acute protection Study. Most of the changes in hematological, biochemical parameters and histopathological Study induced by the toxicant in sub-acute protection Study were reversed significantly by the test drug treatment. The ventricular premature beat and ventricular tachyarrhythmia caused by the toxicant were reversed by the test drug indicate reversal of toxicant induced cardio-toxicity. The acetylcholine induced contractions in leech muscle were inhibited by toxicant and it was reversed by test drug treatment.</AbstractText>The processed borax solution is found as an effective protective agent to acute and sub-acute aconite poisoning, and aconite induced cardiac and neuro-muscular toxicity. Processed borax at therapeutic dose (22.5mg/kg) has shown better antidotal activity profile than five times more than therapeutic dose (112.5mg/kg).</AbstractText>Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
20,575 | Association of digitalis treatment with outcomes following myocardial infarction in patients with heart failure or evidence of left ventricular dysfunction: an analysis from the High-Risk Myocardial Infarction Database Initiative. | Contradictory findings have been reported regarding the safety and efficacy of digitalis in patients recovering from acute myocardial infarction (MI). We studied the association of digitalis use with long-term and short-term prognosis in patients presenting with an acute MI complicated with heart failure (HF), left ventricular dysfunction, or both.</AbstractText>Using the High-Risk MI Database Initiative combining data from 4 major clinical trials, totaling 27,673 patients, we investigated the association between digitalis use at baseline (3093 patients with digitalis and 24,580 without) with the rate of all-cause death, sudden cardiac death, cardiovascular death, HF hospitalization and the combination of the latter two, over a mean follow-up time of 2.7 years. Patients with and without atrial fibrillation (AF) were studied separately. After a propensity score-based analysis, among patients without AF, those receiving digitalis experienced a higher rate of all-cause [hazard ratio (HR) 1.54, 95% confidence interval (CI) 1.42-1.67] and sudden cardiac death (HR 1.65, 95% CI 1.44-1.89), compared to those not receiving digitalis; similar results were found for the other 3 endpoints (all HR around 1.6). In contrast, in AF patients, digitalis had a milder effect on all outcomes (all HR ≤ 1.12), with significant association only for the composite endpoint (HR 1.10, 95% CI 1.00-1.21, p = 0.049); comparable results were obtained at 30 days. Finally, the detrimental effect associated with digitalis use appeared to be more pronounced in patients with ejection fraction ≥ 40%.</AbstractText>In MI survivors with HF and/or systolic dysfunction, digitalis was associated with a significant increased risk of death in patients without AF with mild to neutral associations for patients with AF. These findings raise concerns regarding the safety of digitalis in MI survivors with HF, especially for those without AF.</AbstractText> |
20,576 | Impact of stroke volume on cardiovascular risk during progression of aortic valve stenosis. | In severe aortic valve stenosis (AS), low left ventricular (LV) stroke volume has been associated with increased cardiovascular (CV) mortality, but this association has not been explored during progression of AS in a large prospective study.</AbstractText>In 1671 patients from the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) study, the association of stroke volume indexed for body surface area (SVI) with major CV events during a median of 4.3-year follow-up was assessed in Cox and time-varying Cox regression analyses. Low SVI was defined as <35 mL/m2</sup>.</AbstractText>Peak aortic jet velocity in the total study population was 3.1 ±0.7 m/s. Low SVI was found in 23% at baseline and associated with higher age, body mass index (BMI), heart rate and global LV load, and with lower mean aortic gradient, aortic valve area index, energy loss index, LV mass and ejection fraction and more often inconsistent AS grading (all p<0.05). A 5 mL/m2</sup> lower SVI at baseline was associated with higher HRs of major CV events (n=544) (HR 1.09, 95% CI 1.05 to 1.13, p<0.001) and higher total mortality (n=147) (HR 1.08, 95% CI 1.01 to 1.16, p=0.038), independent of age, sex, atrial fibrillation, mean aortic gradient, LV ejection fraction, LV mass, BMI and study treatment. Adjusting for the same covariates, low SVI at baseline and in-study low SVI were also associated with increased rate of major CV events.</AbstractText>In patients with AS in the SEAS study, lower baseline SVI was associated with higher HR of major CV events and total mortality independent of major confounders.</AbstractText>NCT00092677: Results.</AbstractText>© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.</CopyrightInformation> |
20,577 | The impact of body mass index on the wearable cardioverter defibrillator shock efficacy and patient wear time. | The impact of body mass index (BMI) on the shock efficacy and patient adherence among patients using a wearable cardioverter defibrillator (WCD) is unknown.</AbstractText>Patients prescribed the WCD between January 1, 2008 and June 1, 2013, who experienced at least one episode of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) and who received appropriate WCD therapy, were identified within a registry maintained by the manufacturer for regulatory, reimbursement, and administrative purposes. The registry contained patients' Body Mass Index (BMI) which was categorized as normal (18.0<BMI<25.0), overweight (25.0≤BMI<30.0) or obese (30.0≥BMI). Demographics, indication for WCD prescription and other clinical information were reviewed. Device-stored ECG, transthoracic impedance (TTI) and time worn were downloaded for analyses. A post-shock rhythm which was no longer VT or VF was considered a successful tachyarrhythmia conversion. Only the first-shock arrhythmia conversion and TTI were included in the analyses.</AbstractText>A total of 574 patients were included in the final analyses. Patient characteristics were similar across all groups except the obese group (60±11 years) was younger than the normal (63±16 years) and overweight (64±12 years, P=.001) groups. Mean length of use for normal, overweight and obese groups was 79±131, 82±202 and 55±97 days (P=.12), respectively; the median daily wear time was 21 hours among all groups. In a total of 623 VT/VF events, the median TTI was 44 ohms, 51 ohms and 65 ohms for normal, overweight and obese groups, respectively; TTI was positively correlated to BMI (r=0.33, P<.01). First-shock conversion rate was 92.9% in the normal group, 93.6% and 93.9% in the overweight and obese groups, respectively (P=.93). There was no difference in 24-hour survival among the three groups (91.9%, 94.1% and 92.3%, P=.66).</AbstractText>The WCD first-shock success rate and post-event 24-hour survival were high and independent from BMI. TTI was positively correlated with BMI but did not impact early clinical outcome. WCD was safe to all BMI groups and the patient wear time was excellent across all groups.</AbstractText>Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,578 | Serum albumin level and hospital mortality in acute non-ischemic heart failure. | Hypoalbuminemia is common in heart failure (HF), especially in elderly patients. It is associated with an increased risk of death. The present study sought to examine the prognostic significance of serum albumin level in the prediction of hospital mortality in patients admitted for acute non-ischemic HF.</AbstractText>We examined the association between albumin and hospital mortality in a cohort of 546 patients admitted for acute non-ischemic HF. None of the patients had infectious disease, severe arrhythmias (atrial fibrillation, ventricular tachycardia, ventricular fibrillation), required invasive ventilation, or presented with acute coronary syndrome or primary valvular disease. Thirty-six patients (7%) died during the hospital stay. These patients were significantly older (78 ± 9 vs. 72 ± 12 years; P</i> = 0.006), had higher heart rate (P</i> < 0.0001), increased creatinine level (P</i> = 0.01), lower systolic and diastolic blood pressures (P</i> < 0.05), elevated leucocyte count (P</i> = 0.001), and lower albumin levels (31.3 ± 5.6 g/L vs. 36.9 ± 4.1 g/L; P</i> < 0.001). With multivariable analysis, age (P</i> = 0.01), heart rate (P</i> < 0.0003), diastolic blood pressure (P</i> < 0.01), leukocyte count (P</i> = 0.009), and serum albumin level (P</i> < 0.0001) emerged as independent predictors of hospital mortality. Hypoalbuminemia (<34 g/L) yielded the best sensitivity (78.8%) and specificity (75%) for predicting hospital death.</AbstractText>Serum albumin level measured at admission can serve as a simple prognostic factor in acute non-ischemic HF. Hypoalbuminemia is associated with increased risk of hospital mortality, especially in elderly patients.</AbstractText> |
20,579 | Rosuvastatin reduces the recurrence rate following catheter ablation for atrial fibrillation in patients with heart failure. | The aim of the present study was to assess whether rosuvastatin could reduce the recurrence rate of atrial fibrillation (AF) in patients with heart failure (HF) following catheter ablation (CA). A total of 107 patients with HF and AF who underwent CA of AF by endocardial mapping and radiofrequency between June 2012 and May 2014 were recruited. The patients were randomly divided into three subgroups: i) Administered with 10 mg rosuvastatin daily following ablation (group 1, n=36); ii) administered with 20 mg rosuvastatin daily following ablation (group 2, n=36); and iii) only treated with conventional treatment of HF following ablation (group 3, n=35). After the procedure, patients were followed in the outpatient clinic by interrogation of Holter monitoring. The AF recurrence rate of group 2 was low in comparison with group 1 (22.2% vs. 38.9%, P=0.013) and group 3 (22.2% vs. 48.6%, P=0.021). In comparison with baseline, the parameters of the left ventricular ejection fraction, left atrial diameter (LAD), and the levels of N-terminal pronatriuretic peptide and hypersensitive C-reactive protein (hs-CRP) were all improved in three groups. Furthermore, multivariate analysis demonstrated that LAD [hazard ratio (HR): 1.12, 95% confidence interval (CI): 1.06-1.67, P=0.049], hs-CRP (HR: 1.37, 95% CI: 1.11-1.92, P=0.002) and duration of AF (HR: 1.14, 95% CI: 1.09-1.18, P=0.011) were independent predictors of AF recurrence in patients with HF following CA. Therefore, the present study has demonstrated that treatment with 20 mg rosuvastatin daily following CA was able to significantly decrease the recurrence rate of AF in patients with HF, and LAD, hs-CRP, and duration of AF were independent predictors of AF recurrence in patients with HF following CA. In conclusion, the present study has also demonstrated that CA may improve cardiac function in patients with HF and AF. |
20,580 | A case of ventricular fibrillation as a consequence of capecitabine-induced secondary QT prolongation: A case report. | Capecitabine is an oral fluoropyrimidine which can prolong QT interval. However, there have been no reports that capecitabine induced ventricular fibrillation (VF) due to secondary QT prolongation in patients with no structural heart disease. A 39-year-old woman developed VF during the chemotherapy of capecitabine for colon cancer. At the administration, corrected QT interval (QTc) was prolonged to 559 ms despite no evidence of organic heart disease. Discontinuation of capecitabline normalized the QTc (414 ms). During the follow-up of eight years, neither the QTc prolongation nor the recurrent VF has been detected. We report the rare case of capecitabine-related VF without any organic heart disease. <<b>Learning objective:</b> Capecitabine is an oral fluoropyrimidine carbamate commonly used to treat colorectal and breast cancer. Capecitabine has been reported to be associated with VF due to vasospasm. However, capecitabine is also associated with QT elongation. This is the first report to describe VF due to capecitabine-related secondary long QT syndrome in a patient with no cardiac heart disease. Physicians must carefully follow up patients during capecitabine chemotherapy with serial electrocardiograms.>. |
20,581 | Alcohol consumption, sinus tachycardia, and cardiac arrhythmias at the Munich Octoberfest: results from the Munich Beer Related Electrocardiogram Workup Study (MunichBREW). | Alcohol is a risk factor for cardiac arrhythmias. Retrospective analyses suggest supraventricular arrhythmias consecutive to acute alcohol consumption, but prospective data are limited. We intended to prospectively associate acute alcohol consumption with cardiac arrhythmias.</AbstractText>At the 2015 Munich Octoberfest, we enrolled 3028 voluntary participants who received a smartphone-based ECG and breath alcohol concentration (BAC) measurements. ECGs were analysed for cardiac arrhythmias (sinus tachycardia, sinus arrhythmia, premature atrial/ventricular complexes, atrial fibrillation/flutter) and respiratory sinus arrhythmia. By multivariable adjusted logistic regression we associated BACs with cardiac arrhythmias. Similarly, we analysed 4131 participants of the community-based KORA S4 Study (Co-operative Health Research in the Region of Augsburg) and associated cardiac arrhythmias with chronic alcohol consumption. In our acute alcohol cohort (mean age 34.4 ± 13.3 years, 29% women), mean BAC was 0.85 ± 0.54 g/kg. Cardiac arrhythmias occurred in 30.5% (sinus tachycardia 25.9%; other arrhythmia subtypes 5.4%). Breath alcohol concentration was significantly associated with cardiac arrhythmias overall (odds ratio (OR) per 1-unit change 1.75, 95% confidence interval (CI) 1.50-2.05; P < 0.001) and sinus tachycardia in particular (OR 1.96, 95%CI 1.66-2.31; P < 0.001). Respiratory sinus arrhythmia measuring autonomic tone was significantly reduced under the influence of alcohol. In KORA S4, chronic alcohol consumption was associated with sinus tachycardia (OR 1.03, 95%CI 1.01-1.06; P = 0.006).</AbstractText>Acute alcohol consumption is associated with cardiac arrhythmias and sinus tachycardia in particular. This partly reflects autonomic imbalance as assessed by significantly reduced respiratory sinus arrhythmia. Such imbalance might lead to sympathetically triggered atrial fibrillation resembling the holiday heart syndrome.</AbstractText><AbstractText Label="CLINICALTRIALS.ORG ACCESSION NUMBER" NlmCategory="UNASSIGNED">NCT02550340.</AbstractText>© The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology.</CopyrightInformation> |
20,582 | Multi-band decomposition analysis: application to cardiac alternans as a function of temperature. | It has long been known that variations in temperature can facilitate the development of cardiac arrhythmias. Here, we aim to quantify the effects of temperature on cardiac alternans properties.</AbstractText>in this work, we use optical mapping recordings of canine ventricular epicardial preparations to demonstrate that hypothermia can promote the formation of alternans, which is an important precursor to potentially lethal arrhythmias like fibrillation. We then present a novel quantification of alternans properties for a broad range of cycle lengths under different thermal states. Specifically, we apply the recently developed multi-band-decomposition analysis (MBDA) in the context of cardiac action potential dynamics.</AbstractText>We show that the MBDA offers several advantages compared with traditional analysis of action potential durations. First, MBDA allows a depiction and quantification of the magnitude of alternans at all threshold values simultaneously and thus offers more information about how alternans relates to the action potential morphology while also removing the necessity of choosing a single threshold value. Second, the MBDA technique offers simple ways for assessing action potential amplitude alternans. Finally, MBDA provides a quantification of signal quality without any additional processing.</AbstractText>We find that the MBDA technique shows promise in leading to a deeper understanding of cardiac alternans properties.</AbstractText> |
20,583 | Ventricular fibrillation cardiac arrest produces a chronic striatal hyperdopaminergic state that is worsened by methylphenidate treatment. | Cardiac arrest survival rates have improved with modern resuscitation techniques, but many survivors experience impairments associated with hypoxic-ischemic brain injury (HIBI). Currently, little is understood about chronic changes in striatal dopamine (DA) systems after HIBI. Given the common empiric clinical use of DA enhancing agents in neurorehabilitation, investigation evaluating dopaminergic alterations after cardiac arrest (CA) is necessary to optimize rehabilitation approaches. We hypothesized that striatal DA neurotransmission would be altered chronically after ventricular fibrillation cardiac arrest (VF-CA). Fast-scan cyclic voltammetry was used with median forebrain bundle (MFB) maximal electrical stimulations (60Hz, 10s) in rats to characterize presynaptic components of DA neurotransmission in the dorsal striatum (D-Str) and nucleus accumbens 14 days after a 5-min VF-CA when compared to Sham or Naïve. VF-CA increased D-Str-evoked overflow [DA], total [DA] released, and initial DA release rate versus controls, despite also increasing maximal velocity of DA reuptake (V<sub>max</sub> ). Methylphenidate (10 mg/kg), a DA transporter inhibitor, was administered to VF-CA and Shams after establishing a baseline, pre-drug 60 Hz, 5 s stimulation response. Methylphenidate increased initial evoked overflow [DA] more-so in VF-CA versus Sham and reduced D-Str V<sub>max</sub> in VF-CA but not Shams; these findings are consistent with upregulated striatal DA transporter in VF-CA versus Sham. Our work demonstrates that 5-min VF-CA increases electrically stimulated DA release with concomitant upregulation of DA reuptake 2 weeks after brief VF-CA insult. Future work should elucidate how CA insult duration, time after insult, and insult type influence striatal DA neurotransmission and related cognitive and motor functions. |
20,584 | Mechanical dispersion and global longitudinal strain by speckle tracking echocardiography: Predictors of appropriate implantable cardioverter defibrillator therapy in hypertrophic cardiomyopathy. | In this study, we investigated whether mechanical dispersion which reflects electrical abnormality and other echocardiographic and clinic parameters predict appropriate ICD shock in patients undergone ICD implantation for hypertrophic cardiomyopathy.</AbstractText>Sixty-three patients who received ICD implantation for primary or secondary prevention were included in the study. Patients' clinical, electrocardiographic, 2D classic, and speckle tracking echocardiographic data were collected. Mechanical dispersion was defined as the standard deviation of time to peak negative strain in 18 left ventricular segments. Appropriate ICD therapy was defined as cardioversion or defibrillation due to ventricular tachycardia or fibrillation. Patients were divided into two groups as occurrence or the absence of appropriate ICD therapy.</AbstractText>A total of 17 (26.9%) patients were observed to have an appropriate ICD therapy during follow-up periods. In patients who performed appropriate ICD therapy, a larger left atrial volume index, higher sudden cardiac death (SCD)-Risk Score, longer mechanical dispersion, and decreased global longitudinal peak strain (GLPS) were observed. In multivariate logistic regression analysis, including (GLPS, mechanical dispersion, LAVi, and SCD-Risk Score) was used to determine independent predictors of occurrence of appropriate ICD therapy during the follow-up. Mechanical dispersion, GLPS, and SCD-Risk Score were found to be independent predictors of occurrence of appropriate ICD therapy.</AbstractText>Mechanical dispersion, GLPS, and SCD-Risk Score were found to be predictive for appropriate ICD therapy in patients receiving ICD implantation. Readily measurable mechanical dispersion and GLPS could be helpful to distinguish patients at high risk who could optimally benefit from ICD therapy.</AbstractText>© 2017, Wiley Periodicals, Inc.</CopyrightInformation> |
20,585 | "J waves" induced after short coupling intervals: a manifestations of latent depolarization abnormality? | To confirm the presence of tachycardia-induced slur or notch in the terminal portion of the QRS complexes in a general patient population.</AbstractText>A tachycardia-induced J wave was defined as a slur or notch in the terminal portion of the QRS complexes newly induced at short RR intervals during atrial premature contractions (APCs) or atrial electrical stimulation in the electrophysiological study (EPS). Twenty-three out of 2000 patients with general diseases were involved. All patients with aborted sudden cardiac death, ventricular fibrillation or a family history of sudden cardiac death were excluded. The mean age was 72 ± 9 years, and 11 patients were male (47.8%). When the RR interval was shortened from 821 ± 142 ms to 464 ± 52 ms in the conducted APCs (P < 0.0001), J waves became diagnostic (0.02 ± 0.03 mV to 0.20 ± 0.07 mV, P < 0.0001). J waves were confined to the inferior leads in 22 (95.7%) patients and were notched in 11 (47.8%) and slurred in 12 (52.2%) patients. The induction of J waves was accompanied by visible changes of the QRS morphology. When the post-APC RR interval was prolonged to 992 ± 305 ms (P = 0.0154 vs. baseline), the J waves were similar to baseline levels. During the EPS, J wave induction was confirmed during atrial stimulation. There were no characteristic clinical or ECG features in the patients with tachycardia-induced J waves.</AbstractText>J waves can be newly induced by short RR intervals in a general patient population, and a conduction delay is the likely mechanism causing such J waves.</AbstractText> |
20,586 | Prediction of Both Electrical and Mechanical Reverse Remodeling on Acute Electrocardiogram Changes After Cardiac Resynchronization Therapy. | The development of both electrical reverse remodeling and mechanical reverse remodeling (ERR+MRR) after cardiac resynchronization therapy (CRT) implantation could reduce the incidence of lethal arrhythmia, hence the prediction of ERR+MRR is clinically important.Methods and Results:Eighty-three patients (54 male; 67±12 years old) with CRT >6 months were enrolled. ERR was defined as baseline intrinsic QRS duration (iQRSd) shortening ≥10 ms in lead II on ECG after CRT, and MRR as improvement in LVEF ≥25% on echocardiography after CRT. Acute ECG changes were measured by comparing the pre-implant and immediate post-implant ECG. Ventricular arrhythmia episodes, including ventricular tachycardia and ventricular fibrillation, detected by the implanted device were recorded. Patients were classified as ERR only (n=12), MRR only (n=23), ERR+MRR (n=26), or non-responder (ERR- & MRR-, n=22). On multivariate regression analysis, difference between baseline intrinsic QRS and paced QRS duration (∆QRSd) >35 ms was a significant predictor of ERR+MRR (sensitivity, 68%; specificity, 64%; AUC, 0.7; P=0.003), and paced QTc >443 ms was a negative predictor of ERR+MRR (sensitivity, 78%; specificity, 60%; AUC, 0.7; P=0.002). On Cox proportional hazard modeling, ERR+MRR may reduce risk of ventricular arrhythma around 70% compared with non-responder (HR, 0.29; 95% CI: 0.13-0.65).</AbstractText>Acute ECG changes after CRT were useful predictors of ERR+MRR. ERR+MRR was also a protective factor for ventricular arrhythmia.</AbstractText> |
20,587 | Troubleshooter in electrical storm: Mechanical unloading leads to heart rhythm stabilization. | The electrical storm is a life-threatening situation which causes a complex antiarrhythmic treatment. We firstly report a rhythmological stabilization through mechanical unloading of the left ventricle in a health patient who developed electrical storm after endo- and epicardiac re-ablation and who previously underwent 27 unsuccessful defibrillations. No evidence for a specific etiology of the rhythm disturbances was found. After implantation of a percutaneous left ventricular assist device (pLVAD) a single additional defibrillation was needed to terminate ventricular fibrillation. This unique application of pLVAD might be an unprecedented escape strategy for patients who have exhausted all other commonly recommended therapy options. |
20,588 | [Clinical application of one-stage operation of epicardial permanent pacemaker implantation and cardiac surgery]. | <b>Objective:</b> To summarize the results and clinical application experience of one-stage operation of epicardial permanent pacemaker implantation and cardiac surgery. <b>Methods:</b> From November 2014 to July 2016, 15 patients (9 males and 6 females) with ages ranging from 50 to 73 (63.5±6.2) years requiring cardiac surgery with bradycardia underwent one-stage operation of epicardial permanent pacemaker implantation and cardiac surgery. All operations were performed under general anesthesia with chest median incision approach. Among them, single chamber pacemaker (<i>n</i>=10) and dual chamber pacemaker (<i>n</i>=5) permanent epicardial pacing leads were implanted. Simultaneous procedures included valve replacement in 7 cases, valve replacement combined with atrial fibrillation ablation in 3 cases, coronary artery bypass grafting in 2 cases, aortic root replacement in 2 cases, and valve replacement combined with coronary artery bypass surgery in 1 case. Their parameters of pacemaker including sensitivity, pacing threshold, pacing impedance were measured during surgery and closely followed up at 1 week and 3, 6 months after surgery. <b>Results:</b> All 15 patients with epicardial permanent pacemaker implantation in the same period of cardiac surgery were successfully cured and discharged, without any surgical complications. A total of 20 epicardial electrodes were implanted for them including 5 right atrial electrodes and 15 right ventricular electrodes. The postoperative follow-up period ranged from 3 to 22 months. No electrode fracture and surgical wound infection occurred in those patients, and their impedance, sensing and stimulation thresholds were all in normal ranges during follow-up. <b>Conclusions:</b> For patients with bradycardia who required cardiac surgery, one-stage operation of epicardial permanent pacemaker implantation and cardiac surgery is safe and effective, and the results in the short-term and medium-term are satisfactory, avoiding the risk of staged surgery.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Ren</LastName><ForeName>C L</ForeName><Initials>CL</Initials><AffiliationInfo><Affiliation>Department of Cardiovascular Surgery, Institute of Cardiac Surgery of PLA, Chinese PLA General Hospital, Beijing 100853, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Jiang</LastName><ForeName>S L</ForeName><Initials>SL</Initials></Author><Author ValidYN="Y"><LastName>Xiao</LastName><ForeName>C S</ForeName><Initials>CS</Initials></Author><Author ValidYN="Y"><LastName>Wang</LastName><ForeName>R</ForeName><Initials>R</Initials></Author><Author ValidYN="Y"><LastName>Gao</LastName><ForeName>C Q</ForeName><Initials>CQ</Initials></Author></AuthorList><Language>chi</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList></Article><MedlineJournalInfo><Country>China</Country><MedlineTA>Zhonghua Yi Xue Za Zhi</MedlineTA><NlmUniqueID>7511141</NlmUniqueID><ISSNLinking>0376-2491</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D000368" MajorTopicYN="N">Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D001919" MajorTopicYN="N">Bradycardia</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D002304" MajorTopicYN="Y">Cardiac Pacing, Artificial</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006348" MajorTopicYN="Y">Cardiac Surgical Procedures</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005500" MajorTopicYN="N">Follow-Up Studies</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008297" MajorTopicYN="N">Male</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008875" MajorTopicYN="N">Middle Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D010138" MajorTopicYN="Y">Pacemaker, Artificial</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="chi"><b>目的：</b> 总结心脏手术同期行心外膜永久起搏器植入术的疗效及临床应用经验。 <b>方法：</b> 2014年11月至2016年7月在解放军总医院心血管外科住院治疗的符合心脏起搏器植入指征，需要心脏手术的心动过缓患者15例行心脏手术同期心外膜永久起搏器植入术，男9例，女6例，年龄50～73(63.5±6.2)岁。手术均在全麻下进行，胸部正中切口入路。其中，单腔起搏器手术10例，双腔起搏器手术5例；同期瓣膜置换术7例，瓣膜置换加房颤射频消融术3例，冠状动脉旁路移植术2例，主动脉根部置换术2例，瓣膜置换联合冠状动脉旁路移植术1例。术中、术后1周及6个月随访检测起搏参数变化。 <b>结果：</b> 15例患者在心脏手术同期植入心外膜永久起搏器，均顺利治愈出院，无手术并发症。共植入20根心外膜电极，其中右心房电极5根，右心室电极15根。术后随访3～22个月，中位随访12个月，无电极断裂及手术伤口感染发生，起搏阈值、感知参数及电极阻抗均正常。 <b>结论：</b> 对于需要心脏手术的心动过缓患者在心脏手术同期行心外膜永久起搏器植入术安全有效，近中期结果满意，避免了分期手术风险。. |
20,589 | Propagation of meandering rotors surrounded by areas of high dominant frequency in persistent atrial fibrillation. | Identification of arrhythmogenic regions remains a challenge in persistent atrial fibrillation (persAF). Frequency and phase analysis allows identification of potential ablation targets.</AbstractText>This study aimed to investigate the spatiotemporal association between dominant frequency (DF) and reentrant phase activation areas.</AbstractText>A total of 8 persAF patients undergoing first-time catheter ablation procedure were enrolled. A noncontact array catheter was deployed into the left atrium (LA) and 2048 atrial fibrillation electrograms (AEGs) were acquired for 15 seconds following ventricular far-field cancellation. DF and phase singularity (PS) points were identified from the AEGs and tracked over consecutive frames. The spatiotemporal correlation of high DF areas and PS points was investigated, and the organization index at the core of high-DF areas was compared with that of their periphery.</AbstractText>The phase maps presented multiple simultaneous PS points that drift over the LA, with preferential locations. Regions displaying higher PS concentration showed a degree of colocalization with DF sites, with PS and DF regions being neighbors in 61.8% and with PS and DF regions overlapping in 36.8% of the time windows. Sites with highest DF showed a greater degree of organization at their core compared with their periphery. After ablation, the PS incidence reduced over the entire LA (36.2% ± 23.2%, P < .05), but especially at the pulmonary veins (78.6% ± 22.2%, P < .05).</AbstractText>Multiple PS points drifting over the LA were identified with their clusters correlating spatially with the DF regions. After pulmonary vein isolation, the PS's complexity was reduced, which supports the notion that PS sites represent areas of relevance to the atrial substrate.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,590 | The effect of 50% compared to 100% inspired oxygen fraction on brain oxygenation and post cardiac arrest mitochondrial function in experimental cardiac arrest. | We hypothesised that the use of 50% compared to 100% oxygen maintains cerebral oxygenation and ameliorates the disturbance of cardiac mitochondrial respiration during cardiopulmonary resuscitation (CPR).</AbstractText>Ventricular fibrillation (VF) was induced electrically in anaesthetised healthy adult pigs and left untreated for seven minutes followed by randomisation to manual ventilation with 50% or 100% oxygen and mechanical chest compressions (LUCAS®</sup>). Defibrillation was performed at thirteen minutes and repeated if necessary every two minutes with 1mg intravenous adrenaline. Cerebral oxygenation was measured with near-infrared spectroscopy (rSO2</sub>, INVOS™5100C Cerebral Oximeter) and with a probe (NEUROVENT-PTO, RAUMEDIC) in the frontal brain cortex (PbO2</sub>). Heart biopsies were obtained 20min after the return of spontaneous circulation (ROSC) with an analysis of mitochondrial respiration (OROBOROS Instruments Corp., Innsbruck, Austria), and compared to four control animals without VF and CPR. Brain rSO2</sub> and PbO2</sub> were log transformed and analysed with a mixed linear model and mitochondrial respiration with an analysis of variance.</AbstractText>Of the twenty pigs, one had a breach of protocol and was excluded, leaving nine pigs in the 50% group and ten in the 100% group. Return of spontaneous circulation (ROSC) was achieved in six pigs in the 50% group and eight in the 100% group. The rSO2</sub> (p=0.007) was lower with FiO2</sub> 50%, but the PbO2</sub> was not (p=0.93). After ROSC there were significant interactions between time and FiO2</sub> regarding both rSO2</sub> (p=0.001) and PbO2</sub> (p=0.004). Compared to the controls, mitochondrial respiration was decreased, with adenosine diphosphate (ADP) levels of 57 (17)pmols-1</sup>mg-1</sup> compared to 92 (23)pmols-1</sup>mg-1</sup> (p=0.008), but there was no difference between different oxygen fractions (p=0.79).</AbstractText>The use of 50% oxygen during CPR results in lower cerebral oximetry values compared to 100% oxygen but there is no difference in brain tissue oxygen. Cardiac arrest disturbs cardiac mitochondrial respiration, but it is not alleviated with the use of 50% compared to 100% oxygen (Ethical and hospital approvals ESAVI/1077/04.10.07/2016 and HUS/215/2016, §7 30.3.2016, Funding Helsinki University and others).</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,591 | Renal Denervation Decreases Susceptibility to Arrhythmogenic Cardiac Alternans and Ventricular Arrhythmia in a Rat Model of Post-Myocardial Infarction Heart Failure. | Several studies have shown the beneficial effect of renal denervation (RDN) in the treatment of ventricular arrhythmia, especially in the setting of heart failure (HF). However, the underlying mechanism of antiarrhythmic effect of RDN is unknown. Arrhythmogenic cardiac alternans, particularly spatially discordant repolarization alternans, characterized by simultaneous prolongation and shortening of action potential duration (APD) in different myocardial regions, is central to the genesis of ventricular fibrillation in HF. Whether RDN decreases the susceptibility to arrhythmogenic cardiac alternans in HF has never been addressed before. The authors used a rat model of post-myocardial infarction HF and dual voltage-calcium optical mapping to investigate whether RDN could attenuate arrhythmogenic cardiac alternans that predisposes to ventricular arrhythmias, as well as the hemodynamic effect of RDN in HF. The HF rats had increased body weights, dilated hearts, and lower blood pressure. The HF rats also had longer ventricular APDs and a delay in the decay of the calcium transient, typical electrophysiological features of human HF. Susceptibility to calcium transient alternans, APD alternans, and spatially discordant APD alternans was increased in the HF hearts. RDN significantly attenuated a delay in the decay of the calcium transient, calcium transient and APD alternans, and importantly, the discordant APD alternans, and thereby decreased the incidence of induced ventricular arrhythmia in HF. RDN did not further decrease blood pressure in HF rats. In conclusion, RDN improves calcium cycling and prevents spatially discordant APD alternans and ventricular arrhythmia in HF. RDN does not aggravate hemodynamics in HF. |
20,592 | Catheter ablation to prevent sudden cardiac death. | Since ventricular arrhythmias are a common cause of sudden cardiac death (SCD), treatment for ventricular arrhythmias is the target area of interest in research field. Among different means to prevent ventricular arrhythmias, catheter ablation (CA) has emerged as an effective therapeutic method. CA can decrease the likelihood of SCD in the following arrhythmia categories: 1) idiopathic ventricular fibrillation (VF) that is usually triggered by premature ventricular beats originating in the Purkinje fibres; 2) VF in subjects with structural heart disease, especially after myocardial infarction, that is triggered by premature ventricular beats from surviving Purkinje fibres; 3) Brugada syndrome in which modification of an epicardial substrate in the right ventricular outflow tract might be the most promising strategy; 4) recurrent monomorphic ventricular tachycardias in the setting of structural heart disease; 5) ventricular preexcitation in which CA appears to be a method of choice in high risk patients, regardless of the presence or absence of symptoms. In conclusion, CA is a therapeutic method that may prevent SCD in different subsets of patients. Better understanding of mechanisms and substrates may further improve the rate of success and/or broaden such prophylactic indications. |
20,593 | Feasibility of profound hypothermia as part of extracorporeal life support in a pig model. | To investigate the feasibility of a refined aortic flush catheter and pump system to induce emergency preservation and resuscitation before extracorporeal cardiopulmonary resuscitation in a normovolemic cardiac arrest swine model simulating near real size/weight conditions of adults.</AbstractText>In this feasibility study, 8 female Large White breed pigs weighing 70 to 80 kg underwent ventricular fibrillation cardiac arrest for 15 minutes, followed by 4°C aortic flush (150 mL/kg for the brain; 50 mL/kg for the spine) via a new hardware ensued by resuscitation with extracorporeal cardiopulmonary resuscitation.</AbstractText>Brain temperature was lowered from 39.9°C (interquartile range [IQR] 39.6-40.3) to 24.0°C (IQR 20.8-28.9) in 12 minutes (IQR 11-16) with a median cooling rate of 1.3°C (IQR 0.7-1.6) per minute. A median of 776 mL (IQR 673-840) per minute with a median pump pressure of 1487 mm Hg (IQR 1324-1545) were pumped to the brain.</AbstractText>With the new hardware, we were able to cool the brain within a few minutes in a large pig cardiac arrest model. The exact position; the design, diameter, and length of the flush catheter; and the brain perfusion pressure seem to be critical to effectively reduce brain temperature. Redistribution of peripheral blood could lead to sterile inflammation again and might be avoided.</AbstractText>Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,594 | Conventional Acupuncture for Cardiac Arrhythmia: A Systematic Review of Randomized Controlled Trials. | To exam the effect and safety of conventional acupuncture (CA) on cardiac arrhythmia.</AbstractText>Nine medical databases were searched until February 2016 for randomized controlled trials. Heterogeneity was measured by Cochran Q test. Meta-analysis was conducted if I2</sup> was less than 85% and the characteristics of included trials were similar.</AbstractText>Nine qualified studies involving 638 patients were included. Only 1 study had definitely low risk of bias, while 7 trials were rated as unclear and 1 as high. Meta-analysis of CA alone did not have a significant benefit on response rate compared to amiodarone in patients with atrial fibrillation (Af) and atrial flutter (AF) [relative risk (RR): 1.09; 95% confidence interval (CI): 0.79-1.49; P=0.61; I2</sup>=61%, P=0.11]. However, 1 study with higher methodological quality detected a lower recurrence rate of Af in CA alone as compared with sham acupuncture plus no treatment, and benefits on ventricular rate and time of conversion to normal sinus rhythm were found in CA alone group by 1 study, as well as the response rate in CA plus deslanoside group by another study. Meta-analysis of CA plus anti-arrhythmia drug (AAD) was associated with a significant benefit on the response rate when compared with AAD alone in ventricular premature beat (VPB) patients (RR, 1.19, 95% CI: 1.05-1.34; P=0.005; I2</sup>=13%, P=0.32), and an improvement in quality-of-life score (QOLS) of VPB also showed in 1 individual study. Besides, a lower heart rate was detected in the CA alone group by 1 individual study when compared with no treatment in sinus tachycardia patients (MD-21.84 [-27.21,-16.47]) and lower adverse events of CA alone were reported than amiodarone.</AbstractText>CA may be a useful and safe alternative or additive approach to AADs for cardiac arrhythmia, especially in VPB and Af patients, which mainly based on a pooled estimate and result from 1 study with higher methodological quality. However, we could not reach a robust conclusion due to low quality of overall evidence.</AbstractText> |
20,595 | Diagnostic value of prehospital ECG in acute stroke patients. | To investigate the diagnostic yield of prehospital ECG monitoring provided by emergency medical services in the case of suspected stroke.</AbstractText>Consecutive patients with acute stroke admitted to our tertiary stroke center via emergency medical services and with available prehospital ECG were prospectively included during a 12-month study period. We assessed prehospital ECG recordings and compared the results to regular 12-lead ECG on admission and after continuous ECG monitoring at the stroke unit.</AbstractText>Overall, 259 patients with prehospital ECG recording were included in the study (90.3% ischemic stroke, 9.7% intracerebral hemorrhage). Atrial fibrillation (AF) was detected in 25.1% of patients, second-degree or greater atrioventricular block in 5.4%, significant ST-segment elevation in 5.0%, and ventricular ectopy in 9.7%. In 18 patients, a diagnosis of new-onset AF with direct clinical consequences for the evaluation and secondary prevention of stroke was established by the prehospital recordings. In 2 patients, the AF episodes were limited to the prehospital period and were not detected by ECG on admission or during subsequent monitoring at the stroke unit. Of 126 patients (48.6%) with relevant abnormalities in the prehospital ECG, 16.7% received medical antiarrhythmic therapy during transport to the hospital, and 6.4% were transferred to a cardiology unit within the first 24 hours in the hospital.</AbstractText>In a selected cohort of patients with stroke, the in-field recordings of the ECG detected a relevant rate of cardiac arrhythmia. The results can add to the in-hospital evaluation and should be considered in prehospital care of acute stroke.</AbstractText>© 2017 American Academy of Neurology.</CopyrightInformation> |
20,596 | The Lazarus phenomenon: spontaneous cardioversion after termination of resuscitation in a Scottish hospital. | A 66-year-old man suffered a ventricular fibrillation cardiac arrest after an episode of chest pain. Despite advanced life support, his condition deteriorated; the situation was considered irrecoverable and resuscitation was discontinued. The patient was observed for about 5 min with irregular agonal gasping respirations evident but no palpable pulse. A gradual increase in the regularity of breathing pattern heralded the return of spontaneous circulation. An inferior myocardial infarction was diagnosed. Primary percutaneous coronary intervention was performed. The patient was discharged from hospital after 9 days with no neurological sequelae. There are several possible mechanisms to explain the Lazarus phenomenon including auto-positive end expiratory pressure and delayed drug actions, but cases are rarely reported in the medical literature. After discontinued resuscitation, we suggest consideration should be given to a period of continued monitoring. However, evidence is limited and prospective studies would be welcome to allow firmer recommendations. |
20,597 | The Right Ventricle Is Dilated During Resuscitation From Cardiac Arrest Caused by Hypovolemia: A Porcine Ultrasound Study. | Dilation of the right ventricle during cardiac arrest and resuscitation may be inherent to cardiac arrest rather than being associated with certain causes of arrest such as pulmonary embolism. This study aimed to compare right ventricle diameter during resuscitation from cardiac arrest caused by hypovolemia, hyperkalemia, or primary arrhythmia (i.e., ventricular fibrillation).</AbstractText>Thirty pigs were anesthetized and then randomized to cardiac arrest induced by three diffrent methods. Seven minutes of untreated arrest was followed by resuscitation. Cardiac ultrasonographic images were obtained during induction of cardiac arrest, untreated cardiac arrest, and resuscitation. The right ventricle diameter was measured. Primary endpoint was the right ventricular diameter at the third rhythm analysis.</AbstractText>University hospital animal laboratory.</AbstractText>Female crossbred Landrace/Yorkshire/Duroc pigs (27-32 kg).</AbstractText>Pigs were randomly assigned to cardiac arrest caused by either hypovolemia, hyperkalemia, or primary arrhythmia.</AbstractText>At the third rhythm analysis during resuscitation, the right ventricle diameter was 32 mm (95% CI, 29-35) in the hypovolemia group, 29 mm (95% CI, 26-32) in the hyperkalemia group, and 25 mm (95% CI, 22-28) in the primary arrhythmia group. This was larger than baseline for all groups (p = 0.03). When comparing groups at the third rhythm analysis, the right ventricle was larger for hypovolemia than for primary arrhythmia (p < 0.001).</AbstractText>The right ventricle was dilated during resuscitation from cardiac arrest caused by hypovolemia, hyperkalemia, and primary arrhythmia. These findings indicate that right ventricle dilation may be inherent to cardiac arrest, rather than being associated with certain causes of arrest. This contradicts a widespread clinical assumption that in hypovolemic cardiac arrest, the ventricles are collapsed rather than dilated.</AbstractText> |
20,598 | Ghrelin expression and significance in 92 patients with atrial fibrillation. | Ghrelin is a polypeptide that is closely associated with many cardiovascular diseases, such as hypertension, atherosclerosis, and heart failure. This article aims to understand the expression of ghrelin in patients with atrial fibrillation (AF).</AbstractText>A total of 182 patients with non-valvular heart diseases were recruited, among whom 92 had AF and 90 had sinus arrhythmia (SA). The serum ghrelin amount was tested by the ELASA method. Moreover, blood sugar, lipids, liver function, and renal function were tested. All recruited patients underwent echocardiographic examination following admission. Three cardiac cycles were observed under continuous exhalation. The left atrial diameter (LAD) and the left ventricular ejection fraction (LVEF) were measured and averaged. Patients with AF received conventional treatment, and the aforementioned parameters were re-measured after 8 weeks. The results were statistically analyzed.</AbstractText>The serum ghrelin level in the patients in the AF group (199.55±79.59 pg/mL) was lower than that in the patients in the SA group (313.89±71.13 pg/mL, p<0.01), whereas the serum ghrelin level in those in the paroxysmal AF group (224.44±72.33 pg/mL) was higher than that in those in the persistent AF group (176.00±79.88 pg/mL, p<0.01). There was a positive correlation between the serum ghrelin level and LVEF in the patients in the AF group (r=0.704, p=0.046). After treatment, the serum ghrelin level and LVEF in the patients in the AF group significantly increased, whereas LAD decreased.</AbstractText>The serum ghrelin level in patients with AF was reduced, and after treatment, it significantly increased. There was a positive correlation between the serum ghrelin level and LVEF in the patients in the AF group.</AbstractText> |
20,599 | Impaired left atrial function predicts inappropriate shocks in primary prevention implantable cardioverter-defibrillator candidates. | Inappropriate implantable cardioverter-defibrillator (ICD) shocks, commonly caused by atrial fibrillation (AF), are associated with an increased mortality. Because impaired left atrial (LA) function predicts development of AF, we hypothesized that impaired LA function predicts inappropriate shocks beyond a history of AF.</AbstractText>We prospectively analyzed the association between LA function and incident inappropriate shocks in primary prevention ICD candidates. In the Prospective Observational Study of ICD (PROSE-ICD), we assessed LA function using tissue-tracking cardiac magnetic resonance (CMR) prior to ICD implantation. A total of 162 patients (113 males, age 56 ± 15 years) were included. During the mean follow-up of 4.0 ± 2.9 years, 26 patients (16%) experienced inappropriate shocks due to AF (n = 19; 73%), supraventricular tachycardia (n = 5; 19%), and abnormal sensing (n = 2; 8%). In univariable analyses, inappropriate shocks were associated with AF history prior to ICD implantation, age below 70 years, QRS duration less than 120 milliseconds, larger LA minimum volume, lower LA stroke volume, lower LA emptying fraction, impaired LA maximum and preatrial contraction strains (Smax</sub> and SpreA</sub> ), and impaired LA strain rate during left ventricular systole and atrial contraction (SRs</sub> and SRa</sub> ). In multivariable analysis, impaired Smax</sub> (hazard ratio [HR]: 0.96, P = 0.044), SpreA</sub> (HR: 0.94, P = 0.030), and SRa</sub> (HR: 0.25, P < 0.001) were independently associated with inappropriate shocks. The receiver-operating characteristics curve showed that SRa</sub> improved the predictive value beyond the patient demographics including AF history (P = 0.033).</AbstractText>Impaired LA function assessed by tissue-tracking CMR is an independent predictor of inappropriate shocks in primary prevention ICD candidates beyond AF history.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
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