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20,600 | Improvements in Out-of-Hospital Cardiac Arrest Survival from 1998 to 2013. | Out-of-hospital cardiac arrest (OHCA) remains a major public health burden. Aggregate OHCA survival to hospital discharge has reportedly remained unchanged at 7.6% for almost 30 years from 1970 to 2008. We examined the trends in adult OHCA survival over a 16-year period from 1998 to 2013 within a single EMS agency.</AbstractText>Observational cohort study of adult OHCA patients treated by Tualatin Valley Fire & Rescue (TVF&R) from 1998 to 2013. This is an ALS first response fire agency that maintains an active Utstein style cardiac arrest registry and serves a population of approximately 450,000 in 9 incorporated cities in Oregon. Primary outcomes were survival to hospital discharge in all patients and in the subgroup with witnessed ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). The impact of key covariates on survival was assessed using univariate logistic regression. These included patient factors (age and sex), event factors (location of arrest, witnessed status, and first recorded cardiac arrest rhythm), and EMS system factors (response time interval, bystander CPR, and non-EMS AED shock). We used multivariate logistic regression to examine the impact of year increment on survival after multiple imputation for missing data. Sensitivity analysis was performed with complete cases.</AbstractText>During the study period, 2,528 adult OHCA had attempted field resuscitation. The survival rate for treated cases increased from 6.7% to 18.2%, with witnessed VF/VT cases increasing from 14.3% to 31.4% from 1998 to 2013. Univariate analysis showed that younger age, male sex, public location of arrest, bystander or EMS witnessed event, initial rhythm of pulseless electrical activity (PEA) or VF/VT, bystander CPR, non-EMS AED shock, and a shorter EMS response time were independently associated with survival. After adjustment for covariates, the odds of survival increased by 9% (OR 1.09, 95%CI: 1.05-1.12) per year in all treated cases, and by 6% (OR 1.06, 95% 1.01-1.10) per year in witnessed VF/VT subgroups. Findings remained consistent on sensitivity analysis.</AbstractText>Overall survival from treated OHCA has increased over the last 16 years in this community. These survival increases demonstrate that OHCA is a treatable condition that warrants further investigation and investment of resources.</AbstractText> |
20,601 | Mortality risk factors from converting off-pump coronary artery bypass to on-pump coronary artery bypass. | A number of large-scale retrospective studies revealed that off-pump coronary artery bypass (OPCAB) was superior to on-pump coronary artery bypass (ONCAB). The aim of the study was to investigate risk factors for mortality when OPCAB is converted to ONCAB.</AbstractText>Patients who underwent OPCAB conversion to ONCAB at the Beijing Anzhen Hospital between January 2003 and January 2013 were assigned to the non-survivor and survivor groups. Background demographics, illness history and preoperative, intraoperative and postoperative variables were compared.</AbstractText>Of the 247 cases, 15.4% of the patients died. Patients in the non-survivor group were older and more frequently had diabetes mellitus (DM), arrhythmia, myocardial infarction (MI) in the past 30 days (all p<0.05) and MI combined with mitral regurgitation (p<0.0001); they more frequently had bigger left ventricular end-diastolic dimension (p=0.0019), greater fall in blood pressure, ventricular fibrillation for longer periods, longer conversion time and bypass graft occlusion. All patients in the non-survivor group received intra-aortic balloon pump compared to 89.5% in the survivor group and extracorporeal membrane oxygenation was more common. Left main coronary artery disease (OR=4.431, 95%CI: 2.440-8.048, p<0.0001), blood pressure decline ⩽40 mmHg (OR=0.509, 95%CI: 0.447-0.580, p<0.0001) and time for conversion to ONCAB ⩾20 min were independently associated with mortality. Rates of postoperative complications, such as renal failure, cerebral infarction or hemorrhage, MI and redo sternotomy, were higher in the non-survivor group.</AbstractText>Conversion from OPCAB to ONCAB is associated with high mortality. Risk factors include left main artery disease and duration of blood pressure decline >40 min.</AbstractText> |
20,602 | Risk and Prediction of Sudden Cardiac Death and Ventricular Arrhythmias for Patients with Atrial Fibrillation - A Nationwide Cohort Study. | Sudden cardiac death (SCD) is the most devastating manifestation of ventricular arrhythmias (VAs), and is the leading cause of mortality among atrial fibrillation (AF) patients. The goal of the present study was to investigate the incidence of SCD/VAs amongst patients with and without AF. We also aimed to identify important risk factors of SCD/VAs among AF patients. Using the "National Health Insurance Research Database" in Taiwan, a total of 352,656 AF and 352,656 non-AF patients without antecedent SCD/VAs were identified. The annual risk of SCD/VAs was higher in AF than non-AF groups (0.97% versus 0.47%) with an adjusted hazard ratio (HR) of 1.64. The increased risk of SCD/VAs in AF patients was consistently observed in different age strata, various comorbidities and patients without use of class I/III anti-arrhythmic drugs or digoxin. Among AF patients, age ≥75 years, congestive heart failure, hypertension, diabetes mellitus, previous stroke/transient ischemic attack, vascular diseases, chronic kidney disease and chronic obstructive pulmonary disease were important risk factors for SCD/VAs. In conclusion, the risk of SCD/VAs amongst AF patients was 1.64-fold higher compared to non-AF patients, which was associated with the number of clinical risk factors associated with the particular AF patient. |
20,603 | The management of ventricular dysrhythmia in aconite poisoning. | Aconite poisoning is relatively rare but is frequently complicated by ventricular dysrhythmias, which may be fatal. Molecular basis of aconite alkaloid ventricular arrhythmogenicity: Aconite exerts its toxic effects due to the presence of an admixture of alkaloids present in all parts of the plant. The major target of these aconite alkaloids is the fast voltage-gates sodium channel, where they cause persistent activation. This blockade of the channel in the activated state promotes automaticity within the ventricular myocardium and the generation of ventricular arrhythmias. Aconitine-induced arrhythmias: Aconite alkaloids are known to cause many different types of disturbance of heart rhythm. However, this focused review specifically looks at ventricular rhythm disturbances, namely ventricular ectopy, ventricular tachycardia, torsades des pointes and ventricular fibrillation.</AbstractText>The objective of this review was to identify the outcome of anti-dysrhythmic strategies from animal studies and case reports in humans in order to guide the management of ventricular dysrhythmias in aconite poisoning in humans.</AbstractText>A review of the literature in English was conducted in PubMed and Google Scholar from 1966 to July 2016 using the search terms "aconite/aconitine"; "aconite/aconitine + poisoning" and "aconite/aconitine + dysrhythmia". 168 human case-reports and case-series were identified by these searches, of which 103 were rejected if exposure to aconite did not result in ventricular dysrhythmias, if it was uncertain as to whether aconite had been ingested, if other agents were co-ingested, if there was insufficient information to determine the type of treatments administered or if there was insufficient information to determine outcome. Thus, 65 case reports of probable aconite poisoning that resulted in ventricular dysrhythmias were identified. Toxicokinetic data in aconite poisoning: Data were only available in three papers; the presence of ventricular rhythm disturbances directly correlated with the concentration of aconite alkaloids in the plasma.</AbstractText>54 of 65 cases developed ventricular tachycardia, six developed torsades des pointes, 15 patients developed ventricular fibrillation, 10 developed ventricular ectopics and one developed a broad complex tachycardia not otherwise specified; each dysrhythmia was regarded as separate and patients may have had more than one dysrhythmia. 10 patients died, giving a mortality of 15%. In total, 147 treatments were administered to 65 patients. 46 of the interventions were assessed by the authors as having been associated with successful restoration of sinus rhythm. Flecainide administration was accompanied by dysrhythmia termination in six of seven cases. Mexiletine was connected with correcting dysrhythmias in 3 of 3 cases. Procainamide administration was associated with return to sinus rhythm in 2 of 2 cases. Prolonged cardio-pulmonary resuscitation was administered to 15 patients where it was associated with a return to sinus rhythm in nine of these. Amiodarone was linked to success in correcting dysrhythmias in 11 of 20 cases. Cardiopulmonary bypass use was associated with a return to sinus rhythm in four out of six cases. Epinephrine was documented as being employed on four occasions, and was associated with a restoration of sinus rhythm on two of these. Magnesium sulphate administration was accompanied by dysrhythmia termination in two of nine cases. Direct cardioversion was associated with a return of sinus rhythm in 5 of 30 cases. However, it is not certain whether the drug treatment influenced the course of the dysrhythmia.</AbstractText>Based on the evidence available from human case reports, flecainaide or amiodarone appear to be more associated with a return to sinus rhythm than lidocaine and/or cardioversion, although it is not established whether the administration of treatment caused reversion to normal sinus rhythm. The potential beneficial effects of amiodarone were not observed in animal studies. This may be due to intra-species differences between ion channels or relate to the wider cardiovascular toxicity of aconite that extends beyond arrhythmias. Prolonged cardiopulmonary resuscitation and cardiopulmonary bypass should be considered as an integral part of good clinical care as "time-buying" strategies to allow the body to excrete the toxic alkaloids. There may also be a role for mexiletine, procainamide and magnesium sulphate.</AbstractText> |
20,604 | Early Repolarization Pattern Predicts the Increased Risk of Ventricular Arrhythmias in Patients With Acute Anterior ST-Segment Elevation Myocardial Infarction　- A Propensity Analysis. | The association between the early repolarization pattern (ERP) and ventricular arrhythmias in patients with ST-segment elevation myocardial infarction (STEMI) remains uncertain. We hypothesized that ERP predicts the risk of sustained ventricular tachycardia (VT)/ventricular fibrillation (VF) during the acute phase of anterior STEMI.Methods and Results:We enrolled 1,460 consecutive patients with acute anterior STEMI. We identified an ERP-positive group and a 1:6 propensity-matched ERP-negative group of 183 and 471, respectively. Comparisons of sustained VT/VF, heart failure, major adverse cardiovascular events and all-cause death were based on Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression with adjustment for unmatched confounding factors. In our full matching propensity score cohorts, there were 8 out of 28 variables not matching between the 2 groups. The Kaplan-Meier curves showed ERP increased the risk of sustained VT/VF in 30 days (log-rank test P=0.00065). Adjusted for baseline unmatched confounding risk, the Cox hazards regression analysis showed sustained VT/VF was associated with the present of ERP (hazard ratio=2.915, 95% CI: 1.520-5.588, P=0.001).</AbstractText>In a propensity score-adjusted cohort the presence of ERP had a multivariable-adjusted association with increased risk of sustained VT/VF in patients with anterior STEMI in the early 30 days.</AbstractText> |
20,605 | Predictors of arrhythmia recurrence after balloon cryoablation of atrial fibrillation: the value of CAAP-AF risk scoring system. | In the present study, we aimed to test the value of CAAP-AF score for prediction of atrial fibrillation (AF) recurrence at follow-up in a group of our patients treated by balloon cryoablation.</AbstractText>A total of 283 symptomatic drug-refractory AF patients [261 (92%) with paroxysmal AF] who underwent pulmonary vein isolation (PVI) with second-generation cryoballoon between April 2012 and October 2016 were included. The CAAP-AF score was calculated for every patient.</AbstractText>A total of 283 patients [68 female (20%), mean age 59.8 ± 11.4 years] were included in the present analysis. Eighty-nine patients (31%) had hypertension and 13 (4%) had coronary artery disease. The mean left atrial diameter and left ventricular ejection fraction were 40.6 ± 7.0 mm and 60.0 ± 9.1%, respectively. The mean CHA2</sub>DS2</sub>-VASc score was 1.2 ± 1.1, and mean number of prior failed antiarrhythmic drugs was 1.4 ± 0.8. At 18 ± 6 months follow-up, 25 patients (8.87%) developed AF recurrence. The recurrence rate was as follows: 3.17% (score 0-3), 8.47% (score 4), 16.28% (score 5), 6.67% (score 6), 23.08% (score 7), and 36.36% (score ≥8). The recurrence rate was 4.86% at a score <5 and 16.49% at a value ≥5; a score cutoff ≥5 predicted AF recurrence with a sensitivity 64% and specificity 68%.</AbstractText>The present analysis suggests the usefulness of CAAP-AF scoring system, with its simple and easily obtained six clinical variables, to predict AF recurrence after PVI by means of second-generation cryoballoon. A score value ≥5 predicted AF recurrence with a sensitivity 64% and specificity 68%.</AbstractText> |
20,606 | Optical Mapping Approaches on Muscleblind-Like Compound Knockout Mice for Understanding Mechanistic Insights Into Ventricular Arrhythmias in Myotonic Dystrophy. | Cardiac arrhythmias are common causes of death in patients with myotonic dystrophy (dystrophia myotonica [DM]). Evidence shows that atrial tachyarrhythmia is an independent risk factor for sudden death; however, the relationship is unclear.</AbstractText>Control wild-type (Mbnl1+/+</sup>; Mbnl2+/+</sup></i> ) and DM mutant (Mbnl1-/-</sup>; Mbnl2+/-</sup></i> ) mice were generated by crossing double heterozygous knockout (Mbnl1+/-</sup>; Mbnl2+/-</sup></i> ) mice. In vivo electrophysiological study and optical mapping technique were performed to investigate mechanisms of ventricular tachyarrhythmias. Transmission electron microscopy scanning was performed for myocardium ultrastructural analysis. DM mutant mice were more vulnerable to anesthesia medications and program electrical pacing: 2 of 12 mice had sudden apnea and cardiac arrest during premedication of general anesthesia; 9 of the remaining 10 had atrial tachycardia and/or atrioventricular block, but none of the wild-type mice had spontaneous arrhythmias; and 9 of 10 mice had pacing-induced ventricular tachyarrhythmias, but only 1 of 14 of the wild-type mice. Optical mapping studies revealed prolonged action potential duration, slower conduction velocity, and steeper conduction velocity restitution curves in the DM mutant mice than in the wild-type group. Spatially discordant alternans was more easily inducible in DM mutant than wild-type mice. Transmission electron microscopy showed disarranged myofibrils with enlarged vacuole-occupying mitochondria in the DM mutant group.</AbstractText>This DM mutant mouse model presented with clinical myofibril ultrastructural abnormality and cardiac arrhythmias, including atrial tachyarrhythmias, atrioventricular block, and ventricular tachyarrhythmias. Optical mapping studies revealed prolonged action potential duration and slow conduction velocity in the DM mice, leading to vulnerability of spatially discordant alternans and ventricular arrhythmia induction to pacing.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.</CopyrightInformation> |
20,607 | Cardiac transplantation in children and adolescents with long QT syndrome. | Long QT syndrome (LQTS) is a potentially lethal, yet highly treatable, cardiac channelopathy. Cardiac transplantation has been reported anecdotally for patients with severe LQTS refractory to standard therapies.</AbstractText>The purpose of this study was to evaluate the incidence of and risk factors for cardiac transplantation in children evaluated and treated in an LQTS specialty center.</AbstractText>This was a retrospective review of 349 children with LQTS (mean age at diagnosis, 8.0 ± 5.7 years; mean corrected QT interval, 469 ± 51 ms; long QT syndrome type 1 [LQT1] in 46%, LQT2 in 31%, and LQT3 in 9%) evaluated from 2000 to 2013. A subset analysis was performed on patients referred for cardiac transplantation.</AbstractText>Only 3 patients (0.9%; all LQT3; 2 female) underwent cardiac transplantation at ages 4, 11, and 17 years. Overall, 90 of 349 (26%) were symptomatic (exhibited LQTS-associated cardiac events) before LQTS diagnosis, including those who ultimately underwent transplant. Age at sentinel event was associated with transplantation (3 of 26 [12%] with an event at <1 year of life were transplanted vs 0 of 64 with an event after age 1; P = .02). Genotype was also a risk factor (3 of 32 patients with LQT3 were transplanted [9.4%] vs 0 of 270 patients with LQT1 or LQT2; P = .001). Before transplant, all patients had recurrent ventricular fibrillation-terminating shocks despite combination drug therapy and bilateral sympathetic denervation. All transplanted patients are alive at follow-up.</AbstractText>Cardiac transplantation is seldom necessary for the management of LQTS. However, patients with LQT3 and in utero/neonatal expressivity are at higher risk of treatment failure and refractory ventricular arrhythmias with standard therapy, and cardiac transplantation should be considered for this malignant subset of LQTS.</AbstractText>Copyright © 2017. Published by Elsevier Inc.</CopyrightInformation> |
20,608 | Early repolarization is associated with a significantly increased risk of ventricular arrhythmias and sudden cardiac death in patients with structural heart diseases. | Early repolarization pattern (ERP) has been proved to increase risk of arrhythmia death in the general population, but its prognostic significance in patients with structural heart disease (SHD) is controversial.</AbstractText>The purpose of this study was to conduct a meta-analysis of studies assessing the association between ERP and risk of ventricular arrhythmias (VTAs) and sudden cardiac death (SCD) in patients with SHD.</AbstractText>We performed a literature search using MEDLINE (January 1, 1966, to September 25, 2016) and EMBASE (January 1, 1980, to September 25, 2016) with no restrictions. Studies that reported odds ratio (OR) estimates with 95% confidence intervals (CIs) for the associations of interest were included.</AbstractText>The search yielded 19 observational studies, involving 7268 patients that reported 1127 cases of VTAs or SCD. In the selected studies, the point estimates of the ORs were consistently greater than 1. Compared with those without ERP, patients with ERP experienced a significantly increased risk of developing VTAs or SCD (OR 4.76; 95% CI 3.62-6.26), ventricular fibrillation (OR 7.14; 95% CI 4.31-11.82), and SCD (OR 4.07; 95% CI 1.58-10.51). The results were consistent and statistically significant in all subgroups. ERP with J-point elevation in inferior leads, notching configuration, and horizontal or descending ST segment connote higher risk.</AbstractText>ERP is associated with a significant increased risk of VTAs or SCD in patients with SHD. Future research should attempt to understand the exact mechanisms for the arrhythmia risk and to introduce ERP in the risk stratification in this patient group.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,609 | Effect of Atrial Fibrillation on Mortality, Stroke Risk, and Quality-of-Life Scores in Patients With Heart Failure (from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT-AF]). | The degree to which clinical outcomes are worsened in patients with atrial fibrillation (AF) with heart failure (HF) compared with those without HF is not well described. This study aimed to determine the impact of HF on clinical outcomes in patients with AF. We analyzed data from Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, a national registry of 10,135 patients with AF to determine associations between HF and left ventricular ejection fraction (LVEF) and outcomes, including stroke, mortality, and hospitalization using Cox multivariable modeling. Atrial Fibrillation Effect on Quality-of-Life Questionnaire (AFEQT) scores between groups were also compared. Overall, 33% (n = 3,203) of patients had HF; of these 33% (n = 985) had LVEF ≤40%. Oral anticoagulation was prescribed more commonly in patients with HF (81% vs 74%). Compared with patients without HF, those with HF had similar rate of stroke (1.28 vs 0.88 per 100-patient years, hazard ratio [HR] 1.11, confidence interval [CI] 0.83 to 1.48, p = 0.47) but higher mortality (HR 1.69, CI 1.49 to 1.92, p <0.001) and hospitalization (HR 1.31, CI 1.23 to 1.39, p <0.0001). Patients with LVEF ≤40% had similar stroke risk (HR 1.06, CI 0.67 to 1.67) but higher mortality (HR 2.06, CI 1.74 to 2.44) and hospitalization (HR 1.38, CI 1.25 to 1.51). AFEQT overall score was significantly lower (76.9 vs 83.3, p <0.0001) in patients with HF. In conclusion, HF was associated with increased risk of death and hospitalization and worse quality of life, but similar rates of thromboembolism regardless of LVEF among patients with AF. These findings highlight the need to develop therapeutic strategies targeting functional status and survival for patients with HF and AF. |
20,610 | P1033Echocardiographic predictive model of new-onset postoperative atrial fibrillation after abdominal surgery. | and purpose: Postoperative atrial fibrillation (POAF) is a frequent complication post high-risk abdominal surgery in elderly patients. This study aimed to develop a predictive model of POAF based on preoperative transthoracic echocardiography (TTE) findings in these patients.</AbstractText>We conducted a prospective study of 300 consecutive patients, age ≥ 65 years (mean age 72±6 years, 61% men), who underwent high-risk abdominal surgery under general anesthesia. Preoperative TTE was performed in all patients, including tissue Doppler imaging (TDI). We measured the time interval between the onset of the P-wave on ECG and a point of the peak-A wave on TDI from the lateral mitral annulus (PA lateral) and septal mitral annulus (PA septal). Left atrial (LA) dyssynchrony was measured by subtracting the PA septal from PA lateral. Right ventricular systolic pressure was estimated by using the tricuspid regurgitation jet (TRJ) Doppler velocity method. The primary endpoint was the occurance of new-onset POAF.</AbstractText>Thirty-seven (12%) patients developed POAF. Multiple echocardiographic parameters were measured and tested in different combinations. The final model included the following variables with cutoff points predictive of POAF: PA lateral > 139 ms (69% sensitivity, 92% specificity), LA dyssynchrony > 35 ms (78% sensitivity, 89% specificity), and TRJ Doppler velocity >2.6 m/s (89% sensitivity, 64% specificity). A value of 0 was assigned when the result was below the cutoff point and a value of 1 if above the cutoff point. Coding of these three variables in the following order: PA lateral- TRJ Doppler- left atrial dyssynchrony can predict the probability of POAF. The model showed a postive predictive value of 79% and a negative predictive value of 95%.</AbstractText>A model using three echocardiographic variables: PA lateral, LA dyssynchrony and TRJ Doppler velocity, can predict the incidence of POAF after high-risk abdominal surgery. The model can be used preoperatively to identify high-risk patients that would need aggressive prophylactic treatment.</AbstractText>PA lateral >139 ms-TRJ Doppler velocity >2.6 m/s-LA dyssynchrony >35 msProbability of POAF0- 0- 0; 0- 1- 0No0- 0- 1; 0- 1- 1; 1- 0- 0; 1- 0- 1; 1- 1- 0; 1- 1- 1Yes.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: Journals.permissions@oup.com.</CopyrightInformation> |
20,611 | ECG Of The Month: Mental Disturbance for 4 days. | A family brought their 61-year-old mother to the emergency department because for 4 days she had been confused, incoherent, and somnolent. She also had dysphagia, dysarthria, diplopia, and had fallen out of bed. She had been in the hospital 3 weeks earlier for atrial fibrillation and an exacerbation of congestive heart failure. She also carried a diagnosis of chronic obstructive pulmonary disease and used an albuterol inhaler. She was obese (BMI of 45); and had adult-onset diabetes mellitus. She had a 43 pack-year history of cigarette smoking but had recently quit. Soon after arriving in the emergency department, she had an ECG (Figure);. |
20,612 | Purulent Pericarditis Due to an Infected Pacemaker Lead. | Intravenous drug users have a substantially increased risk of infective endocarditis, especially in the setting of implanted cardiac devices. Purulent pericarditis is a rare occurrence that can occur iatrogenically or through direct or hematogenous spread.</AbstractText>A 75 year old man with a past medical history significant for hepatitis C, IV drug abuse, and sick sinus syndrome status post pacemaker was brought in by EMS with a chief complaint of diaphoresis and chest pain. Initial EKG revealed atrial fibrillation with ST elevations in multiple leads. The patient was taken urgently to the cardiac catheterization lab due to concern for STEMI. Left heart catheterization revealed nonobstructive CAD; bedside echo was significant for a pericardial effusion and a pacemaker lead vegetation. CT of the chest revealed extension of the ventricular pacemaker lead through the anterior right ventricular wall and pericardium and into the pleural cavity. Cardiothoracic surgery performed a pacemaker removal as well as pericardial window due to early tamponade; approximately 900 mL of purulent fluid was drained from the pericardial space. The patient was septic with initial blood cultures growing MSSA. He was also found to have multiple other foci of infection including a left-sided pleural effusion and a perihepatic fluid collection, both of which were drained and also grew out MSSA. The patient initially improved on antibiotics after his pacemaker removal and drainage of the infected fluid collections. However, several days after the pacemaker removal he gradually became more bradycardic; due to his multiple comorbidities and active infection, he was not a candidate for a replacement implanted pacemaker. He became profoundly bradycardic and hypotensive overnight and died despite the use of multiple pressors to maintain his blood pressure as well as transcutaneous pacing to maintain his heart rate.</AbstractText>Purulent pericarditis has become a relatively uncommon occurrence since the development of effective antibiotics. This case illustrates a rare example of purulent pericarditis and cardiac tamponade secondary to the extension of an infected pacemaker wire through the pericardium and into the thoracic cavity. The presence of multiple other infected fluid collections in this case also illustrates the need to thoroughly assess for secondary foci of infection in cases of bacterial endocarditis.</AbstractText> |
20,613 | Three's a Crowd - An Extremely Rare Case of Cor Triatriatum Dexter. | Cor triatriatum is a congenital cardiac anomaly in which the left (sinister) or right (dexter) atrium is divided into two compartments by residual embryonic tissue, resulting in a tri-atrial heart. As cor triatriatum dextrum can present clinically in various ways and have multiple associated cardiac anomalies, this report attempts to contribute to what is known about this exceedingly rare disorder.</AbstractText>A 40 year old Hispanic man with a medical history of gastritis presented with complaints of palpitations, dizziness and bilateral lower extremity edema. He was found to have atrial fibrillation and new onset heart failure. The patient was admitted for rate control and further evaluation, which revealed several cardiac anomalies. Initial 2D echocardiography demonstrated severe right atrial enlargement, right ventricular hypertrophy and an engorged coronary sinus, which prompted further assessment of the patient's cardiovascular anatomy. Transesophageal echocardiography (TEE) revealed a severely enlarged, septated right atrium with a possible unroofed coronary sinus and a small patent foramen ovale (PFO). Left- and right-heart catheterization established a coronary-cameral fistula between the right coronary artery (RCA) and right atrium, as well as left-to-right shunt. The patient improved clinically with conservative management including diet modification, furosemide and digoxin for fluid and rate control, and was referred to cardiothoracic surgery for further evaluation.</AbstractText>Cor triatriatum dextrum is an extremely rare cardiac condition: In high-volume echocardiographic laboratories, prevalence is less than 0.01 percent. This case highlights the association between cor triatriatum and other congenital cardiac anomalies, including persistent left superior vena cava with an unroofed coronary sinus, PFO and left-to-right shunt; all of which were found in this patient. While cases of cor-triatriatum sinistrum often require correction in infancy (due to left sided heart failure, pulmonary edema and cyanosis), cor-triatriatum dextrum is sometimes diagnosed in adulthood due to the lack of left heart and pulmonary involvement.</AbstractText> |
20,614 | The Mysterious Case of Dyspnea. | Dehiscence of a mitral valve annuloplasty ring is a rare occurrence that often manifests as mitral regurgitation and heart failure. We present a case of mitral ring dehiscence which was initially unrecognized by standard 2-dimensional transthoracic echocardiography (2D TTE); and 2-dimensional transesophageal echocardiography (2D TEE);.</AbstractText>A 65-year-old woman was referred to Cardiology clinic for evaluation of dyspnea. Her history included tobacco abuse, atrial fibrillation status post pulmonary vein isolation, nonischemic cardiomyopathy, and prior mitral valve repair with annuloplasty ring for rheumatic valvular disease. She had been asymptomatic post-surgery. Physical examination, cardiac rhythm and initial ischemic workup were unremarkable. Pulmonary function tests revealed moderate emphysematous type obstructive lung disease. A 2D TTE demonstrated moderate mitral regurgitation with normal left ventricular function. In right heart catheterization, large v waves were noted and 2D TEE also revealed severe mitral regurgitation. On 2D TEE, the mitral valve annuloplasty ring was visible above the native anterior mitral valve leaflet. Color Doppler flow estimated the effective regurgitation orifice area of 0.4cm2 using the proximal isovelocity surface area method and regurgitant volume of 58 cc, consistent with severe mitral regurgitation. A "floating mitral ring" and dehiscence measuring 1 cm in diameter were seen on high resolution three-dimensional reconstruction resulting from the detachment of the ring from the weakened posterior annulus. Based on these findings patient was referred to cardiothoracic surgeon for re-do mitral valve surgery.</AbstractText>This was a perplexing case as the patient's dyspnea could be explained by many disease processes including atrial fibrillation, mitral regurgitation and chronic obstructive lung disease. The standard imaging modalities did not help us to formulate a diagnosis. 3D TEE provided invaluable and unparalleled information of mitral valve pathology. Annuloplasty ring dehiscence is a well described complication of mitral valve repair and should always be considered in symptomatic patients.</AbstractText> |
20,615 | Frequency of pacemaker malfunction associated with monopolar electrosurgery during pulse generator replacement or upgrade surgery. | The aim of this study is to investigate the frequency of electrosurgery-related pacemaker malfunction.</AbstractText>A retrospective study was conducted to investigate electrosurgery-related pacemaker malfunction in consecutive patients undergoing pulse generator (PG) replacement or upgrade from two large hospitals in Minneapolis, MN between January 2011 and January 2014. The occurrence of this pacemaker malfunction was then studied by using MAUDE database for all four major device vendors.</AbstractText>A total of 1398 consecutive patients from 2 large tertiary referral centers in Minneapolis, MN undergoing PG replacement or upgrade surgery were retrospectively studied. Four patients (0.3% of all patients), all with pacemakers from St Jude Medical (2.8%, 4 of 142) had output failure or inappropriately low pacing rate below 30 bpm during electrosurgery, despite being programmed in an asynchronous mode. During the same period, 1174 cases of pacemaker malfunctions were reported on the same models in MAUDE database, 37 of which (3.2%) were electrosurgery-related. Twenty-four cases (65%) had output failure or inappropriate low pacing rate. The distribution of adverse events was loss of pacing (59.5%), reversion to backup pacing (32.4%), inappropriate low pacing rate (5.4%), and ventricular fibrillation (2.7%). The majority of these (78.5%) occurred during PG replacement at ERI or upgrade surgery. No electrosurgery-related malfunction was found in MAUDE database on 862 pacemaker malfunction cases during the same period from other vendors.</AbstractText>Electrosurgery during PG replacement or upgrade surgery can trigger output failure or inappropriate low pacing rate in certain models of modern pacemakers. Cautions should be taken for pacemaker-dependent patients.</AbstractText> |
20,616 | Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention. | Coronary occlusion and pulmonary embolism are responsible for the majority of cases of out-of-hospital cardiac arrest (OHCA). Despite previous favourable results of pre-hospital fibrinolysis in cases of OHCA, the benefit could not be confirmed in a large controlled study using the fibrinolytic tenecteplase. For reteplase (r-PA), there are hardly any data regarding pre-hospital fibrinolysis during ongoing resuscitation. The present study reported results using r-PA therapy in a German physician-supported Emergency Medical Services system. The data of OHCA patients who received pre-hospital fibrinolytic treatment with r-PA after an individual risk/benefit assessment were retrospectively analysed. To assess the effectiveness of this approach, the rate of patients with a return of spontaneous circulation (ROSC) was compared with the corresponding figure that was calculated with the help of the RACA (ROSC after cardiac arrest) score. The RACA algorithm predicts the probability of ROSC based on data from the German Resuscitation Registry. Further outcome data comprised hospital discharge rate and neurologic status at discharge. From 2001 to 2009, 43 patients (mean age, 58.5 years; 65.1% male; 58.1% ventricular fibrillation) received r-PA. Of these, 20 patients (46.5%) achieved ROSC, compared to a probability of 49.8% according to the RACA score (P=0.58). A total of 8 patients (18.6%) were discharged alive, including 5 (11.2%) with a good neurological outcome. For the analysed small patient collective, pre-hospital r-PA did not offer any benefits with regard to the ROSC rate. Further analyses of larger patient numbers on a nationwide registry basis are recommended. |
20,617 | Paediatric-onset coronary artery anomalies in pregnancy: a single-centre experience and systematic literature review. | Individuals with childhood-onset coronary artery anomalies are at increased risk of lifelong complications. Although pregnancy is thought to confer additional risk, a few data are available regarding outcomes in this group of women. We sought to define outcomes of pregnancy in this unique population.</AbstractText>We performed a retrospective survey of women with paediatric-onset coronary anomalies and pregnancy in our institution, combined with a systematic review of published cases. We defined paediatric-onset coronary artery anomalies as congenital coronary anomalies and inflammatory arteriopathies of childhood that cause coronary aneurysms. Major cardiovascular events were defined as pulmonary oedema, sustained arrhythmia requiring treatment, stroke, myocardial infarction, cardiac arrest, or death.</AbstractText>A total of 25 surveys were mailed, and 20 were returned (80% response rate). We included 46 articles from the literature, which described cardiovascular outcomes in 82 women (138 pregnancies). These data were amalgamated for a total of 102 women and 194 pregnancies; 59% of women were known to have paediatric-onset coronary artery anomalies before pregnancy. In 23%, the anomaly was unmasked during or shortly after pregnancy. The remainder, 18%, was diagnosed later in life. Major cardiovascular events occurred in 14 women (14%) and included heart failure (n=5, 5%), myocardial infarction (n=7, 7%), maternal death (n=2, 2%), cardiac arrest secondary to ventricular fibrillation (n=1, 1%), and stroke (n=1, 1%). The majority of maternal events (13/14, 93%) occurred in women with no previous diagnosis of coronary disease.</AbstractText>Women with paediatric-onset coronary artery anomalies have a 14% risk of adverse cardiovascular events in pregnancy, indicating the need for careful assessment and close follow-up. Prospective, multicentre studies are required to better define risk and predictors of complications during pregnancy.</AbstractText> |
20,618 | RV Contractile Function and its Coupling to Pulmonary Circulation in Heart Failure With Preserved Ejection Fraction: Stratification of Clinical Phenotypes and Outcomes. | This study sought to investigate how right ventricular (RV) contractile function and its coupling with pulmonary circulation (PC) stratify clinical phenotypes and outcome in heart failure preserved ejection fraction (HFpEF) patients.</AbstractText>Pulmonary hypertension and RV dysfunction are key hemodynamic abnormalities in HFpEF.</AbstractText>Three hundred eighty seven HFpEF patients (mean age 64 ± 12 years, 59% females, left ventricular ejection fraction 59 ± 7%) underwent RV and pulmonary hemodynamic evaluation by echocardiography (entire population) and right heart catheterization (219 patients). Patients were investigated by tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) relationship and stratified according to TAPSE/PASP ratio tertiles (1: <0.35; 2: 0.35 to 0.57; 3: >0.57). Specifically, TAPSE/PASP ratio was taken as a noninvasive index of RV to PC coupling based on the correlation with invasively evaluated RV systolic elastance/arterial elastance (r = 0.35; p < 0.0001).</AbstractText>Groups had similar prevalence of comorbidities except for a higher prevalence of atrial fibrillation and kidney dysfunction in tertile 1. Progressively increasing levels of natriuretic peptides, worse systemic and pulmonary hemodynamics, abnormal exercise aerobic capacity and ventilatory inefficiency were observed from the highest to lowest TAPSE/PASP tertile. TASPE/PASP correlated with pulmonary artery compliance (r = 0.69; p < 0.0001). Remarkably, the tertile 1 group distributed along the worse portion of the curve at lower pulmonary artery compliance and higher pulmonary vascular resistances. In addition, the TAPSE/PASP ratio emerged as an independent predictor of worse outcomes.</AbstractText>A thorough assessment of RV-PC coupling and RV contractile function stratify HFpEF phenotypes at different level of risk. These observations shift the interest toward therapeutic strategies that may benefit the right heart as primary unmet need in the complex pathophysiology of the HFpEF syndrome.</AbstractText>Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,619 | Outcome of isolated aortic valve replacement in patients with classic and paradoxical low-flow, low-gradient aortic stenosis. | To analyze operative outcomes and mid-term results after isolated aortic valve replacement (AVR) in low-flow, low-gradient aortic stenosis (LFLG AS) by comparing the 2 subcategories (classic low-flow, low-gradient aortic stenosis [CLFLG] and paradoxical low-flow, low-gradient aortic stenosis [PLFLG]).</AbstractText>This was a retrospective analysis of prospectively collected data for all isolated AVR in LFLG AS performed in our center during the last 13 years (n = 198; CLFLG AS, n = 66, 33% and PLFLG AS, n = 132, 67%). Median follow-up was 3.7 ± 3.3 years.</AbstractText>Preoperative mean gradient was 30.2 ± 8.8 mm Hg in the CLFLG AS group and 31.4. ± 7.0 mmHg in the PLFLG AS group (P = .001). Female sex, hypertension, and neurologic and renal disease were more frequent in the PLFLG AS group (P < .01) whereas advanced New York Heart Association class, atrial fibrillation, and pulmonary hypertension were more frequent in the CLFLG AS group (P < .01). In-hospital mortality was 3% in the CLFLG AS group and 2.3% in the PLFLG AS group, P = .08. One- and five-year mortality rates were significantly greater in the CLFLG AS group (27% and 42% vs 6% and 20% in the PLFLG AS group, respectively, P = .001). On follow-up, 90% of the total survivors were in New York Heart Association class I-II, and 51% of the patients in the CLFLG AS group had an improvement in their ventricular function.</AbstractText>AVR can be performed in LFLG AS with low in-hospital mortality. CLFLG AS carries similar in-hospital mortality to PLFLG AS but greater mid-term mortality. Surgery provided excellent functional status among survivors.</AbstractText>Copyright © 2017 The American Association for Thoracic Surgery. All rights reserved.</CopyrightInformation> |
20,620 | The QUIDAM study: Hydroquinidine therapy for the management of Brugada syndrome patients at high arrhythmic risk. | Although the implantable cardioverter-defibrillator (ICD) remains the main therapy for Brugada syndrome (BrS), it does not reduce life-threatening ventricular arrhythmia. Based on pathophysiologic mechanisms, hydroquinidine (HQ) has been suggested for effective prevention of arrhythmia.</AbstractText>The purpose of this study was to provide evidence-based data supporting HQ use to prevent life-threatening ventricular arrhythmia in high-risk patients with BrS.</AbstractText>We performed a prospective multicenter randomized (HQ vs placebo) double-blind study with two 18-month crossover phases in patients with BrS and implanted with an ICD.</AbstractText>Among the 50 patients enrolled (mean age 47.0 ± 11.4 years, 42 [84%] male), 26 (52%) fully completed both phases. Thirty-four (68%) presented HQ-related side effects, mainly gastrointestinal, which led to discontinuation of the therapy in 13 (26%). HQ lengthened the QTc interval (409 ± 32 ms vs 433 ± 37 ms; P = .027) and increased repolarization dispersion as evaluated by Tpe max in precordial leads (89 ± 15 ms vs 108 ± 27 ms; P <.0001) with no significant changes in J-point elevation. During the 36-month follow-up, 1 appropriate ICD shock (0.97% event per year), 1 self-terminating ventricular fibrillation, and 1 inappropriate ICD shock occurred under placebo therapy. No arrhythmic events were reported under HQ therapy.</AbstractText>Although HQ seems to be effective in preventing life-threatening ventricular arrhythmia, it could not be an alternative for ICD implantation. Its frequent side effects greatly reduce its probable compliance and therefore do not reveal a significant effect. HQ increases repolarization dispersal with no changes in BrS pattern, which could indicate a more complex action of HQ than its Ito</sub> blocking effect alone.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,621 | Early predictors of poor outcome after out-of-hospital cardiac arrest. | Early identification of predictors for a poor long-term outcome in patients who survive the initial phase of out-of-hospital cardiac arrest (OHCA) may facilitate future clinical research, the process of care and information provided to relatives. The aim of this study was to determine the association between variables available from the patient's history and status at intensive care admission with outcome in unconscious survivors of OHCA.</AbstractText>Using the cohort of the Target Temperature Management trial, we performed a post hoc analysis of 933 unconscious patients with OHCA of presumed cardiac cause who had a complete 6-month follow-up. Outcomes were survival and neurological function as defined by the Cerebral Performance Category (CPC) scale at 6 months after OHCA. After multiple imputations to compensate for missing data, backward stepwise multivariable logistic regression was applied to identify factors independently predictive of a poor outcome (CPC 3-5). On the basis of these factors, a risk score for poor outcome was constructed.</AbstractText>We identified ten independent predictors of a poor outcome: older age, cardiac arrest occurring at home, initial rhythm other than ventricular fibrillation/tachycardia, longer duration of no flow, longer duration of low flow, administration of adrenaline, bilateral absence of corneal and pupillary reflexes, Glasgow Coma Scale motor response 1, lower pH and a partial pressure of carbon dioxide in arterial blood value lower than 4.5 kPa at hospital admission. A risk score based on the impact of each of these variables in the model yielded a median (range) AUC of 0.842 (0.840-0.845) and good calibration. Internal validation of the score using bootstrapping yielded a median (range) AUC corrected for optimism of 0.818 (0.816-0.821).</AbstractText>Among variables available at admission to intensive care, we identified ten independent predictors of a poor outcome at 6 months for initial survivors of OHCA. They reflected pre-hospital circumstances (six variables) and patient status on hospital admission (four variables). By using a simple and easy-to-use risk scoring system based on these variables, patients at high risk for a poor outcome after OHCA may be identified early.</AbstractText> |
20,622 | Aborted Sudden Cardiac Death in a Female Patient Presenting with Takotsubo-Like Cardiomyopathy due to Epicardial Coronary Vasospasm. | Takotsubo cardiomyopathy is characterized by apical ballooning of the left ventricle (LV) in the absence of relevant coronary artery stenosis, which typically occurs in elderly women after emotional stress. Catecholamine cardiotoxicity, metabolic disturbance, and coronary microvascular impairment have previously been proposed as underlying pathophysiologic mechanisms of takotsubo cardiomyopathy, whereas myocardial stunning resulting from epicardial coronary artery vasospasm is not generally accepted as a cause of takotsubo cardiomyopathy. The prognosis of takotsubo cardiomyopathy is generally more favourable compared to myocardial infarction; however, severe complications such as rupture of the LV and life-threatening arrhythmias may occur. Herein, we describe a case of an 84-year-old female, who presented with aborted sudden cardiac death due to ventricular fibrillation. Echocardiography suggested LV apical ballooning with severely impaired LV-function, so that takotsubo cardiomyopathy was suspected. However, coronary angiography revealed epicardial spasm of the left anterior ascending, which resolved after intracoronary injection of 0.2 mg nitroglycerine. Cardiac magnetic resonance exhibited subendocardial late enhancement and echocardiography showed normalization of LV dysfunction during follow-up. The patient was put on conservative treatment with nitrates and calcium inhibitors and ICD implantation were deferred. |
20,623 | Early Effects of Prolonged Cardiac Arrest and Ischemic Postconditioning during Cardiopulmonary Resuscitation on Cardiac and Brain Mitochondrial Function in Pigs. | Out-of-hospital cardiac arrest (CA) is a prevalent medical crisis resulting in severe injury to the heart and brain and an overall survival of less than 10%. Mitochondrial dysfunction is predicted to be a key determinant of poor outcomes following prolonged CA. However, the onset and severity of mitochondrial dysfunction during CA and cardiopulmonary resuscitation (CPR) is not fully understood. Ischemic postconditioning (IPC), controlled pauses during the initiation of CPR, has been shown to improve cardiac function and neurologically favorable outcomes after 15min of CA. We tested the hypothesis that mitochondrial dysfunction develops during prolonged CA and can be rescued with IPC during CPR (IPC-CPR).</AbstractText>A total of 63 swine were randomized to no ischemia (Naïve), 19min of ventricular fibrillation (VF) CA without CPR (Untreated VF), or 15min of CA with 4min of reperfusion with either standard CPR (S-CPR) or IPC-CPR. Mitochondria were isolated from the heart and brain to quantify respiration, rate of ATP synthesis, and calcium retention capacity (CRC). Reactive oxygen species (ROS) production was quantified from fresh frozen heart and brain tissue.</AbstractText>Compared to Naïve, Untreated VF induced cardiac and brain ROS overproduction concurrent with decreased mitochondrial respiratory coupling and CRC, as well as decreased cardiac ATP synthesis. Compared to Untreated VF, S-CPR attenuated brain ROS overproduction but had no other effect on mitochondrial function in the heart or brain. Compared to Untreated VF, IPC-CPR improved cardiac mitochondrial respiratory coupling and rate of ATP synthesis, and decreased ROS overproduction in the heart and brain.</AbstractText>Fifteen minutes of VF CA results in diminished mitochondrial respiration, ATP synthesis, CRC, and increased ROS production in the heart and brain. IPC-CPR attenuates cardiac mitochondrial dysfunction caused by prolonged VF CA after only 4min of reperfusion, suggesting that IPC-CPR is an effective intervention to reduce cardiac injury. However, reperfusion with both CPR methods had limited effect on mitochondrial function in the brain, emphasizing an important physiological divergence in post-arrest recovery between those two vital organs.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,624 | Prevalence and Predictors of Early Heart Failure With Preserved Ejection Fraction in Patients With Paroxysmal Atrial Fibrillation. | Patients with atrial fibrillation (AF) have an increased risk of diastolic dysfunction and heart failure. The purpose of this study was to identify independent predictors of early (ie, only exercise-induced) heart failure with preserved ejection fraction (HFpEF) and to describe the prevalence of early HFpEF among patients with paroxysmal AF.</AbstractText>One hundred patients with paroxysmal AF and preserved left ventricular ejection fraction (LVEF) underwent catheterization for left atrial pressure (LAP) measurements at rest and at the peak of arm exercise (LAP-exe). Based on resting and exercise LAP values, the patients were divided into 3 groups. Sixty-one patients had no evidence of HFpEF (LAP at rest ≤15 mm Hg, LAP-exe <25 mm Hg). Twenty-five subjects had early HFpEF (LAP at rest ≤15 mm Hg, LAP-exe ≥25 mm Hg, prevalence 25%). Fourteen patients already had HFpEF at rest (LAP at rest >15 mm Hg). Multivariate exact logistic regression analysis identified age ≥58 years, LAP at rest ≥11 mm Hg, and peak systolic mitral annular velocity ≤9.3 cm/s to be independent predictors of early HFpEF.</AbstractText>In patients with paroxysmal AF and preserved LVEF, there appears to be a clinically significant prevalence of early HFpEF.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,625 | Effect of CPAP on diastolic function in coronary artery disease patients with nonsleepy obstructive sleep apnea: A randomized controlled trial. | Obstructive sleep apnea (OSA) has been associated with worse diastolic function in patients with coronary artery disease (CAD). This analysis determined whether continuous positive airway pressure (CPAP) treatment would improve diastolic function in CAD patients with nonsleepy OSA.</AbstractText>Between December 2005 and November 2010, 244 revascularized CAD patients with nonsleepy OSA (apnea-hypopnea index (AHI) ≥15/h, Epworth Sleepiness Scale [ESS] score<10) were randomly assigned to CPAP or no-CPAP. Echocardiographic measurements were obtained at baseline, and after 3 and 12months.</AbstractText>A total of 171 patients with preserved left ventricular ejection fraction (≥50%), no atrial fibrillation or severe valve abnormalities, and technically adequate echocardiograms at baseline and follow-up visits were included (CPAP, n=87; no-CPAP, n=84). In the intention-to-treat analysis, CPAP had no significant effect on echocardiographic parameters of mild (enlarged left atrium or decreased diastolic relaxation velocity) or worse (increased E/é filling index [presumed elevated left ventricular filling pressure]) diastolic function. Post-hoc analysis revealed a significant association between CPAP usage for ≥4h/night and an increase in diastolic relaxation velocity at 12months' follow-up (odds ratio 2.3, 95% confidence interval 1.0-4.9; p=0.039) after adjustment for age, sex, body mass index, and left atrium diameter at baseline.</AbstractText>CPAP did not improve diastolic dysfunction in CAD patients with nonsleepy OSA. However, good CPAP adherence was significantly associated with an increase in diastolic relaxation velocity after one year.</AbstractText>Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.</CopyrightInformation> |
20,626 | Global Bi-ventricular endocardial distribution of activation rate during long duration ventricular fibrillation in normal and heart failure canines. | The objective of this study was to detect differences in the distribution of the left and right ventricle (LV & RV) activation rate (AR) during short-duration ventricular fibrillation (SDVF, <1 min) and long-duration ventricular fibrillation VF (LDVF, >1 min) in normal and heart failure (HF) canine hearts.</AbstractText>Ventricular fibrillation (VF) was electrically induced in six healthy dogs (control group) and six dogs with right ventricular pacing-induced congestive HF (HF group). Two 64-electrode basket catheters deployed in the LV and RV were used for global endocardium electrical mapping. The AR of VF was estimated by fast Fourier transform analysis from each electrode.</AbstractText>In the control group, the LV was activated faster than the RV in the first 20 s, after which there was no detectable difference in the AR between them. When analyzing the distribution of the AR within the bi-ventricles at 3 min of LDVF, the posterior LV was activated fastest, while the anterior was slowest. In the HF group, a detectable AR gradient existed between the two ventricles within 3 min of VF, with the LV activating more quickly than the RV. When analyzing the distribution of the AR within the bi-ventricles at 3 min of LDVF, the septum of the LV was activated fastest, while the anterior was activated slowest.</AbstractText>A global bi-ventricular endocardial AR gradient existed within the first 20 s of VF but disappeared in the LDVF in healthy hearts. However, the AR gradient was always observed in both SDVF and LDVF in HF hearts. The findings of this study suggest that LDVF in HF hearts can be maintained differently from normal hearts, which accordingly should lead to the development of different management strategies for LDVF resuscitation.</AbstractText> |
20,627 | Left atrial ball thrombus after edge-to-edge mitral valve repair. | A thrombus can develop in the left atrium during atrial fibrillation because the loss of contractile function leads to blood flow stasis. Anticoagulation therapy is indicated for prevention of systemic embolism, usually maintaining an international normalized ratio between 2 and 3. Rarely a massive thrombosis develops in the atrium resulting in a peduncolated ball valve thrombus or in a free-floating thrombus. These two conditions are characterized by variables in the physical findings. Such masses are hazardous and upon discovery surgical treatment, often in emergency, is mandatory. We present here the case of a patient who developed an unnoticed huge left atrial ball thrombus despite warfarin therapy after previous mitral valve surgery. <<b>Learning objective:</b> Risk of atrial thrombosis threatens patients suffering from atrial fibrillation. The presence of a ring and a modified valve anatomy following a surgical repair could represent an additional drive in the thrombus formation pathway. A free-floating ball thrombus in the left atrium is an unusual occurrence that may cause fatal systemic emboli or left ventricular inflow obstruction, often resulting in sudden death. In such cases, even in the absence of symptoms, prompt surgical excision is recommended.>. |
20,628 | Recurrent Ventricular Tachycardia Due to Long QT Syndrome. | Long QT syndrome (LQTS) is a rare inherited heart condition in which delayed repolarization of the heart following a heartbeat, increases the risk of episodes of Torsades de pointes (TdP, a form of irregular heartbeat that originates from the ventricles). These episodes may lead to palpitations, fainting, and sudden death due to ventricular fibrillation. Episodes may be provoked by various stimuli, depending on the subtype of the condition. We are reporting a case of 37 years old male whom we diagnosed to have long QT syndrome on the basis of clinical and ECG findings. |
20,629 | Effects of Mild Hypothermia on Cerebral Large and Small Microvessels Blood Flow in a Porcine Model of Cardiac Arrest. | The effect of mild hypothermia (MH) on microcirculation after resuscitation from cardiac arrest is controversial. The aim of this study was to determine whether MH improves or aggravates the disturbance of cerebral microcirculation.</AbstractText>Twenty domestic male pigs were randomized into the MH group (n = 8), non-hypothermia (NH) group (n = 8) or sham operation group (n = 4). In the MH group, the animals were initiated rapid intravascular cooling at 1 h after return of spontaneous circulation (ROSC) from 8 min ventricular fibrillation, and the core temperature was reduced to 33 °C for 12 h and then rewarmed to 37 °C. In the NH group, animals did not receive hypothermia treatment after ROSC. In the sham operation group, the same surgical procedure was performed, but without inducing ventricular fibrillation and hypothermia treatment. The cerebral microvascular flow index (MFI) of large microvessel (diameter > 20 μm) and small microvessel (diameter < 20 μm) was measured after ROSC. Cerebral oxygen extraction ratio, internal jugular venous-artery lactate difference, and CO2</sub> difference were also calculated.</AbstractText>Cerebral MFI dramatically reduced after ROSC, and MH further aggravated the decrease in MFI of small microvessel compared with NH (p < 0.05). Internal jugular venous-arterial lactate difference and CO2</sub> difference, and oxygen extraction ratio were all significantly increased after ROSC. MH significantly decreased the values compared with NH (p < 0.05).</AbstractText>MH decreases cerebral small microvessel blood flow and cerebral metabolism after ROSC compared with NH. However, the total effect is that cerebral oxygen supply-demand relationship is improved during hypothermia.</AbstractText> |
20,630 | Mechanisms of vortices termination in the cardiac muscle. | We propose a solution to a long-standing problem: how to terminate multiple vortices in the heart, when the locations of their cores and their critical time windows are unknown. We scan the phases of all pinned vortices in parallel with electric field pulses (E-pulses). We specify a condition on pacing parameters that guarantees termination of one vortex. For more than one vortex with significantly different frequencies, the success of scanning depends on chance, and all vortices are terminated with a success rate of less than one. We found that a similar mechanism terminates also a free (not pinned) vortex. A series of about 500 experiments with termination of ventricular fibrillation by E-pulses in pig isolated hearts is evidence that pinned vortices, hidden from direct observation, are significant in fibrillation. These results form a physical basis needed for the creation of new effective low energy defibrillation methods based on the termination of vortices underlying fibrillation. |
20,631 | Inappropriate implantable cardioverter-defibrillator shocks in Brugada syndrome: Pattern in primary and secondary prevention. | Inappropriate implantable cardioverter-defibrillator (ICD) shocks is a common complication in Brugada syndrome. However, the incidence in recipients of ICD for primary and secondary prevention is unknown.</AbstractText>We compared the rate of inappropriate shocks in patients with Brugada syndrome that had an ICD for primary and secondary prevention. We studied 51 patients, 86.5% of whom were males. Their mean age at diagnosis was 47 ± 11 years. Eighteen (35%) were asymptomatic, while 25 (49%) experienced syncope prior to implantation. Eight (16%) patients were resuscitated from ventricular fibrillation before implantation. During a mean follow-up of 78 ± 46 months, none of the asymptomatic patients experienced appropriate therapy, whereas 21.6% of symptomatic patients had ≥1 shock. Inappropriate shock occurred in 7 (13.7%) patients, with a mean IS of 6.57 ± 6.94 shocks per patient occurring 16.14 ± 10.38 months after implantation. There was a trend towards higher incidence of inappropriate shock in the asymptomatic group (p = 0.09). The interval from implantation to inappropriate shock occurrence was 13.91 ± 12.98 months. The risk of IS at 3 years was 13.7%, which eventually plateaued over the time.</AbstractText>Inappropriate shock is common in Brugada syndrome during the early periods after an ICD implantation, and seems to be more likely in asymptomatic patients. This finding may warrant a review of the indications for ICD implantation, especially in the young and apparently healthy population of patients with Brugada syndrome.</AbstractText>Copyright © 2016 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,632 | Prognosis associated with redo cardiac resynchronization therapy following complete device and lead extraction due to device-related infection. | An increase in the number of cardiac resynchronization therapy (CRT) device implantations worldwide has led to a consequent increase in the number of infections associated with the device, making extraction of the CRT device inevitable. Redo CRT implantation after treatment and recovery following device extraction is challenging. This study aimed to evaluate the success rate, complications, and long-term prognosis of redo CRT implantation, including the rates of subclavian, cava, and coronary sinus (CS) vein thrombosis as well as re-infection.</AbstractText>Between 2007 and 2014, 1712 lead extractions were performed in 537 patients with device-related infection at Heart Center Brandenburg. Of the 537 patients, 125 (23%) underwent CRT device and lead extraction, including extraction of the left ventricular lead from the coronary sinus. Of these 125, 62 (50%) patients underwent redo CRT implantation (mean age, 68 ± 10 years); 34 patients had coronary artery disease (CAD) while 28 had dilated cardiomyopathy (DCM). The mean left ventricular ejection fraction was 27% ± 7%. The mean QRS duration of the left bundle branch block was 158 (range, 147-162) ms, and 25 patients had atrial fibrillation (AF). All these patients were followed up for a median duration of 29.6 (range, 15-43) months. In 53 of the 62 patients (85%), the CRT system was successfully re-implanted; however, the original CS vein could be used again only in 28 (45%) patients. The all-cause mortality rate was 7.1% after 1 year, and it was significantly higher in patients whose N-terminal pro B-type natriuretic peptide level was  ≥3,000 pg/mL (P < 0.001), those who were aged  ≥64 years (P = 0.028), those who had CAD (P = 0.042) or chronic kidney insufficiency (P = 0.001), those with AF (P = 0.001) and those whose blood cultures were positive for Staphylococcus aureus (P = 0.014).</AbstractText>Redo CRT implantation after device extraction owing to device-related infection has a low success rate and shows a higher rate of re-infection than that observed in patients who undergo CRT implantation for the first time. Further, patients whose blood cultures are positive for S. aureus show a particularly poor outcome.</AbstractText> |
20,633 | The prognostic benefit of cardiac resynchronization therapy is greater in concordant vs. discordant left bundle branch block in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT). | Discordant and concordant left bundle branch block (dLBBB/cLBBB) are characterized by negative or positive T waves, respectively, in lateral leads. We assessed if the two morphologies are associated with different clinical status and prognosis in patients with heart failure (HF) and current indication to Cardiac Resynchronization Therapy (CRT)/CRT-Defibrillator (CRT-D).</AbstractText>Baseline electrocardiograms of 1270 patients with LBBB in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy cohort were analysed to identify dLBBB and cLBBB. The two groups were compared with respect to baseline clinical characteristics, primary endpoint (HF event or death), and secondary endpoint (ventricular tachycardia, ventricular fibrillation, or death) over a 3.5-year period, and benefit of CRT-D over implantable cardioverter defibrillator (ICD). dLBBB was identified in 909 (72%) patients, and cLBBB in 361 (28%). Patients with dLBBB were older, had more severe symptoms and systolic dysfunction, as well as higher brain natriuretic peptide. CRT-D was superior to ICD in patients with both LBBB morphologies. The occurrence of the primary outcome was significantly more frequent in patients with dLBBB than in those with cLBBB, both in the entire cohort (P = 0.005), and in the CRT-D arm (P = 0.002). There was a trend towards more frequent occurrence of the secondary endpoint in patients with dLBBB than in those with cLBBB, but statistical significance was not reached in the whole population or in the subgroup undergoing CRT-D. Among patients receiving CRT-D, dLBBB was an independent predictor of the primary endpoint.</AbstractText>dLBBB morphology is associated with more severe HF clinical status and worse prognosis, even in patients receiving CRT-D, compared with cLBBB morphology.</AbstractText> |
20,634 | [Digitalis, a drug to be scrapped?]. | We performed a comprehensive review of the scientific literature on the use of digoxin in heart failure and atrial fibrillation. In congestive heart failure (CHF) there is only one randomized trial with a statistical sample sufficiently large. In this trial (DIG trial), which enrolled patients with systolic left ventricular dysfunction in sinus rhythm, digoxin had a neutral action on mortality and modestly reduced the overall need of hospitalization. The study was conducted in the pre-beta-blocker era and, therefore, it has a doubtful application to the current clinical context. There are no randomized trials on atrial fibrillation, either with or without heart failure. Several observational and retrospective studies and meta-analysis have shown an association between the use of digoxin and increased mortality about 20%. Both in the European and American guidelines, even in class I recommendations, evidence is not supported by randomized or observational trials, but just by experts' opinions. Digoxin use in CHF and atrial fibrillation is related to the physician's clinical judgment, based more on consolidated custom that on established scientific evidence. In our opinion, this therapy should be withdrawn until new randomized controlled trials will provide evidence of its efficacy. Two trials have been planned to this aim. Also the issue of toxicity threshold is still unresolved; digoxinemia values should be <1 ng/ml if digoxin is used, to avoid overdosing and toxicity with increased mortality. |
20,635 | Epidemiology, anatomy, pathophysiology and clinical evaluation of functional tricuspid regurgitation. | Tricuspid regurgitation (TR) is commonly encountered in the management of patients with a variety of cardiovascular diseases. Primary TR is the result of structural abnormalities of the valve or chordal attachments whereas functional TR results from alterations in right ventricular (RV) or right atrial (RA) size, shape or function. The vast majority of TR cases seen in practice are functional in nature and usually results from left-sided heart disease (e.g., mitral valve disease, left ventricular (LV) systolic dysfunction) and/or pulmonary vascular disease, though it also manifests in the presence of isolated chronic atrial fibrillation (AF). The relationships among the tricuspid leaflets, annulus, chordal attachments and papillary muscles are critical to normal valve function. Disruption of these interactions through annular dilation and apical displacement of the papillary muscles underlies the pathophysiology of functional TR. Two-dimensional transthoracic echocardiography (2D-TTE) is the primary modality used to assess TR. In situations where 2D-TEE is limited, 3D-TTE and transesophageal echocardiography (TEE), multidetector computed tomography (CT) and cardiac magnetic resonance imaging (MRI) can provide additional information. Classification schemes have been proposed that focus not only on the severity of TR, but also on annular dilation and the mode of leaflet coaptation. Despite often being referred to as the "forgotten valve," there is increasing evidence that functional TR is prognostically significant and may warrant intervention. Appropriate patient selection for and timing of intervention are important clinical tasks that require a comprehensive understanding of the pathophysiology and natural history of functional TR. |
20,636 | Life-threatening and life-saving inappropriate implantable cardioverter defibrillator shocks. | An implantable cardioverter defibrillator (ICD) lead dislodgement into the right atrium is a dangerous situation, particularly in patients in atrial fibrillation because atrial fibrillation can be sensed as ventricular fibrillation and true ventricular fibrillation induced with an inappropriate shock. In the presence of shocks, ICD interrogation should be performed as soon as possible. |
20,637 | Dobutamine Stress Echocardiography: Impact of Abnormal Blood Potassium Levels on Cardiac Arrhythmias. | Guidelines suggest that an abnormal blood potassium level is a relative contraindication to performing dobutamine stress echocardiography (DSE). However, this has not been previously studied.</AbstractText>We reviewed a consecutive series of patients who had potassium testing within 48 hours of undergoing DSE for the evaluation of myocardial ischemia over a 10-year period (N = 13,198). Normal potassium range in our laboratory is 3.6-5.2 mmol/L. Hemolyzed samples were not included. The association of potassium levels with the development of supraventricular and ventricular arrhythmias was assessed.</AbstractText>The incidence of clinically significant arrhythmias was very low (supraventricular tachycardia/atrial fibrillation, 4.9%; nonsustained ventricular tachycardia, 2.9%; sustained ventricular tachycardia or ventricular fibrillation, 0.1%), confirming the overall safety of DSE. Most arrhythmias (88%) occurred in patients with normal potassium levels, and arrhythmia rates remained low in patients with potassium abnormalities. Patients with hyperkalemia had a lower risk of developing mild (odds ratio [OR], 0.39; 95% CI, 0.22-0.71) and severe (OR, 0.13; 95% CI, 0.01-0.68) supraventricular arrhythmias as well as mild ventricular arrhythmias (OR, 0.58; 95% CI, 0.40-0.83). Even though events were rare, patients with severe hypokalemia (potassium levels ≤ 3.1 mmol/L) had an increased risk of supraventricular arrhythmia and ventricular ectopy.</AbstractText>DSE is safe even in the setting of abnormalities in blood potassium concentrations, and hence cancellation of DSE in patients with potassium abnormalities does not appear warranted. Elevated potassium levels are associated with lower rates of clinically significant supraventricular and ventricular arrhythmias. While remaining at relatively low risk, patients with very low potassium levels (≤3.1 mmol/L) at the time of DSE have a modestly increased risk of arrhythmia. Consideration could be given to correcting severe hypokalemia prior to DSE.</AbstractText>Copyright © 2017 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,638 | Comparison of Levosimendan versus Dobutamine in Patients with Moderate to Severe Left Ventricular Dysfunction Undergoing Off-pump Coronary Artery Bypass Grafting: A Randomized Prospective Study. | Recent upsurge in referral of patients with compromised left ventricular (LV) function for cardiac surgery has led to an increasing use inotropes to achieve improvement of tissue perfusion in the perioperative period.</AbstractText>To compare the hemodynamic effects and immediate postoperative outcomes with levosimendan and dobutamine in patients with moderate to severe LV dysfunction undergoing off-pump coronary artery bypass grafting (OPCAB).</AbstractText>University teaching hospital, randomized control study.</AbstractText>Eighty patients were randomly divided into two groups of 40 each. Group I received levosimendan at 0.1 μg/kg/min and Group II received dobutamine at 5 μg/kg/min. Hemodynamic data were noted at 30 min, during obtuse marginal grafting, 1, 6, 12, and 24 h after surgery. Heart rate (HR), mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), systemic vascular resistance index (SVRI) and pulmonary vascular resistance index (PVRI), left ventricular stroke work index (LVSWI) and right ventricular stroke work index (RVSWI), mixed venous oximetry (SvO2), and lactate were measured.</AbstractText>Chi-square and Student's t-test.</AbstractText>The HR, MAP, PCWP, SVRI, and PVRI were lower in Group I when compared to Group II. Group I patients showed a statistically significant increase in LVSWI, RVSWI, and CI, when compared to Group II. Comparatively, Group I patients maintained higher SvO2and lower lactate levels. Duration of ventilation, Intensive Care Unit (ICU), and hospital stay were lower in Group I.</AbstractText>Levosimendan was associated with statistically significant increase in indices of contractility (CI, LVSWI, and RVSWI) and decrease in PCWP during and after OPCAB. Levosimendan group had lower incidence of atrial fibrillation, shorter length of ICU, and hospital stay.</AbstractText> |
20,639 | Prognostic impact of heart rate in elderly with systolic heart failure and concomitant atrial fibrillation. | The present study aimed to investigate the impact of resting heart rate (HR) on 5-year all-cause mortality in patients ≥80 years with heart failure (HF) with reduced ejection fraction (HFrEF) and concomitant atrial fibrillation (AF) after optimal up-titration of beta-blockers (BBs).</AbstractText>Patients (n = 185) aged ≥80 years with HF and left ventricular ejection fraction ≤40% were included between January 2000 and January 2008 from two university hospitals, Sahlgrenska and Östra and retrospectively studied from January 2 to May 30, 2013. Up-titrations of guideline recommended medications were performed at HF outpatient clinics.</AbstractText>Of whole study population, 54% (n= 100) had AF. After optimal up-titration of BBs and angiotensin converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), mean HR in patients with AF was 73 ± 15 beats/minute (bpm), 36% had resting HR ≤65 bpm. Five-year all-cause mortality among patients with AF was significantly lower in patients with HR ≤65 bpm (63%) compared to HR >65 (80%). Cox proportional-hazard regression analysis adjusted for clinically important baseline variables and doses of ACEIs/ARBs and BBs demonstrated resting HR ≤65 bpm as an independent predictor of improved survival compared to resting HR >65 bpm (HR 0.3, 95%CI 0.1-0.7, P 0.005).</AbstractText>In octogenarians with HFrEF and concomitant AF, lowering resting HR to levels as low as HR ≤65 bpm was still associated with improved survival from all-cause mortality. Our data indicate that mortality in AF became comparable to SR when patients were on maximally up-titrated beta-blocker doses with HR as low as 75 bpm.</AbstractText> |
20,640 | The role of the autonomic nervous system in arrhythmias and sudden cardiac death. | The autonomic nervous system (ANS) is complex and plays an important role in cardiac arrhythmia pathogenesis. A deeper understanding of the anatomy and development of the ANS has shed light on its involvement in cardiac arrhythmias. Alterations in levels of Sema-3a and NGF, both growth factors involved in innervation patterning during development of the ANS, leads to cardiac arrhythmias. Dysregulation of the ANS, including polymorphisms in genes involved in ANS development, have been implicated in sudden infant death syndrome. Disruptions in the sympathetic and/or parasympathetic systems of the ANS can lead to cardiac arrhythmias and can vary depending on the type of arrhythmia. Simultaneous stimulation of both the sympathetic and parasympathetic systems is thought to lead to atrial fibrillation whereas increased sympathetic stimulation is thought to lead to ventricular fibrillation or ventricular tachycardia. In inherited arrhythmia syndromes, such as Long QT and Catecholaminergic Polymorphic Ventricular Tachycardia, sympathetic system stimulation is thought to lead to ventricular tachycardia, subsequent arrhythmias, and in severe cases, cardiac death. On the other hand, arrhythmic events in Brugada Syndrome have been associated with periods of high parasympathetic tone. Increasing evidence suggests that modulation of the ANS as a therapeutic strategy in the treatment of cardiac arrhythmias is safe and effective. Further studies investigating the involvement of the ANS in arrhythmia pathogenesis and its modulation for the treatment of cardiac arrhythmias is warranted. |
20,641 | Association of air pollution with increased incidence of ventricular tachyarrhythmias recorded by implantable cardioverter defibrillators: Vulnerable patients to air pollution. | This study investigated the acute effects of exposure to air pollution on ventricular tachyarrhythmias (VTAs) in an East Asian population. The association between air pollution and VTA has not yet been studied in an East Asian country affected by the Asian dust phenomenon, which worsens air quality.</AbstractText>The study cohort consisted of 160patients with implantable cardioverter defibrillator (ICD) devices in the Seoul metropolitan area who were followed for 5.5±3.8years. We used ICD records of VTAs and matched these with hourly measurements of air pollutant concentrations and meteorological data. Fine particle mass and gaseous air pollution plus temperature and relative humidity were measured hourly during the study period.</AbstractText>During the study period, 1064 VTA events including 204 instances of ventricular fibrillation (VF) were observed. We found a statistically significant association between overall VTA events and SO2</sub> (lag 24h; OR 1.49, 95%CI 1.16-1.92, p=0.002), PM10</sub> (lag 2h; OR 2.56, 95%CI 2.03-3.23, p<0.001), NO2</sub> (lag 24h; OR 1.25, 95%CI 1.19-1.31, p<0.001) and CO (lag 24h; OR 1.05, 95%CI 1.02-1.08, p=0.003). Sustained ventricular tachycardia or VF was also independently associated with SO2</sub>, PM10</sub>, NO2</sub> and CO (all p<0.01). Exposures to SO2</sub>, PM10</sub>, NO2</sub>, and CO (all p<0.01) were significantly related to overall VTAs, especially in patients with structural heart disease (SHD).</AbstractText>Associations between air pollution and VTA were observed in a metropolitan area of an East Asian country. Exposures to SO2</sub>, PM10</sub>, NO2</sub>, and CO were significantly associated with VTAs in ICD patients with SHD.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,642 | Myotonic dystrophy and Brugada syndrome: A common pathophysiologic pathway? | Type 1 myotonic dystrophy (DM1) is a hereditary neuromuscular disease affecting multiple organs in human adults. Here we report a 42-year-old man diagnosed with DM1. Having a history of progressive muscular weakness and gradual loss of visual acuity, he was referred to us by his ophthalmologist for risk assessment of undergoing cataract surgery. Cardiology workup revealed type 1 Brugada ECG pattern, positive late potentials and inducible ventricular fibrillation in an electrophysiology study. Literature review revealed that those ECG changes may be observed in DM1, suggesting that DM1 and Brugada syndrome may share a common pathophysiologic pathway. |
20,643 | [Analysis of arrhythmia and recovering in early stage pregnancy of older pregnant women]. | To observe the abnormality of the electrocardiogram (ECG) and the characteristics of arrhythmia in the early stage of older pregnant women and to record the late outcome of atrial and ventricular arrhythmia.</AbstractText>Two hundrend and ninty pregnant women were divided into 3 groups by age under 35 group, 35~39 group and 40~45 group. The ECG waveform was analyzed systematically when the patients were subjected to routine ECG examination and abnormal changes of ECG were collected and recorded, including ST segment changes, various arrhythmias, etc. Then the recovery and deterioration rate of atrial, ventricular arrhythmia was recorded.</AbstractText>The incidence of arrhythmia in 35~39 group and 40~45 group was significantly higher than under 35 group (P</i><0.05); the incidence of abnormal ST section in 35~39 group and 40~45 group was significantly higher than under 35 group(P</i><0.05); and the incidence of widened QRS wave in 40~45 group was higher than under 35 group (P</i><0.05). The incidence of sinus tachycardia, sinus irregularityand atrial premature beats in 35~39 group and 40~45 group was obviously lower than that under 35 group (P</i><0.05); the incidence of Paroxysmal supraventricular tachycardia in 40~45 group was obviously higher than under 35 group (P</i><0.05) and the incidence of ventricular premature beat and atrial fibrillation in 35~39 group and 40~45 group was significantly higher than under 35 group (P</i><0.05). The recovery rate of atrial arrhythmia in 40~45 group was obviously lower than under 35 group (P</i><0.05);the exacerbation rate of trial and ventricular arrhythmia in 40~45 group was obviously higher than over 35 group (P</i><0.05). The incidences of IUGR in 35~39 group and 40~45 group with abnormal ECG was obviously higher than under 35 group and 35~39 group with normal ECG; The incidences of fetal distress in 35~39 year-old group and 40~45 year-old group with abnormal ECG was obviously higher than under 35 group(P</i><0.05).</AbstractText>There is a positive correlation between the old age and the incidence of arrhythmia in the early stage of pregnancy, and old age factors can reduce the recovery rate but increase the incidence of deterioration of arrhythmia. And older pregnant women with abnormal ECG have undesirable effect to perinatal infant.</AbstractText> |
20,644 | Clinical decision tool for CRT-P vs. CRT-D implantation: Findings from PROSE-ICD. | Cardiac resynchronization therapy (CRT) devices reduce mortality through pacing-induced cardiac resynchronization and implantable cardioverter defibrillator (ICD) therapy for ventricular arrhythmias (VAs). Whether certain factors can predict if patients will benefit more from implantation of CRT pacemakers (CRT-P) or CRT defibrillators (CRT-D) remains unclear.</AbstractText>We followed 305 primary prevention CRT-D recipients for the two primary outcomes of HF hospitalization and ICD therapy for VAs. Serum biomarkers, electrocardiographic and clinical variables were collected prior to implant. Multivariable analysis using Cox-proportional hazards model was used to fit the final models. Among 282 patients with follow-up outcome data, 75 (26.6%) were hospitalized for HF and 31 (11%) received appropriate ICD therapy. Independent predictors of HF hospitalization were atrial fibrillation (HR = 1.8 (1.1,2.9)), NYHA class III/IV (HR = 2.2 (1.3,3.6)), ejection fraction <20% (HR = 1.7 (1.1,2.7)), HS-IL6 >4.03pg/ml (HR = 1.7 (1.1,2.9)) and hemoglobin (<12g/dl) (HR = 2.2 (1.3,3.6)). Independent predictors of appropriate therapy included BUN >20mg/dL (HR = 3.0 (1.3,7.1)), HS-CRP >9.42mg/L (HR = 2.3 (1.1,4.7)), no beta blocker therapy (HR = 3.2 (1.4,7.1)) and hematocrit ≥38% (HR = 2.7 (1.03,7.0)). Patients with 0-1 risk factors for appropriate therapy (IR 1 per 100 person-years) and ≥3 risk factors for HF hospitalization (IR 23 per 100-person-years) were more likely to die prior to receiving an appropriate ICD therapy.</AbstractText>Clinical and biomarker data can risk stratify CRT patients for HF progression and VAs. These findings may help characterize subgroups of patients that may benefit more from the use of CRT-P vs. CRT-D systems.</AbstractText>ClinicalTrials.gov NCT00733590.</AbstractText> |
20,645 | Is echocardiography valid and reproducible in patients with atrial fibrillation? A systematic review. | Echocardiography is vital in the routine assessment and management of atrial fibrillation (AF). We performed a systematic review of the validity and reproducibility of echocardiographic left ventricular systolic and diastolic function in AF, and optimal acquisition methods.</AbstractText>Online databases were searched for studies in patients with AF at the time of echocardiography (1960 to August 2015), prospectively registered with PROSPERO (CRD42015025297). The systematic review included 32 studies from 3 066 search results (1 968 patients with AF). Average age was 67 years, 33% were women, mean LVEF 53% (±10%), and average E/e' 11.7 (±2.7). Data on the validity and reproducibility of systolic indices were extremely limited. In contrast, diastolic parameters demonstrated correlation with invasive filling pressure and adequate reproducibility: E/e' (n = 444) r = 0.47 to 0.79; IVRT (n = 177) r = -0.70 to -0.95; E/Vp` (n = 55) r = 0.63 and 0.65; pulmonary vein diastolic flow (n = 67) r = -0.80 and -0.91. Elevated E/e' (>15) was associated with functional capacity, quality of life, and impaired prognosis. For optimal acquisition in AF patients, cardiac cycles with controlled heart rate (<100 beats/min) and similar preceding and pre-preceding RR intervals are required. Cardiac cycle length and equivalence were more important than the number of beats averaged.</AbstractText>With careful selection of appropriate cardiac cycles, echocardiography is a valid tool to identify diastolic dysfunction in AF, and E/e' is an independent marker of clinical status and adverse prognosis. However, data on systolic function was extremely limited and requires further prospective study and assessment of variability in clinical practice.</AbstractText>© The Author 2017. Published on behalf of the European Society of Cardiology.</CopyrightInformation> |
20,646 | Long-term prognosis of patients with life-threatening ventricular arrhythmias induced by coronary artery spasm. | Coronary artery spasm (CAS) is associated with ventricular arrhythmias (VA). Much controversy remains regarding the best therapeutic interventions for this specific patient subset. We aimed to evaluate the clinical outcomes of patients with a history of life-threatening VA due to CAS with various medical interventions, as well as the need for ICD placement in the setting of optimal medical therapy.</AbstractText>A multicentre European retrospective survey of patients with VA in the setting of CAS was aggregated and relevant clinical and demographic data was analysed. Forty-nine appropriate patients were identified: 43 (87.8%) presented with VF and 6 (12.2%) with rapid VT. ICD implantation was performed in 44 (89.8%). During follow-up [59 (17-117) months], appropriate ICD shocks were documented in 12. In 8/12 (66.6%) no more ICD therapies were recorded after optimizing calcium channel blocker (CCB) therapy. SCD occurred in one patient without ICD. Treatment with beta-blockers was predictive of appropriate device discharge. Conversely, non-dihydropyridine CCB therapy was significantly protective against VAs.</AbstractText>Patients with life-threatening VAs secondary to CAS are at particularly high-risk for recurrence, especially when insufficient medical therapy is administered. Non-dihydropyridine CCBs are capable of suppressing episodes, whereas beta-blocker treatment is predictive of VAs. Ultimately, in spite of medical intervention, some patients exhibited arrhythmogenic events in the long-term, suggesting that ICD implantation may still be indicated for all.</AbstractText> |
20,647 | Arrhythmogenic effects of energy drinks. | Energy drinks (ED) are increasingly popular, especially among adolescents and young adults. They are marketed as enhancers of energy, alertness, and physical performance. ED contain high doses of caffeine and other active ingredients. Their safety has come under question due to reports temporally linking ED consumption with serious cardiovascular events, including arrhythmias and sudden cardiac death. In this article, we report 2 cases of life-threatening ventricular arrhythmias in young patients after consuming ED. We also review the ingredients of ED, the physiologic effects on the cardiovascular system, and the available evidence suggesting arrhythmogenecity. |
20,648 | Non-invasive measurement of right atrial pressure by near-infrared spectroscopy: preliminary experience. A report from the SICA-HF study. | To assess the clinical value of measuring right atrial pressure (RAP) using near-infrared spectroscopy (NIRS) in patients with chronic heart failure (CHF).</AbstractText>RAP was measured non-invasively using NIRS over the external jugular vein (Venus 1000, Mespere LifeSciences, Canada) in ambulatory patients with CHF enrolled in the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF) programme. Comparing 243 patients with CHF (mean age 71 years; mean left ventricular ejection fraction (LVEF) 45%, median NT-proBNP 788 ng/L) to 49 controls (NT-proBNP ≤125 ng/L), RAP was 7 [interquartile range (IQR) 4-11] mmHg vs. 4 (IQR 3-8) mmHg (P < 0.001). Those with RAP ≥10 mmHg (n = 75) were older, had more severe clinical congestion and renal dysfunction, higher plasma NT-proBNP, larger left atrial volume, higher systolic pulmonary pressure and were more often in atrial fibrillation but their LVEF was similar to patients with lower RAP. During a median follow-up of 595 (IQR: 492-714) days, 49 patients (20%) died or were hospitalized for worsening CHF. Compared with patients with RAP ≤5 mmHg, those with RAP ≥10 mmHg had a greater risk of an event (hazard ratio 2.38, 95% confidence interval 1.19-4.75, P = 0.014). RAP measured by NIRS predicted outcome, competing with NT-proBNP in multivariable models.</AbstractText>Measuring RAP using NIRS identifies ambulatory patients with CHF who have more severe congestion and a worse outcome. The device might be a useful objective method of monitoring RAP, especially for those inexperienced in eliciting physical signs or when measurement of natriuretic peptides is not immediately available.</AbstractText>© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.</CopyrightInformation> |
20,649 | Epidemiology and one-year outcomes in patients with chronic heart failure and preserved, mid-range and reduced ejection fraction: an analysis of the ESC Heart Failure Long-Term Registry. | The objectives of the present study were to describe epidemiology and outcomes in ambulatory heart failure (HF) patients stratified by left ventricular ejection fraction (LVEF) and to identify predictors for mortality at 1 year in each group.</AbstractText>The European Society of Cardiology Heart Failure Long-Term Registry is a prospective, observational study collecting epidemiological information and 1-year follow-up data in 9134 HF patients. Patients were classified according to baseline LVEF into HF with reduced EF [EF <40% (HFrEF)], mid-range EF [EF 40-50% (HFmrEF)] and preserved EF [EF >50% (HFpEF)]. In comparison with HFpEF subjects, patients with HFrEF were younger (64 years vs. 69 years), more commonly male (78% vs. 52%), more likely to have an ischaemic aetiology (49% vs. 24%) and left bundle branch block (24% vs. 9%), but less likely to have hypertension (56% vs. 67%) or atrial fibrillation (18% vs. 32%). The HFmrEF group resembled the HFrEF group in some features, including age, gender and ischaemic aetiology, but had less left ventricular and atrial dilation. Mortality at 1 year differed significantly between HFrEF and HFpEF (8.8% vs. 6.3%); HFmrEF patients experienced intermediate rates (7.6%). Age, New York Heart Association (NYHA) class III/IV status and chronic kidney disease predicted mortality in all LVEF groups. Low systolic blood pressure and high heart rate were predictors for mortality in HFrEF and HFmrEF. A lower body mass index was independently associated with mortality in HFrEF and HFpEF patients. Atrial fibrillation predicted mortality in HFpEF patients.</AbstractText>Heart failure patients stratified according to different categories of LVEF represent diverse phenotypes of demography, clinical presentation, aetiology and outcomes at 1 year. Differences in predictors for mortality might improve risk stratification and management goals.</AbstractText>© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.</CopyrightInformation> |
20,650 | Acute Myocardial Infarction Due to Coronary Artery Embolism in a 22-Year-Old Woman with Mitral Stenosis with Atrial Fibrillation Under Warfarinization: Successful Management with Anticoagulation. | BACKGROUND Coronary artery embolization is an exceedingly rare cause of myocardial infarction, but a few cases in association with prosthetic mechanical valves have been reported. We report a case of embolic myocardial infarction caused by a thrombus in the left atrium with deranged coagulation profile in a patient with critical mitral stenosis under warfarinization. CASE REPORT A 22-year-old woman was taken to the catheterization lab for early coronary intervention in lieu of non-ST elevation myocardial infarction. Electrocardiography showed T↓ in V1 to V4, and atrial fibrillation with controlled ventricular rate. Coronary angiography showed total occlusion of the mid-left anterior descending artery with thrombus. After upstream treatment with tirofiban, the apparent thrombus was dislodged distally while passing a BMW wire. No abnormalities were seen by intravascular ultrasound study. Echocardiography revealed critical mitral stenosis, and left atrial clot with mild left ventricular dysfunction. Coagulation profile revealed sub-therapeutic international normalized ratio levels. The sequential angiographic images, normal intravascular ultrasound study, and presence of atrial fibrillation are confirmatory of coronary embolism as the cause of myocardial infarction. Anticoagulation and treatment of acute coronary syndrome were initiated and she was referred for closed mitral valvulotomy. CONCLUSIONS Coronary artery thromboembolism as a nonatherosclerotic cause of acute coronary syndrome is rare. The treatment consists of aggressive anticoagulation, antiplatelet therapy, and interventional options, including simple wiring when possible. In this context, primary prevention in the form of patient education on optimal anticoagulation with oral vitamin K antagonist and medical advice about imminent thromboembolic risks are of extreme importance. |
20,651 | Dieldrin Augments mTOR Signaling and Regulates Genes Associated with Cardiovascular Disease in the Adult Zebrafish Heart (<i>Danio rerio</i>). | Dieldrin is a legacy organochlorine pesticide that is persistent in the environment, despite being discontinued from use in North America since the 1970s. Some epidemiologic studies suggest that exposure to dieldrin is associated with increased risks of neurodegenerative disease and breast cancer by inducing inflammatory responses in tissues as well as oxidative stress. However, the direct effects of organochlorine pesticides on the heart have not been adequately addressed to date given that these chemicals are detectable in human serum and are environmentally persistent; thus, individuals may show latent adverse effects in the cardiovascular system due to long-term, low-dose exposure over time. Our objective was to determine whether low-level exposure to dieldrin at an environmentally relevant dose results in aberrant molecular signaling in the vertebrate heart. Using transcriptomic profiling and immunoblotting, we determined the global gene and targeted protein expression response to dieldrin treatment and show that dieldrin affects gene networks in the heart that are associated with processes related to cardiovascular disease, specifically cardiac arrest and ventricular fibrillation. We report that genes regulating inflammatory responses, a significant risk factor for cardiovascular disease, are upregulated by dieldrin whereas transcripts related to lysosomal function are significantly downregulated. To verify these findings, proteins in these pathways were examined with immunoblotting, and our results demonstrate that dieldrin constitutively activates Akt/mTOR signaling and downregulates lysosomal genes, participating in autophagy. Our data demonstrate that dieldrin induces genes associated with cardiovascular dysfunction and compromised lysosomal physiology, thereby identifying a novel mechanism for pesticide-induced cardiotoxicity. |
20,652 | Independent Risk Factors Contributing to Acute Kidney Injury According to Updated Valve Academic Research Consortium-2 Criteria After Transcatheter Aortic Valve Implantation: A Meta-analysis and Meta-regression of 13 Studies. | This study aimed to examine the risk factors for transcatheter aortic valve implantation (TAVI)-associated acute kidney injury (AKI) according to the AKI definition from the Valve Academic Research Consortium-2 (VARC-2).</AbstractText>A meta-analysis.</AbstractText>A total of 661 patients with post-TAVI AKI according to the VARC-2 definition and 2,012 controls were included in the meta-analysis.</AbstractText>Patients undergoing TAVI were included in this meta-analysis.</AbstractText>Multiple electronic databases were searched using predefined criteria. The diagnosis of AKI was based on the VARC-2 classification. The authors found that preoperative New York Heart Association class IV (odds ratio [OR], 7.77; 95% confidence interval [CI], 3.81-15.85), previous chronic renal disease (CKD) (OR, 2.81; 95% CI, 1.96-4.03), and requirement for transfusion (OR, 2.03; 95% CI, 1.59-2.59) were associated significantly with an increased risk for post-TAVI AKI. Furthermore, previous peripheral vascular disease (PVD), hypertension, atrial fibrillation, congestive heart failure, diabetes mellitus, and stroke were also risk factors for TAVI-associated AKI. Additionally, transfemoral access significantly correlated with a reduced risk for post-TAVI AKI (OR, 0.43; 95% CI, 0.33-0.57). The potential confounders, including Society of Thoracic Surgeons Score, the logistic European System for Cardiac Operative Risk Evaluation, aortic valve area, mean pressure gradient, left ventricular ejection fraction, age, body mass index, contrast volume, and valve type, had no impact on the association between the risk factors and post-TAVI AKI. Subgroup analysis of the eligible studies presenting multivariate logistic regression analysis on the independent risk factors for post-TAVI AKI revealed that previous CKD, previous PVD, and transapical access were independent risk factors for TAVI-associated AKI.</AbstractText>The current meta-analysis suggested that previous CKD, previous PVD, and transapical access may be independent risk factors for TAVI-associated AKI.</AbstractText>Copyright © 2017. Published by Elsevier Inc.</CopyrightInformation> |
20,653 | Outcome among VF/VT patients in the LINC (LUCAS IN cardiac arrest) trial-A randomised, controlled trial. | The LINC trial evaluated two ALS-CPR algorithms for OHCA patients, consisting of 3min' mechanical chest compression (LUCAS) cycles with defibrillation attempt through compressions vs. 2min' manual compressions with compression pause for defibrillation. The PARAMEDIC trial, using 2min' algorithm found worse outcome for patients with initial VF/VT in the LUCAS group and they received more adrenalin compared to the manual group. We wanted to evaluate if these algorithms had any outcome effect for patients still in VF/VT after the initial defibrillation and how adrenalin timing impacted it.</AbstractText>Both groups received manual chest compressions first. Based on non-electronic CPR process documentation, outcome, neurologic status and its relation to CPR duration prior to the first detected return of spontaneous circulation (ROSC), time to defibrillation and adrenalin given were analysed in the subgroup of VF/VT patients.</AbstractText>Seven hundred and fifty-seven patients had still VF/VT after initial chest compressions combined with a defibrillation attempt (374 received mechanical CPR) or not (383 received manual CPR). No differences were found for ROSC (mechanical CPR 58.3% vs. manual CPR 58.6%, p=0.94), or 6-month survival with good neurologic outcome (mechanical CPR 25.1% vs. manual CPR 23.0%, p=0.50). A significant difference was found regarding the time from start of manual chest compression to the first defibrillation (mechanical CPR: 4 (2-5) min vs manual CPR 3 (2-4) min, P<0.001). The time from the start of manual chest compressions to ROSC was longer in the mechanical CPR group.</AbstractText>No difference in short- or long-term outcomes was found between the 2 algorithms for patients still in VF/VT after the initial defibrillation. The time to the 1st defibrillation and the interval between defibrillations were longer in the mechanical CPR group without impacting the overall outcome. The number of defibrillations required to achieve ROSC or adrenalin doses did not differ between the groups.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,654 | Centhaquin Effects in a Swine Model of Ventricular Fibrillation: Centhaquin and Cardiac Arrest. | Centhaquin citrate is a novel agent being developed for use in the treatment of haemorrhagic shock. The aim of our study was to assess whether the administration of centhaquin would improve initial resuscitation success, 24-hour survival, and neurologic outcome compared with adrenaline alone in a porcine model of ventricular fibrillation.</AbstractText>Ventricular fibrillation was induced in 20 healthy Landrace/Large White piglets. The animals were randomised to receive placebo plus adrenaline 0.02mg/kg (n=10, Group C) and adrenaline 0.02mg/kg plus centhaquin 0.015mg/kg (n=10, Group S). All animals were resuscitated according to the 2010 European Resuscitation Council guidelines. Haemodynamic variables were measured before arrest, during arrest and resuscitation, and during the first two hours after return of spontaneous circulation (ROSC). Survival and a neurologic alertness score were measured at 24hours after ROSC.</AbstractText>A significant difference was observed in ROSC rate between the two groups, as 10 animals (100%) from Group S and 4 animals (40%) from Group C achieved ROSC (p=0.011). Systolic, diastolic, and mean aortic pressure and coronary perfusion pressure were significantly higher in Group S at the end of the second cycle of CPR. In our study, all subjects with ROSC survived for 24hours, while we observed no statistically significant differences in neurologic examination (Group C 100±0, Group S 96±12.64; p=0.527).</AbstractText>The addition of centhaquin to adrenaline improved ROSC rates in a swine model of VF cardiac arrest.</AbstractText>Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,655 | Comparison of the three conventional methods for the postoperative atrial fibrillation prediction. | Although various risk factors have been defined for the development of postoperative atrial fibrillation (PAF), these parameters have not been adequately verified and validated. We investigated the atrial fibrillation detection capabilities of echocardiographic parameters in PAF developing and the determination of predictive values for clinical use.</AbstractText>We enrolled 60 consecutive patients with 234 lesions who underwent CABG surgery. All patients underwent preoperative echocardiographic evaluation. Patients were divided into two groups according to PAF development status.</AbstractText>The mean age of the patients was 67, and 73% were male and PAF occurred in 19 patients. In univariate analysis, left atrial volume index (LAVi), left ventricular global strain (LVGS) and ejection fraction were associated with PAF development. Parameters which were significant in univariate analysis were included in a logistic regression model to determine the independent predictors of PAF. LAVi was found to be an independent predictor of PAF.</AbstractText>Although several parameters have been defined for PAF development, LAVi is more advantageous than the other conventional methods in clinical decision making.</AbstractText>© 2017, Wiley Periodicals, Inc.</CopyrightInformation> |
20,656 | Catheter Ablation of Ventricular Tachycardia/Fibrillation in a Patient with Right Ventricular Amyloidosis with Initial Manifestations Mimicking Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. | Differentiating arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) from other cardiomyopathies is clinically important but challenging. Although the modified Task Force Criteria can facilitate diagnosis of ARVD/C according to clinical manifestations, histopathological examination plays a pivotal role in excluding other diseases that can mimic ARVD/C. Here, we report a patient with amyloidosis that initially presented similarly to ARVD/C. The diagnosis was confirmed by endomyocardial biopsy, and catheter ablation eliminated the ventricular tachyarrhythmias through an epicardial approach. |
20,657 | Purulent Pericarditis: An Uncommon Presentation of a Common Organism. | BACKGROUND In the modern antibiotic era, Streptococcus agalactiae infection of the endocardium and pericardial space is a rare occurrence. However, once the disease spreads it can lead to life-threatening illness despite advances in diagnostic and treatment modalities, partly because the symptoms and signs associated with pericarditis are frequently missing, and due to the rarity of the disease, diagnosis is often overlooked. We report an extremely rare case of purulent pericarditis caused by Streptococcus agalactiae. CASE REPORT A 65-year-old diabetic woman presented with generalized weakness, high-grade fever, and altered mental status. There were no signs or symptoms suggestive of cardiac tamponade on presentation. A computerized tomography (CT) scan of the chest showed a small pericardial effusion. She was managed for diabetic ketoacidosis and sepsis. An electrocardiogram was significant for new-onset atrial fibrillation. Her clinical status deteriorated rapidly as she developed acute hypoxic respiratory failure and shock. A bedside echocardiogram showed large pericardial effusion around the right ventricle and right ventricular diastolic collapse. She developed cardiac arrest, and during resuscitation bedside pericardiocentesis was done with drainage of 15 cc of serosanguineous fluid. However, the patient could not be revived. Subsequently, blood cultures grew Streptococcus agalactiae a day after she died. On autopsy, she was found to have findings of infective endocarditis and purulent pericarditis. CONCLUSIONS A high index of clinical suspicion is crucial when acute pericarditis is suspected, for early diagnosis and for timely initiation of appropriate therapy with antibiotics and aggressive pericardial drainage to prevent fatal outcome. |
20,658 | Brugada-Phenocopy Induced by Propafenone Overdose and Successful Treatment: A Case Report. | Brugada syndrome is an inherited arrhythmogenic disease that may cause sudden cardiac death due to ventricular fibrillation in young adults. Brugada syndrome caused by propafenone intoxication has been noted rarely in the literature. We report a rare case, Brugada phenocopy due to propafenone intoxication and its treatment.</AbstractText>A 15-year-old girl having a seizure was brought to the emergency room. She took 1.5 g propafenone (Rythmol, Abbott, Chicago, IL, USA) for suicidal intention. She had metabolic acidosis. Long QRS interval and ST elevation in leads V1 through V3 were seen on electrocardiography. After bicarbonate infusion for 4 hours, haemodynamic and neurologic findings were recovered, and all electrocardiography abnormalities disappeared. The Brugada-like electrocardiography pattern was not recognized in her surface and 24-hour Holter electrocardiography at follow-up. Ajmaline challenge test was negative 2 weeks later.</AbstractText>Absence of symptoms and documented ventricular tachycardia, negative challenge test, and a negative family history demonstrated that the Brugada phenocopy was a transient finding in this case and related to propafenone intoxication.</AbstractText> |
20,659 | Rat Models of Ventricular Fibrillation Following Acute Myocardial Infarction. | A number of animal models have been designed in order to unravel the underlying mechanisms of acute ischemia-induced arrhythmias and to test compounds and interventions for antiarrhythmic therapy. This is important as acute myocardial infarction (AMI) continues to be the major cause of sudden cardiac death, and we are yet to discover safe and effective treatments of the lethal arrhythmias occurring in the acute setting. Animal models therefore continue to be relevant for our understanding and treatment of acute ischemic arrhythmias. This review discusses the applicability of the rat as a model for ventricular arrhythmias occurring during the acute phase of AMI. It provides a description of models developed, advantages and disadvantages of rats, as well as an overview of the most important interventions investigated and the relevance for human pathophysiology. |
20,660 | [Carotid sinus massage is not a benign intervention]. | Carotid sinus massage for diagnosis and termination of supraventricular tachycardia (SVT) is still a widely used vagal manoeuvre in the A&E department. However, itsefficacy is limited (termination of the SVT in approximately 20%) and carotid sinus massage may be complicated by (potentially devastating) neurologic complications in 0.2-1% of the patients. There are safer interventions without neurologic complications, such as the modified Valsalva manoeuvre (efficacy 43%) and intravenous administration of adenosine (efficacy 75%). Monitor observation of the heart rhythm is required, both for vagal manoeuvres and for adenosine administration, because of the possibility of ventricular tachycardia or ventricular fibrillation induction (incidence 0.08%). Carotid sinus massage remains an important diagnostic method in patients with unexplained syncope in whom, based on the clinical history, carotid sinus hypersensitivity is suspected. It should be avoided in patients with previous TIA or stroke within the past 3 months, or those with carotid bruits, except if carotid Doppler studies have excluded significant stenosis (≥ 70%). |
20,661 | Genetic epidemiological study doesn't support GLA IVS4+919G>A variant is a significant mutation in Fabry disease. | The GLA IVS4+919G>A which is linked to late-onset Fabry disease shows high frequency in Taiwan.</AbstractText>To determine whether IVS4+919G>A is a frequent cause of heart disease, we genotyped it in normal controls and other disease cohorts (type 2 diabetes, heart failure, ventricular tachycardia, atrial fibrillation and coronary artery disease). Normal controls and diabetes patients carrying the variant were evaluated for their cardiac condition. Minigene constructs were used to study GLA splicing patterns in different cell lines.</AbstractText>GLA IVS4+919A was found in 4/1634 males (0.245%) and 2/1634 females (0.123%) in normal controls and in 4/2133 males (0.188%) and 7/1816 females (0.385%) in the type 2 diabetes cohort. Of all the 17 IVS4+919A carriers in these two groups, only two males reported heart-related disease (myocardial infarction and hypertensive heart disease). Furthermore, in the heart disease cohort (n=649), only one male carried the variant. Minigene constructs showed that the AGS (stomach) cell line showed a distinct GLA splicing pattern.</AbstractText>Most subjects carrying GLA IVS4+919A did not show abnormal cardiac phenotypes. The near-absence of GLA IVS4+919A in heart disease cohort suggested that this variant is not a frequent cause of overt heart diseases in Taiwan and that the genotype-phenotype correlation and natural course of the disease need further investigation. We also showed that the GLA IVS4+919G>A nucleotide change did influence alternative splicing in a tissue-specific manner.</AbstractText>The GLA IVS4+919G>A variant is not a frequent cause of overt heart disease in Taiwan.</AbstractText>Copyright © 2017. Published by Elsevier Inc.</CopyrightInformation> |
20,662 | Effect of preoperative left ventricular diastolic dysfunction on mid-term outcomes after surgical ventricular restoration for ischemic cardiomyopathy. | The impact of surgical ventricular restoration (SVR) on survival and major adverse cardiac events (MACEs) is still controversial. The purposes of this study were to analyze our surgical experience with SVR for ischemic cardiomyopathy and to determine the effect of preoperative left ventricular diastolic dysfunction on mid-term outcomes after SVR.</AbstractText>Between April 2010 and May 2016, 19 patients underwent SVR. The mean age was 60 ± 11 years and the mean New York Heart Association functional class was 2.9 ± 0.8. Preoperative mean left ventricular end systolic volume index (LVESVI) and ejection fraction (LVEF) were 134 ± 56 mL/m2</sup> and 24 ± 7%, respectively. The early-to-late mitral valve flow ratio (E/A) on echocardiogram was 2.4 ± 1.8 and 9 patients had E/A ≥2, excluding 2 patients with atrial fibrillation. The mean follow-up period was 29 ± 16 months. One patient died of heart failure at 6 months postoperative; the overall survival rate at 3 years was 95%. MACEs requiring hospitalization occurred in 10 patients; E/A ≥2, or restrictive filling pattern, was the only significant predictor of MACE in multivariate analysis. Reverse remodeling was associated with E/A <2, but not E/A ≥2. There was also a significant difference between patients with E/A <2 vs. ≥2 with respect to MACE-free survival rates at 3 years (100 vs. 10%; p = 0.001).</AbstractText>The degree of preoperative diastolic dysfunction can influence the outcome after SVR. Patients with E/A ≥2 may not be good candidates for SVR.</AbstractText> |
20,663 | Association of CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc Scores with Left Atrial Thrombus with Nonvalvular Atrial Fibrillation: A Single Center Based Retrospective Study in a Cohort of 2695 Chinese Subjects. | The main mechanism of the CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc scores to predict stroke in nonvalvular atrial fibrillation (NVAF) is still controversial. We evaluated the association of the CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc scores with left atrial thrombus (LAT) as detected by transesophageal echocardiographic (TEE) and compared the predictive ability of these risk stratification schemes with nonvalvular atrial fibrillation (NVAF). Data from 2,695 consecutive NVAF patients in whom TEE was performed for screening LAT from July 2007 to February 2014 were analyzed. Only 3% of the subjects had LAT. Presence of LAT was not significantly associated with either CHADS<sub>2</sub>  (<i>P</i> = 0.07) or CHA<sub>2</sub>DS<sub>2</sub>-VASc score (<i>P</i> = 0.12). The area under the curve (AUC) concerning LAT prediction using CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc was 0.574 and 0.569, respectively. A composition model includes previous stroke or transient ischemic attack, nonparoxysmal AF, moderate to severe left ventricular systolic dysfunction, left atrial enlargement, and cardiomyopathy which improved the discrimination significantly (AUC = 0.743). In our cohort, both CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc scores were of limited value for predicting LAT in patients with NVAF. This questions the CHADS<sub>2</sub>/CHA<sub>2</sub>DS<sub>2</sub>-VASc score predicting stroke mainly through the mechanism of cardiogenic embolism. A scoring scheme combining clinical and echocardiographic parameters may better predict LAT as a surrogate for cardioembolic risk in NVAF patients. |
20,664 | Acute Gastric Volvulus and Atrial Fibrillation with RVR: A Coincidence or Association. | Gastric volvulus is a rare and life-threatening condition that involves the abnormal rotation of the stomach around its axis by more than 180°. The association between acute gastric volvulus and atrial fibrillation with rapid ventricular response is rare with only few cases that have been reported. Our patient was an 86-year-old female who presented with upper abdominal pain, distension, nausea, and shortness of breath. Clinical and laboratory workup revealed acute gastric volvulus with diaphragmatic hernia. On presentation, she was also in atrial fibrillation with rapid ventricular response. She was successfully treated by laparotomy with reduction of the gastric volvulus and repair of the diaphragmatic hernia, with significant improvement. |
20,665 | Left ventricular noncompaction-A rare form of cardiomyopathy: Revelation modes and predictors of mortality in adults through 23 cases. | To describe modes of clinical presentation and echocardiographic, angiographic, and rhythmic features, and prognostic characteristics of left ventricular noncompaction cardiomyopathy (LVNC) in North African adults, through one of the first series in Morocco.</AbstractText>LVNC is a rare congenital disorder, described for the first time by Engberding in 1984. The suspected diagnosis in thromboembolic, hemodynamic, or rhythm events requires both echocardiography and cardiovascular magnetic resonance (CMR). Its therapeutic management is not yet well codified but akin to that proposed for dilated cardiomyopathy.</AbstractText>This study included a retrospective, descriptive, and analytical cohort of 23 cases of cardiomyopathy with LVNC diagnosed in the Noninvasive Explorations Laboratory at the Military Hospital of Rabat, Morocco, between January 2009 and October 2014. The echocardiographic criteria for LVNC include the absence of any coexisting cardiac anomalies. The characteristic appearance of numerous excessively prominent trabeculations and deep intertrabecular recesses and intertrabecular spaces filled by direct blood flow from the ventricular cavity, as visualized on color Doppler imaging with noncompacted/compacted ratio > 2 according to Jenni criteria. Twenty-three adults fulfilled the diagnostic criteria and were followed prospectively.</AbstractText>At diagnosis, the mean age was 47 ± 13 years with a male predominance at 65.2%. Of them, 56.5% had a left bundle branch block and 21.7% were in atrial fibrillation. Left ventricular end-diastolic diameter was 67.7 ± 6.6 mm and ejection fraction was at 27 ± 8%. Apex and/or midventricular segments of both the inferior and lateral wall were involved in more than 80% of patients with an average of 4.8 noncompacted segments. CMR was performed in 12 patients and was decisive for the diagnosis. Major complications were heart failure in 31% of patients, ventricular tachycardia in three patients, and thromboembolic events in one patient. Twenty eight point six percent of patients started a long-term anticoagulant therapy. One patient underwent implantation of a double-room pacemaker. Automated defibrillators were implanted in two patients. There were three deaths: one sudden death and two end-stage heart failure.</AbstractText>LVNC should be looked for at any dilated cardiomyopathy particularly in young patients. It requires a careful echocardiographic examination and sometimes CMR to confirm the diagnosis. It is characterized by severe systolic and diastolic dysfunction that would provide poor prognosis.</AbstractText> |
20,666 | Tachyarrhythmias and Bradyarrhythmias: Differential Diagnosis and Initial Management in the Primary Care Office. | Tachyarrhythmias and bradyarrhythmias are often seen in the outpatient setting. Patients can present minimally symptomatic or in extremis. Accurate diagnosis of the rhythm, plus a detailed clinical history, are critical for best management and optimal outcome. A 12-lead electrocardiogram is the cornerstone for diagnosis. Practitioners must identify patients who need immediate transport to an emergency department versus those who can safely wait for an outpatient specialty referral. This article reviews how to accurately diagnose and differentiate the most common tachyarrhythmias and bradyarrhythmias, the associated symptoms, and important concepts for the initial steps in the office management of such arrhythmias. |
20,667 | Prevalence of Arrhythmias in Dogs Examined between 2008 and 2014. | The prevalence of arrhythmias in dogs and the influence of sex, breed, age, and body weight were analysed over a seven-year span.</AbstractText>In total, 1189 referrals for cardiological examination by electrocardiography were received at one academic centre in Poland between 2008 and 2014. The largest proportion of the examined dogs were cross-breeds with body weight below 25 kg (n = 153, 12.87%), followed by German Shepherds (n = 122, 10.26%), Labrador Retrievers (n = 68, 5.72%), Yorkshire Terriers (n = 63, 5.3%), and Boxers (n = 60, 5.05%). Retrospective analysis was made of 1201 standing or right recumbent electrocardiograms without pharmacological sedation. The prevalence of arrhythmias was examined in terms of sex, age, body weight, and breed of the dogs.</AbstractText>A total of 630 (52.46%) electrocardiograms showed no signs of arrhythmia, but 96 (7.99%) and 475 (39.55%) pointed to physiological and pathological arrhythmias respectively. The most commonly diagnosed type was atrial fibrillation with 33.68% incidence, followed by ventricular arrhythmias (28%), sinus pauses (27.58%), supraventricular arrhythmias (24%), and atrioventricular blocks (22.95%). Pathological arrhythmias were most commonly found in male dogs and in German Shepherds.</AbstractText>Atrial fibrillation predominated, followed by premature ventricular complexes. Male dogs were generally more prone to heart rhythm disturbances.</AbstractText> |
20,668 | Restitution slope is principally determined by steady-state action potential duration. | The steepness of the action potential duration (APD) restitution curve and local tissue refractoriness are both thought to play important roles in arrhythmogenesis. Despite this, there has been little recognition of the apparent association between steady-state APD and the slope of the restitution curve. The objective of this study was to test the hypothesis that restitution slope is determined by APD and to examine the relationship between restitution slope, refractoriness and susceptibility to VF.</AbstractText>Experiments were conducted in isolated hearts and ventricular myocytes from adult guinea pigs and rabbits. Restitution curves were measured under control conditions and following intervention to prolong (clofilium, veratridine, bretylium, low [Ca]e, chronic transverse aortic constriction) or shorten (catecholamines, rapid pacing) ventricular APD. Despite markedly differing mechanisms of action, all interventions that prolonged the action potential led to a steepening of the restitution curve (and vice versa). Normalizing the restitution curve as a % of steady-state APD abolished the difference in restitution curves with all interventions. Effects on restitution were preserved when APD was modulated by current injection in myocytes pre-treated with the calcium chelator BAPTA-AM - to abolish the intracellular calcium transient. The non-linear relation between APD and the rate of repolarization of the action potential is shown to underpin the common influence of APD on the slope of the restitution curve. Susceptibility to VF was found to parallel changes in APD/refractoriness, rather than restitution slope.</AbstractText><AbstractText Label="CONCLUSION(S)" NlmCategory="CONCLUSIONS">Steady-state APD is the principal determinant of the slope of the ventricular electrical restitution curve. In the absence of post-repolarization refractoriness, factors that prolong the action potential would be expected to steepen the restitution curve. However, concomitant changes in tissue refractoriness act to reduce susceptibility to sustained VF. Dependence on steady-state APD may contribute to the failure of restitution slope to predict sudden cardiac death.</AbstractText>© The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology</CopyrightInformation> |
20,669 | ECG-Based Classification of Resuscitation Cardiac Rhythms for Retrospective Data Analysis. | There is a need to monitor the heart rhythm in resuscitation to improve treatment quality. Resuscitation rhythms are categorized into: ventricular tachycardia (VT), ventricular fibrillation (VF), pulseless electrical activity (PEA), asystole (AS), and pulse-generating rhythm (PR). Manual annotation of rhythms is time-consuming and infeasible for large datasets. Our objective was to develop ECG-based algorithms for the retrospective and automatic classification of resuscitation cardiac rhythms.</AbstractText>The dataset consisted of 1631 3-s ECG segments with clinical rhythm annotations, obtained from 298 out-of-hospital cardiac arrest patients. In total, 47 wavelet- and time-domain-based features were computed from the ECG. Features were selected using a wrapper-based feature selection architecture. Classifiers based on Bayesian decision theory, k-nearest neighbor, k-local hyperplane distance nearest neighbor, artificial neural network (ANN), and ensemble of decision trees were studied.</AbstractText>The best results were obtained for ANN classifier with Bayesian regularization backpropagation training algorithm with 14 features, which forms the proposed algorithm. The overall accuracy for the proposed algorithm was 78.5%. The sensitivities (and positive-predictive-values) for AS, PEA, PR, VF, and VT were 88.7% (91.0%), 68.9% (70.4%), 65.9% (69.0%), 86.2% (83.8%), and 78.8% (72.9%), respectively.</AbstractText>The results demonstrate that it is possible to classify resuscitation cardiac rhythms automatically, but the accuracy for the organized rhythms (PEA and PR) is low.</AbstractText>We have made an important step toward making classification of resuscitation rhythms more efficient in the sense of minimal feedback from human experts.</AbstractText> |
20,670 | Design of the effect of adaptive servo-ventilation on survival and cardiovascular hospital admissions in patients with heart failure and sleep apnoea: the ADVENT-HF trial. | Both types of sleep-disordered breathing (SDB), obstructive and central sleep apnoea (OSA and CSA, respectively), are common in patients with heart failure and reduced ejection fraction (HFrEF). In such patients, SDB is associated with increased cardiovascular morbidity and mortality but it remains uncertain whether treating SDB by adaptive servo-ventilation (ASV) in such patients reduces morbidity and mortality.</AbstractText>ADVENT-HF is designed to assess the effects of treating SDB with ASV on morbidity and mortality in patients with HFrEF.</AbstractText>ADVENT-HF is a multicentre, multinational, randomized, parallel-group, open-label trial with blinded assessment of endpoints of standard medical therapy for HFrEF alone vs. with the addition of ASV in patients with HFrEF and SDB. Patients with a history of HFrEF undergo echocardiography and polysomnography. Those with a left ventricular ejection fraction ≤45% and SDB (apnoea-hypopnoea index ≥15) are eligible. SDB is stratified into OSA with ≥50% of events obstructive or CSA with >50% of events central. Those with OSA must not have excessive daytime sleepiness (Epworth score of ≤10). Patients are then randomized to receive or not receive ASV. The primary outcome is the composite of all-cause mortality, cardiovascular hospital admissions, new-onset atrial fibrillation requiring anti-coagulation but not hospitalization, and delivery of an appropriate discharge from an implantable cardioverter-defibrillator not resulting in hospitalization during a maximum follow-up time of 5 years.</AbstractText>The ADVENT-HF trial will help to determine whether treating SDB by ASV in patients with HFrEF improves morbidity and mortality.</AbstractText>© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.</CopyrightInformation> |
20,671 | Multiple targets for flecainide action: implications for cardiac arrhythmogenesis. | Flecainide suppresses cardiac tachyarrhythmias including paroxysmal atrial fibrillation, supraventricular tachycardia and arrhythmic long QT syndromes (LQTS), as well as the Ca2+</sup> -mediated, catecholaminergic polymorphic ventricular tachycardia (CPVT). However, flecainide can also exert pro-arrhythmic effects most notably following myocardial infarction and when used to diagnose Brugada syndrome (BrS). These divergent actions result from its physiological and pharmacological actions at multiple, interacting levels of cellular organization. These were studied in murine genetic models with modified Nav</sub> channel or intracellular ryanodine receptor (RyR2)-Ca2+</sup> channel function. Flecainide accesses its transmembrane Nav</sub> 1.5 channel binding site during activated, open, states producing a use-dependent antagonism. Closing either activation or inactivation gates traps flecainide within the pore. An early peak INa</sub> related to activation of Nav</sub> channels followed by rapid de-activation, drives action potential (AP) upstrokes and their propagation. This is diminished in pro-arrhythmic conditions reflecting loss of function of Nav</sub> 1.5 channels, such as BrS, accordingly exacerbated by flecainide challenge. Contrastingly, pro-arrhythmic effects attributed to prolonged AP recovery by abnormal late INaL</sub> following gain-of-function modifications of Nav</sub> 1.5 channels in LQTS3 are reduced by flecainide. Anti-arrhythmic effects of flecainide that reduce triggering in CPVT models mediated by sarcoplasmic reticular Ca2+</sup> release could arise from its primary actions on Nav</sub> channels indirectly decreasing [Ca2+</sup> ]i</sub> through a reduced [Na+</sup> ]i</sub> and/or direct open-state RyR2-Ca2+</sup> channel antagonism. The consequent [Ca2+</sup> ]i</sub> alterations could also modify AP propagation velocity and therefore arrhythmic substrate through its actions on Nav</sub> 1.5 channel function. This is consistent with the paradoxical differences between flecainide actions upon Na+</sup> currents, AP conduction and arrhythmogenesis under circumstances of normal and increased RyR2 function.</AbstractText>This article is part of a themed section on Spotlight on Small Molecules in Cardiovascular Diseases. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.8/issuetoc.</AbstractText>© 2017 The British Pharmacological Society.</CopyrightInformation> |
20,672 | Ranolazine therapy in drug-refractory ventricular arrhythmias. | Ranolazine is an antiischemic and antianginal agent, but experimental and preclinical data provided evidence of additional antiarrhythmic properties. The aim of this study was to evaluate the safety and efficacy of ranolazine in reducing episodes of ventricular arrhythmias in patients with recurrent antiarrhythmic drug-refractory ventricular arrhythmias or with chronic angina.</AbstractText>Seventeen implantable cardioverter defibrillator (ICD) recipients, who had experienced a worsening of their ventricular arrhythmia burden, and 12 ICD recipients with angina were enrolled. Patients were followed up for 6 months after the addition of ranolazine (postranolazine). Data were compared with before its administration (preranolazine).</AbstractText>In the Arrhythmias group, a significant reduction was found in the median number of ventricular tachycardia episodes per patient (4 vs. 0, P = 0.01), and in ICD interventions in terms of both antitachycardia pacing (2 vs. 0, P = 0.04) and shock delivery (2 vs. 0, P = 0.02) after the addition of ranolazine. Moreover, fewer patients experienced episodes of nonsustained ventricular tachycardia (71 vs. 41%, P = 0.04), ventricular tachycardia (76 vs. 24%, P = 0.01), ICD antitachycardia pacing (47 vs. 18%, P = 0.02), and ICD shocks (47 vs. 6%, P = 0.03). In the Angina group, none of the patients developed major ventricular arrhythmias while on ranolazine treatment. No adverse effects were observed.</AbstractText>In this small study, ranolazine proved to be effective, well tolerated, and safe in reducing ventricular arrhythmia episodes and ICD interventions in patients with recurrent antiarrhythmic drug-refractory events. In addition, none of the patients with chronic angina developed major ventricular arrhythmias.</AbstractText> |
20,673 | Effect of Obesity on the Prognostic Impact of Atrial Fibrillation in Heart Failure With Preserved Ejection Fraction. | Although obesity is associated with left ventricular hypertrophy, diastolic dysfunction, and occurrence of atrial fibrillation (AF), obese heart failure (HF) patients have a more favorable clinical outcome (obesity paradox). The clinical impact of AF on obese or lean HF patients has not been fully elucidated.Methods and Results:We analyzed 1,681 patients who were enrolled in the West Tokyo Heart Failure Registry (WET-HF Registry), a multicenter, prospective cohort registry from 2005 through 2014. We assigned them to 3 categories based on body mass index (BMI): low, BMI <18.5; medium, BMI ≥18.5 and <25; and high, BMI ≥25 (n=182/915/400). The clinical endpoint was all-cause death or readmission for acute decompensated HF. During 406 days of follow-up (IQR, 116-739 days), AF was associated with a higher risk of the endpoint in the HF with preserved ejection fraction (HFpEF) group (P<0.001, log-rank test), but not in the HF with reduced EF (HFrEF) group. AF was associated with a higher risk of the endpoint in low and medium BMI patients with HFpEF (P=0.016 and 0.009, respectively). On Multivariate Cox proportional hazards analysis, AF was an independent predictor of the endpoint in patients with BMI <25 from the HFpEF group (hazard ratio, 1.74; 95% CI: 1.21-2.54, P=0.003), but not in the other subgroups.</AbstractText>AF had a negative impact on clinical outcome in non-obese patients with HFpEF.</AbstractText> |
20,674 | Sudden Death in End Stage Renal Disease: Comparing Hemodialysis versus Peritoneal Dialysis. | <AbstractText Label="BACKGROUND/AIMS">This study aimed to evaluate total and sudden death (SD) in a cohort of dialysis patients, comparing hemodialysis (HD) vs. peritoneal dialysis (PD).</AbstractText>This is a multicenter retrospective cohort study.</AbstractText>Deaths were 626 out of 1,823 in HD and 62 of 249 in PD patients. HD patients had a greater number of comorbidities (p < 0.05). PD patients had a lower risk of death than HD patients (p < 0.001); however, the advantage decreased with time (p < 0.001). Mortality predictors were left ventricular ejection fraction (LVEF) ≤35%, older age, ischemic heart disease, diabetes mellitus, previous stroke, and atrial fibrillation (p < 0.03). SDs were 84:71 in HD and 13 in PD population (12.1 and 22.8% of all causes of death, respectively). A non-significant risk of SD among PD compared to HD patients was detected. SD predictors were older age, ischemic heart disease, and LVEF ≤35% (p < 0.05).</AbstractText>HD patients showed a greater presence of comorbidities and reduced survival compared to PD patients; however, the incidence of SD does not differ in the 2 populations. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=464347.</AbstractText>© 2017 S. Karger AG, Basel.</CopyrightInformation> |
20,675 | Benefits of Permanent His Bundle Pacing Combined With Atrioventricular Node Ablation in Atrial Fibrillation Patients With Heart Failure With Both Preserved and Reduced Left Ventricular Ejection Fraction. | Clinical benefits from His bundle pacing (HBP) in heart failure patients with preserved and reduced left ventricular ejection fraction are still inconclusive. This study evaluated clinical outcomes of permanent HBP in atrial fibrillation patients with narrow QRS who underwent atrioventricular node ablation for heart failure symptoms despite rate control by medication.</AbstractText>The study enrolled 52 consecutive heart failure patients who underwent attempted atrioventricular node ablation and HBP for symptomatic atrial fibrillation. Echocardiographic left ventricular ejection fraction and left ventricular end-diastolic dimension, New York Heart Association classification and use of diuretics for heart failure were assessed during follow-up visits after permanent HBP. Of 52 patients, 42 patients (80.8%) received permanent HBP and atrioventricular node ablation with a median 20-month follow-up. There was no significant change between native and paced QRS duration (107.1±25.8 versus 105.3±23.9 milliseconds, P</i>=0.07). Left ventricular end-diastolic dimension decreased from the baseline (P</i><0.001), and left ventricular ejection fraction increased from baseline (P</i><0.001) in patients with a greater improvement in heart failure with reduced ejection fraction patients (N=20) than in heart failure with preserved ejection fraction patients (N=22). New York Heart Association classification improved from a baseline 2.9±0.6 to 1.4±0.4 after HBP in heart failure with reduced ejection fraction patients and from a baseline 2.7±0.6 to 1.4±0.5 after HBP in heart failure with preserved ejection fraction patients. After 1 year of HBP, the numbers of patients who used diuretics for heart failure decreased significantly (P</i><0.001) when compared to the baseline diuretics use.</AbstractText>Permanent HBP post-atrioventricular node ablation significantly improved echocardiographic measurements and New York Heart Association classification and reduced diuretics use for heart failure management in atrial fibrillation patients with narrow QRS who suffered from heart failure with preserved or reduced ejection fraction.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.</CopyrightInformation> |
20,676 | Hopes and disappointments with antiarrhythmic drugs. | Ventricular arrhythmias such as sustained ventricular tachycardia and ventricular fibrillation account for two thirds of sudden cardiac deaths. Most ventricular tachyarrhythmias have well understood mechanisms such that it is theoretically possible to conceive of an antiarrhythmic drug-based intervention that would prevent arrhythmias that cause sudden cardiac death. Pharmaceutical agents which interfere with ion channel activity are known as antiarrhythmic drugs. Acute experiments showing antiarrhythmic effects in the basic science laboratory have often not translated into clinical effectiveness. Evidence of efficacy has been difficult to assess and appears to be sparse. However, proarrhythmia is common and complicates assessment of the potential value of antiarrhythmic drugs. Important studies such as the Cardiac Arrhythmia Suppression Trial and the Survival With ORal d-sotalol study confirmed that antiarrhythmic drugs could kill rather than cure patients at risk of sudden cardiac death, and spelled the death knell for widespread use of antiarrhythmic drugs for the primary prevention of sudden cardia death in high risk patients. However, when the implantable cardioverter defibrillator was introduced into clinical practice the situation changed - a drug that generally suppressed ventricular tachyarrhythmias was needed, but safety concerns were alleviated because the ICD could reverse proarrhythmic adverse effects. The accent changed towards the development of drugs that might reduce the prevalence or the symptomatic burden of ventricular arrhythmias. Similarly, antiarrhythmic drug development progressed towards finding an agent that might reduce symptoms associated with recurrent atrial fibrillation rather than for the treatment of ventricular arrhythmia. In recent times the goal of antiarrhythmic therapy has changed again. No longer is it thought necessary to develop blockbuster therapies, but to concentrate on the specific mechanisms of cardiac arrhythmias in individuals and to develop therapies that can be specifically engineered to help carefully defined phenotypes. Personalised or precision medicine is now guiding the development of antiarrhythmic agents that are directed to very specific targets and arrhythmia mechanisms and are without off-target effects that may compromise their efficacy. The value of antiarrhythmic medical therapy has raised great hopes which have been followed by disillusionment. Now hopes and needs are rising again, and we are better prepared to make this therapy successful. If we understand the arrhythmias we may be able to design effective and uncomplicated therapy. |
20,677 | Utility of 12-lead and signal-averaged Holter electrocardiograms after pilsicainide provocation for risk stratification in Brugada syndrome. | Non-invasive risk stratification for ventricular fibrillation (VF) in Brugada syndrome (BrS) has not been fully evaluated. The aim of this study was to assess the utility of signal-averaged Holter electrocardiogram (Holter SAECG) and 12-lead Holter electrocardiogram (Holter ECG) after a pilsicainide provocation test for non-invasive risk stratification in BrS. We enrolled 30 consecutive patients with BrS [divided into 2 groups: the VF group, those with a previous history of VF (n = 10); and the non-VF group, those without a history of VF (n = 20)] and 10 control subjects without type 1 ECG. We evaluated late potentials [LP: filtered QRS (f-QRS), RMS40, and LAS40] on the Holter SAECG for 4 h after the pilsicainide provocation and in the same patients on another day without performing the pilsicainide provocation. Furthermore, we measured QRS duration and QTc interval in leads V2 and V5, and J amplitude in lead V2 on the Holter ECG after the pilsicainide provocation. On the Holter SAECG, the f-QRS at 1 h and LAS40 at 3 h after the pilsicainide provocation were significantly larger in the VF group than in the non-VF group (f-QRS at 1 h: 113.9 ± 8.9 vs. 104.9 ± 8 ms; p = 0.01, LAS40 at 3 h: 45.4 ± 5.9 vs. 35.5 ± 7.4 ms; p < 0.001). The receiver-operating characteristic curve analysis for a single parameter of VF occurrence was determined [f-QRS at 1 h: area under the curve (AUC) 0.8, with sensitivity 80% and specificity 80%; and LAS40 at 3 h: AUC 0.87, with sensitivity 90% and specificity 75%]. On the Holter ECG, there were no significant differences in these parameters between the VF and non-VF groups. In conclusion, the LP after the pilsicainide provocation using Holter SAECG may be useful for risk stratification of VF episodes in patients with BrS. |
20,678 | Ventricular fibrillation waveform characteristics of the surface ECG: Impact of the left ventricular diameter and mass. | Despite a promising association between VF waveform characteristics and prognosis after resuscitation, studies with VF-guided treatment have so far not improved outcomes. While driven by the idea that the VF waveform reflects arrest duration, increasing evidence suggests that pre-existent disease-related changes of the myocardium affect ECG-characteristics of VF as well. In this context, we studied the impact of the left ventricular (LV) diameter and mass.</AbstractText>Cohort of 193 ICD-patients with defibrillation testing at the Radboudumc (2010-2014). Surface ECG-recordings (leads I,II,aVF,V1,V3,V6) were analysed to study amplitude and frequency characteristics of the induced VF. Both for LV diameter and mass, patients were categorised in two groups, using echocardiographic data (ASE-guidelines).</AbstractText>In all ECG-leads, dominant and median frequencies were significantly lower in patients with (n=40) than in patients without (n=151) an increased LV diameter. The mean amplitude and amplitude spectrum area (AMSA) did not differ. In contrast, we observed no differences in frequency characteristics in relation to the LV mass, whereas mean amplitude (I,aVF,V3) and AMSA (I,V3) were significantly higher in patients with (n=57) than in patients without (n=120) an increased LV mass.</AbstractText>Frequency characteristics of VF were consistently lower in case of an increased LV diameter. Whereas LV mass does not affect the frequency of the VF waveform, amplitudes seem higher with increasing mass. These findings add to the current knowledge of factors that modulate VF characteristics of the surface ECG and provide insight into factors which may be accounted for in future studies on VF-guided resuscitative interventions.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,679 | Body mass index and outcome of out-of-hospital cardiac arrest patients not treated by targeted temperature management. | Obesity has been demonstrated to increase the risk of out-of-hospital cardiac arrest (OHCA) and may influence the quality and effectiveness of cardiopulmonary resuscitation. Our aim was to investigate the association between body mass index (BMI) and the outcome of OHCA victims not treated by targeted temperature management.</AbstractText>This was a prospective observational study of OHCA patients. The patients were categorized according to BMI into two groups: the normal BMI group (nBMI) and the elevated BMI group (eBMI). The primary endpoint was return of spontaneous circulation (ROSC), while secondary outcomes were survival to intensive care unit (ICU) admission and survival to ICU discharge.</AbstractText>Of the initial 99 patients who were transported to the Emergency Department, 84 (85%) were included in the study. Mean BMI was 29.8kg/m2</sup>. Thirteen (15.5%) patients achieved ROSC and were admitted to the ICU, with the mean duration of ICU length of stay being 6.7±4.9days. Survival to ICU admission and ICU discharge were higher in the eBMI group (17.6% vs. 6.25%, p=0.010 and 10.3% vs. 6.25%, p=0.021, respectively). Survival to ICU discharge was higher in ventricular fibrillation patients compared to patients with non-shockable rhythms, irrespectively of their BMI (p=0.002). All patients that survived to ICU discharge did so with a cerebral performance category score of 2.</AbstractText>Survival to ICU admission and ICU discharge were higher in the eBMI group.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,680 | Extracorporeal CPR and intra-aortic balloon pumping in tachycardia-induced cardiomyopathy complicating cardiac arrest. | Although tachycardia-induced cardiomyopathy (TIC) due to atrial fibrillation occurs frequently, it is under-recognized in clinical settings. TIC has a wide range of clinical manifestations, from asymptomatic tachycardia to cardiomyopathy leading to end stage heart failure. We present a case of a 48year-old-woman who presented as cardiogenic shock, and rapidly progressed to cardiac arrest from recently diagnosed but undertreated atrial fibrillation, resulting TIC in the emergency department (ED). She was rescued by extracorporeal cardiopulmonary resuscitation (E-CPR) for refractory cardiac arrest in the ED, and received concomitant intra-aortic balloon counterpulsation (IABP) support for severe left ventricular failure. Cardiogenic shock can present as an initial manifestation of TIC, and E-CPR and subsequent IABP support can be a valuable rescue therapy for severe TIC. |
20,681 | Estimation of Oxidative Stress Involvement by Superoxide Dismutase Variation in Cardiac Arrhythmias. | Cardiac arrhythmias, commonly diagnosed in young people, involve multiple etiopathogenic factors, including oxidative stress.</AbstractText>Evaluation of superoxide dismutase (SOD) variations as an antioxidant enzyme (with a physiological role in the dismutation of highly reactive oxygen free radicals into oxygen and water) in young patients with cardiac arrhythmias.</AbstractText>The study was conducted on a group of 40 young patients with a mean age of 34 years old, of both sexes, with non-lesional cardiac dysrhythmias, compared to a control group of 40 healthy subjects, determining for both groups the SOD serum level. Diagnosis of cardiac rhythm disorder was supported by electrocardiogram, imaging and laboratory investigations.</AbstractText>SOD recorded a 61% decrease of mean values in patients compared to controls. The decreasing variation was found in all arrhythmia types, as follows: atrial fibrillation (51,54%), sinus bradycardia (54,86%), atrial flutter (55,71%), extrasystolic ventricular arrhythmia (64,20%), extrasystolic atrial arrhythmia (65,27%), combined arrhythmias (65,93%), supraventricular paroxysmal tachycardia (71,32%) and sinus tachycardia (74,24%). SOD deficiency demonstrates the involvement of oxidative stress in cardiac arrhythmic pathogenesis, excess oxygen radicals interfering with multiple mechanisms related to the onset of arrhythmogenesis. The SOD decrease was more important in females (60,57%) than in males (67,06%) and in those with nutrition poor in antioxidants.</AbstractText>SOD estimation represents a biomarker whose decrease and deficiency implies occurrence of oxidative stress and implicitly highlights its role in cardiac arrhythmic pathology in young people, with the possibility of monitoring and correction by pharmacological or non-pharmacological therapeutic means.</AbstractText> |
20,682 | Vernakalant versus ibutilide for immediate conversion of recent-onset atrial fibrillation. | The pharmacological cardioversion of recent-onset atrial fibrillation (AF) is a challenge for the clinician. The aim of the study was to compare the efficacy, the safety, and the overall cost of intravenous (iv) administration of vernakalant, which is a relatively new atrial-selective antiarrhythmic agent, versus ibutilide, in cardioversion of recent-onset AF.</AbstractText>We enrolled in this study 78 patients (56 men, 22 women; mean age 63.72 ± 6.67 years) who presented with recent-onset AF. Cardioversion was attempted in 36 patients (group A: 24 men, 12 women; mean age 62.44 ± 7.24 years) by iv administration of vernakalant (3 mg/kg over 10 min and if needed after 15 min, a second dose 2 mg/kg over 10 min) while in 42 patients (group B: 32 men, 10 women; mean age 64.81 ± 6 years) iv ibutilide was administered (1 mg over 10 min and if needed after 10 min, a second dose 1 mg over 10 min).</AbstractText>AF was successfully converted in 52.78 % of (n =19) patients of group A vs 52.38 % of (n =22) patients of group B (p =0.58), with an average time of conversion 11.8 ± 4.3 min for group A patients vs 33.9 ± 20.25 min for group B patients (p <0.0001). The average length of hospital stay for patients of group A was 17.64 ± 15.96 hours vs 41.09 ± 17.6 hours for patients of Group B (p <0.0001). In one patient of group A, the administration of vernakalant was discontinued due to hypotension while two other patients reported dysgeusia during their hospitalization. In three patients of group B, the administration of ibutilide was discontinued due to development of nonsustained ventricular tachycardia, which resolved with discontinuation of the drug. The cost of administered drugs was estimated at 488.22 ± 170.34 € for patients of group A vs 142.43 ± 54.45 € for patients of group B (p <0.0001), however, hospitalization costs were significantly lower in patients of group A (258.5 8± 124.73 € over 414.43 ± 100.32; p =0.002).</AbstractText>There was no significant difference in the efficiency of converting recent-onset AF between vernakalant and ibutilide. Although vernakalant is an expensive drug, we recorded fewer side effects and more rapid restoration, which reduced the overall cost of hospitalization of these patients. HIPPOKRATIA 2017, 21(2): 67-73.</AbstractText> |
20,683 | Multimodality Strategy for Cardiovascular Risk Assessment: Performance in 2 Population-Based Cohorts. | Current strategies for cardiovascular disease (CVD) risk assessment among adults without known CVD are limited by suboptimal performance and a narrow focus on only atherosclerotic CVD (ASCVD). We hypothesized that a strategy combining promising biomarkers across multiple different testing modalities would improve global and atherosclerotic CVD risk assessment among individuals without known CVD.</AbstractText>We included participants from MESA (Multi-Ethnic Study of Atherosclerosis) (n=6621) and the Dallas Heart Study (n=2202) who were free from CVD and underwent measurement of left ventricular hypertrophy by ECG, coronary artery calcium, N-terminal pro B-type natriuretic peptide, high-sensitivity cardiac troponin T, and high-sensitivity C-reactive protein. Associations of test results with the global composite CVD outcome (CVD death, myocardial infarction, stroke, coronary or peripheral revascularization, incident heart failure, or atrial fibrillation) and ASCVD (fatal or nonfatal myocardial infarction or stroke) were assessed over >10 years of follow-up. Multivariable analyses for the primary global CVD end point adjusted for traditional risk factors plus statin use and creatinine (base model).</AbstractText>Each test result was independently associated with global composite CVD events in MESA after adjustment for the components of the base model and the other test results (P</i><0.05 for each). When the 5 tests were added to the base model, the c-statistic improved from 0.74 to 0.79 (P</i>=0.001), significant integrated discrimination improvement (0.07, 95% confidence interval [CI] 0.06-0.08, P</i><0.001) and category free net reclassification improvement (0.47; 95% CI, 0.38-0.56; P</i>=0.003) were observed, and the model was well calibrated (χ2</sup>=12.2, P</i>=0.20). Using a simple integer score counting the number of abnormal tests, compared with those with a score of 0, global CVD risk was increased among participants with a score of 1 (adjusted hazard ratio, 1.9; 95% CI, 1.4-2.6), 2 (hazard ratio, 3.2; 95% CI, 2.3-4.4), 3 (hazard ratio, 4.7; 95% CI, 3.4-6.5), and ≥4 (hazard ratio, 7.5; 95% CI, 5.2-10.6). Findings replicated in the Dallas Health Study were similar for the ASCVD outcome.</AbstractText>Among adults without known CVD, a novel multimodality testing strategy using left ventricular hypertrophy by ECG, coronary artery calcium, N-terminal pro B-type natriuretic peptide, high-sensitivity cardiac troponin T, and high-sensitivity C-reactive protein significantly improved global CVD and ASCVD risk assessment.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,684 | State Requirements for Automated External Defibrillators in American Schools: Framing the Debate About Legislative Action. | Installation of automated external defibrillators (AEDs) in schools has been associated with increased survival after sudden cardiac arrest. An authoritative academic research database was interrogated to identify all current state statutes pertaining to AEDs in schools. As of February 2016, 17 of 50 U.S. states (34%) require AED installation in at least some of their schools; the remaining states have no legislation. However, requirements are far from comprehensive in these 17 states. Only 5 states offer unequivocal funding to schools for purchasing AEDs. A minority of U.S. states have legislation requiring AED placement in schools, and even fewer provide funding. State legislatures that have not yet enacted legislation requiring AEDs in schools may look to neighboring states for examples of child and adult lifesaving law. Placement of an AED in schools should be implemented with an emergency response plan that trains staff in the recognition and response to cardiac arrest. |
20,685 | [A retrospective analysis of clinical characteristics and outcomes of heart failure patients with different left ventricular ejection fractions]. | <b>Objective:</b> To compare the clinical characteristics, and outcomes of patients with heart failure with different left ventricular ejection fractions (LVEF). <b>Methods:</b> A total of 1 182 hospitalized patients with heart failure (HF) were enrolled and retrospectively studied in the present study. The patients were stratified by LVEF as reduced (HFrEF, LVEF<40%, <i>n</i>=313), mid-range (HFmrEF, 40% ≤LVEF <50%, <i>n</i>=287) and preserved (HFpEF, LVEF≥50%, <i>n</i>=582) ejection fraction groups. Among the 1 182 cases, 941 of them (81.3%, 84.9%, and 84.0% inHFrEF, HFmrEF and HFpEF groups, respectively) were followed up for an median duration of 27.3 months. <b>Results:</b> (1) Among the study patients, 26.5% were in HFrEF, 24.3% in HFmrEF, and 49.2% in HFpEF groups. (2) Ischemic heart disease with HFmrEF was more frequent than that in patients with HFrEF. The average age, percentage of female subjects, systolic blood pressure, uric acid, N terminal B-type natriuretic peptide precursor (NT-proBNP), hemoglobin, and the incidence of hypertensive heart disease, anemia, atrial fibrillation in patients with HFmrEF were higher than those in patients with HFrEF, but lower than those in patients with HFpEF (all <i>P</i><0.01). (3) The all-cause cumulative mortality was 10.8% at 1 year, 20.6% at 2 years and 35.9% at 5 years. No difference was observed in the all-cause cumulative mortality at 1 year, 2 years, 5 years among the three groups (all <i>P</i>>0.05). <b>Conclusions:</b> The HFmrEF patients, as a new and distinct group, were with many intermediate characteristics compared with HFrEF and HFpEF subjects. However, the all-cause mortality was not significantly different among HF patients with different LVEF.</Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Zhou</LastName><ForeName>H B</ForeName><Initials>HB</Initials><AffiliationInfo><Affiliation>Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>An</LastName><ForeName>D Q</ForeName><Initials>DQ</Initials></Author><Author ValidYN="Y"><LastName>Zhan</LastName><ForeName>Q</ForeName><Initials>Q</Initials></Author><Author ValidYN="Y"><LastName>Liu</LastName><ForeName>Z H</ForeName><Initials>ZH</Initials></Author><Author ValidYN="Y"><LastName>Hua</LastName><ForeName>J H</ForeName><Initials>JH</Initials></Author><Author ValidYN="Y"><LastName>Lai</LastName><ForeName>W Y</ForeName><Initials>WY</Initials></Author><Author ValidYN="Y"><LastName>Huang</LastName><ForeName>Y L</ForeName><Initials>YL</Initials></Author><Author ValidYN="Y"><LastName>Zeng</LastName><ForeName>Q C</ForeName><Initials>QC</Initials></Author><Author ValidYN="Y"><LastName>Xu</LastName><ForeName>D L</ForeName><Initials>DL</Initials></Author></AuthorList><Language>chi</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList></Article><MedlineJournalInfo><Country>China</Country><MedlineTA>Zhonghua Nei Ke Za Zhi</MedlineTA><NlmUniqueID>16210490R</NlmUniqueID><ISSNLinking>0578-1426</ISSNLinking></MedlineJournalInfo><ChemicalList><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="D010446">Peptide Fragments</NameOfSubstance></Chemical><Chemical><RegistryNumber>0</RegistryNumber><NameOfSubstance UI="C109794">pro-brain natriuretic peptide (1-76)</NameOfSubstance></Chemical><Chemical><RegistryNumber>114471-18-0</RegistryNumber><NameOfSubstance UI="D020097">Natriuretic Peptide, Brain</NameOfSubstance></Chemical></ChemicalList><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D000368" MajorTopicYN="N">Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D001794" MajorTopicYN="N">Blood Pressure</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D002318" MajorTopicYN="N">Cardiovascular Diseases</DescriptorName><QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006333" MajorTopicYN="N">Heart Failure</DescriptorName><QualifierName UI="Q000175" MajorTopicYN="N">diagnosis</QualifierName><QualifierName UI="Q000503" MajorTopicYN="Y">physiopathology</QualifierName><QualifierName UI="Q000628" MajorTopicYN="N">therapy</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D006760" MajorTopicYN="N">Hospitalization</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008297" MajorTopicYN="N">Male</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D020097" MajorTopicYN="N">Natriuretic Peptide, Brain</DescriptorName><QualifierName UI="Q000097" MajorTopicYN="Y">blood</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D010446" MajorTopicYN="N">Peptide Fragments</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012189" MajorTopicYN="N">Retrospective Studies</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D013318" MajorTopicYN="Y">Stroke Volume</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D016896" MajorTopicYN="N">Treatment Outcome</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D016277" MajorTopicYN="Y">Ventricular Function, Left</DescriptorName></MeshHeading></MeshHeadingList><OtherAbstract Type="Publisher" Language="chi"><b>目的：</b> 比较不同左心室射血分数(LVEF)心力衰竭(心衰)患者的临床特征和预后。 <b>方法：</b> 纳入因心衰住院的患者1 182例，根据其LVEF分为射血分数减低型心衰(HFrEF，LVEF<40%，313例)、射血分数中间范围型心衰(HFmrEF，LVEF 40%～<50%，287例)、射血分数保留型心衰(HFpEF，LVEF≥50%，582例)3组，对3组进行回顾观察性研究，并进行中位时间为23.7个月的随访，随访率83.6%(941例)，HFrEF组、HFmrEF组、HFpEF组的随访率分别为81.3%、84.9%、84.0%。 <b>结果：</b> (1)在本研究中，HFrEF患者313例(26.5%)，HFmrEF患者287例(24.3%)，HFpEF患者582例(49.2%)。(2)与HFrEF组相比，HFmrEF组缺血性心脏病更多见。HFmrEF组的年龄、女性比例、收缩压、血尿酸、N末端B型利钠肽前体、血红蛋白及高血压心脏病、贫血、心房颤动患病率等高于HFrEF组，但低于HFpEF组(<i>P</i>值均<0.01)。(3)本组心衰患者第1、2、5年的全因死亡率分别为10.8%、20.6%、35.9%，3组间第1、2、5年全因死亡率差异均无统计学意义(<i>P</i>值均>0.05)。 <b>结论：</b> HFmrEF代表着一个新的、不同的心衰分类，其很多特征介于HFrEF和HFpEF之间。不同LVEF心衰患者全因死亡率差异无统计学意义。. |
20,686 | Mild hypothermia alleviates brain oedema and blood-brain barrier disruption by attenuating tight junction and adherens junction breakdown in a swine model of cardiopulmonary resuscitation. | Mild hypothermia improves survival and neurological recovery after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). However, the mechanism underlying this phenomenon is not fully elucidated. The aim of this study was to determine whether mild hypothermia alleviates early blood-brain barrier (BBB) disruption. We investigated the effects of mild hypothermia on neurologic outcome, survival rate, brain water content, BBB permeability and changes in tight junctions (TJs) and adherens junctions (AJs) after CA and CPR. Pigs were subjected to 8 min of untreated ventricular fibrillation followed by CPR. Mild hypothermia (33°C) was intravascularly induced and maintained at this temperature for 12 h, followed by active rewarming. Mild hypothermia significantly reduced cortical water content, decreased BBB permeability and attenuated TJ ultrastructural and basement membrane breakdown in brain cortical microvessels. Mild hypothermia also attenuated the CPR-induced decreases in TJ (occludin, claudin-5, ZO-1) and AJ (VE-cadherin) protein and mRNA expression. Furthermore, mild hypothermia decreased the CA- and CPR-induced increases in matrix metalloproteinase-9 (MMP-9) and vascular endothelial growth factor (VEGF) expression and increased angiogenin-1 (Ang-1) expression. Our findings suggest that mild hypothermia attenuates the CA- and resuscitation-induced early brain oedema and BBB disruption, and this improvement might be at least partially associated with attenuation of the breakdown of TJ and AJ, suppression of MMP-9 and VEGF expression, and upregulation of Ang-1 expression. |
20,687 | Prognostic value of red blood cell distribution width in patients with left ventricular systolic dysfunction: Insights from the COMMIT-HF registry. | Previous studies have reported that in patients with heart failure, an increased value of red cell distribution width (RDW) is associated with adverse outcomes. Nonetheless, data regarding the association between RDW values and long-term mortality in patients with left ventricular systolic dysfunction (LVSD) are lacking. The aim of this investigation was to examine the relationship between mortality and RDW in patients with ischemic and non-ischemic LVSD.</AbstractText>Under analysis was 1734 patients with a left ventricular ejection fraction (LVEF) ≤ 35% of whom were hospitalized between 2009 and 2013. Patients were divided into three groups based on RDW tertiles. Low, medium and high tertiles were defined as RDW ≤ 13.4%, 13.4% < RDW ≤ 14.6% and RDW > 14.6%, respectively.</AbstractText>There was a stepwise relationship between RDW intervals and comorbidities. Patients with the highest RDW values were older and more often diagnosed with anemia, diabetes, atrial fibrillation and chronic kidney disease. The main finding of our analysis was the presence of an 8-fold increase in all-cause mortality in the entire cohort between high and low RDW tertile. Cox hazard analysis identi-fied RDW as an independent predictive factor of mortality in all patients (HR 2.8; 95% CI 2.1-3.8; p < 0.0001) and in subgroups of patients with ischemic (HR 2.8; 95% CI 2.0-3.9; p < 0.0001) and non-ischemic (HR 3.3; 95% CI 2.01-5.5; p < 0.0001) LVSD.</AbstractText>The highest RDW tertile was independently associated with higher long-term mortality compared with low and medium tertiles, both in all patients with a LVEF ≤ 35% and in subgroups of patients with ischemic and non-ischemic LVSD.</AbstractText> |
20,688 | Efficacy and effects on cardiac function of radiofrequency catheter ablation vs. direct current cardioversion of persistent atrial fibrillation with left ventricular systolic dysfunction. | To evaluate the effect of catheter ablation vs. direct current synchronized cardioversion (DCC) in patients with persistent atrial fibrillation (AF) and left ventricular systolic dysfunction, and to define baseline features of patients that will get more benefit from ablation.</AbstractText>From July 2013 to October 2014, 97 consecutive single-center patients with persistent AF and symptomatic heart failure (left ventricular ejection fraction (LVEF) <50%) underwent DCC followed by amiodarone (n = 40) or circumferential pulmonary vein isolation (PVI; n = 57) according to patient's preference were recruited in the study. Post-ablation recurrence was treated with atrial roof and mitral isthmus lines ablation with or without PVI based on restoration or not of pulmonary vein (PV) potential conduction. Study outcomes were 12-month rate of sustained sinus rhythm (SR) and cardiac function. Baseline characteristics were compared between patients with and without cardiac function improvement post ablation.</AbstractText>With similarly distributed characteristics at baseline, ablation (mean 1.8 procedures) relative to DCC yielded significantly higher level of 12-month SR maintenance rate (68.42% vs. 35%, P = 0.001); and better LVEF and New York Heart Association class. with significant effect for DCC only in maintained SR cases. Post ablation LVEF increased (>20% or to over 55%) in 31 (54.39%) patients with worse baseline cardiac function and ventricular rate control.</AbstractText>Catheter ablation relative to cardioversion of persistent AF with symptomatic heart failure yielded better 12-month SR maintenance and cardiac function. Compared with non-responders, patients with improved LVEF post-ablation had poorer ventricular rate control and cardiac function at baseline, suggesting a significant component of tachycardia-induced cardiomyopathy in this group.</AbstractText> |
20,689 | Incidence and Predictors of Aggravation of Mitral Regurgitation After Atrial Septal Defect Closure. | The association between atrial septal defect (ASD) and mitral regurgitation (MR) is well known. However, data about the predictors of changes in MR after ASD closure are limited. The purpose of this study was to clarify the chronological changes in MR after ASD closure and the predictors of aggravation of MR.</AbstractText>In this single-center cohort study, we retrospectively investigated 129 consecutive adult patients (mean age, 53 ± 14 years) who underwent surgical ASD closure between 1987 and 2014. The MR grade was qualitatively classified as none, mild, moderate, or severe by echocardiography. Aggravation of MR was defined as an increase by two or more grades after ASD closure. Clinical factors and echocardiographic and catheterization data were evaluated.</AbstractText>The mean follow-up period was 77 months. Aggravation of MR after ASD closure occurred in 16 patients (12%). The rate of perioperative atrial fibrillation was higher (odds ratio, 5.89), the anterior mitral leaflet was thicker (odds ratio, 1.91), and the posterior mitral leaflet length was shorter (odds ratio, 1.58) in patients with aggravation of MR than in the remaining 113 patients. The mechanism of aggravated MR was poor coaptation associated with annular dilatation, thickened anterior mitral leaflet, and shortened posterior mitral leaflet.</AbstractText>A thickened anterior mitral leaflet and shortened posterior mitral leaflet, combined with mitral annular dilation associated with atrial fibrillation and restored left ventricular geometry, may aggravate MR after ASD closure. Careful follow-up is needed for patients with atrial fibrillation, a thickened anterior mitral leaflet, or a shortened posterior mitral leaflet.</AbstractText>Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,690 | Atrioventricular nodal ablation in patients with resynchronization therapy and atrial fibrillation - long term results. | Atrioventricular nodal ablation (AVNA) is recommended for patients (pts) with cardiac resynchronization therapy (CRT) having atrial fibrillation (AF) and incomplete ventricular capture (Class IIa, level B). AVNA reduces mortality and improves the New York Heart Association (NYHA) functional class during intermediate term follow-up. The objectives were to study the long-term outcome regarding quality of life (QoL) and survival of our CRT pts after AVNA.</AbstractText>37 CRT-pts undergoing AVNA due to inadequate biventricular pacing were included in the study. Data were retrospectively obtained from clinical records and through telephone interviews.</AbstractText>Twenty pts died during the follow-up period of average 30.6 ± 24 months. After AVNA the ventricular capture improved significantly from 68.4 ± 23% to 98.5 ± 2% (p < 0.001). A significant and sustained improvement of average 0.3 ± 0.5 (p = 0.001) in NYHA functional class was found. Additionally a large percentage of pts discontinued taking rate reducing drugs with potential severe side effects.</AbstractText>AVNA in CRT pts was safe and effective. The treatment resulted in a sustained improvement in QoL, including long-term improvement in NYHA functional class.</AbstractText> |
20,691 | Effect of botulinum toxin on inducibility and maintenance of atrial fibrillation in ovine myocardial tissue. | Aberrant vagal stimulation may promote the generation and propagation of atrial fibrillation (AF). Researchers have suggested that botulinum toxin (BTX), a neurotoxin that decreases neural vagal stimulation, may decrease the incidence of postoperative AF. The exact electrophysiologic mechanism underlying the observations and histopathologic alterations associated with BTX are unclear.</AbstractText>To investigate the electrophysiologic, functional, and histopathologic effects of BTX on fibrillation induction in ovine atria.</AbstractText>Eight sheep underwent BTX injections into their pulmonary veins, atrial fat pads, and ventricular walls. Electrophysiology with pacing was performed at baseline and 7 days after injection to evaluate the atrial effective refractory period (ERP) and vulnerability to AF with and without vagal stimulation. Echocardiography was performed at baseline and day 7. After euthanasia, histopathologic analysis was performed.</AbstractText>Seven sheep completed the study. For both atria, there was significant shortening in the ERP with vagal stimulation versus no stimulation on day 0 but not on day 7. More aggressive pacing was required to induce AF in the left atrium on day 7 than on day 0. Echocardiography on day 7 showed no significant changes in ejection fraction or new wall-motion abnormalities of the left and right ventricle. Histopathologic analysis showed no significant adverse effects.</AbstractText>The subacute BTX effect reduced the vulnerability of atrial tissue to AF induction and reduced the vagal influence on atrial ERP shortening compared to baseline levels. Direct BTX injection did not cause myocardial dysfunction or histologic adverse effects.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,692 | Voltage-directed cavo-tricuspid isthmus ablation using a novel ablation catheter mapping technology in a myotonic dystrophy type I patient. | A successful case of maximum voltage-directed cavo-tricuspid isthmus (CTI) ablation using a novel ablation catheter mapping technology in a myotonic dystrophy type I (DM1) patient is reported. The patient complained recurrent episodes of atrial flutter, revealed by the atrio-ventricular electrograms analysis during the routine pacemaker controls. |
20,693 | Adult out-of-hospital cardiac arrest in philadelphia from 2008-2012: An epidemiological study. | Wide variation in out-of-hospital cardiac arrest (OHCA) survival has been reported, with low survival in urban settings. We sought to describe the epidemiology of OHCA in Philadelphia, Pennsylvania, the fifth largest U.S. city, and identify potential areas for targeted interventions to improve survival.</AbstractText>Retrospective chart review of adult, non-traumatic, OHCA occurring in Philadelphia between 2008 and 2012. We determined incidence and epidemiological factors including: demographics, initial cardiac rhythm, bystander cardiopulmonary resuscitation, automated external defibrillator use, return of spontaneous circulation and 30-day survival. 5198 cases of adult, non-traumatic OHCA were identified. The incidence was 81.5/100,000. The majority of cases occurred in a residence (76.2%); 30.4% were witnessed events; the initial cardiac rhythm was pulseless ventricular tachycardia or ventricular fibrillation in 6.2% of cases, pulseless electrical activity in 21.0%, asystole in 38.3% and was unknown or undocumented in the remaining 34.5%. Multivariate logistic regression analysis demonstrated increased 30-day survival with younger age, shockable cardiac rhythms, and daytime arrest. 30-day survival was 8.1% for EMS-assessed patients and 8.6% for EMS-transported patients.</AbstractText>Philadelphia's reported incidence is consistent with urban settings although the survival rate is higher than other urban centers.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,694 | [Emergency treatment of tachycardias]. | The treatment of symptomatic tachycardia is a key challenge in intensive care medicine and emergency care. Making a quick and authoritative diagnosis on an ECG and applying adequate emergency treatment requires a structured approach to analyzing and treating arrhythmias. This CME article offers a practical categorization of the multitude of tachycardias, with medical and electrical treatment options and ECG examples. Appropriate first- and second-line treatment options are presented for most common tachyarrhythmias. |
20,695 | Use of Antiarrhythmic Medications in Medicare Part D Patients With an Implantable Cardioverter-Defibrillator and Ventricular Tachycardia. | Ventricular tachycardia (VT) is common in cardiomyopathy patients with an implantable cardioverter-defibrillator. This analysis evaluated antiarrhythmic medication use and change in use over time in patients with VT and structural heart disease. Query of Medicare claims identified patients with an implantable cardioverter-defibrillator and VT. Patients with atrial fibrillation or supraventricular tachycardia were excluded. Two cohorts were created of patients enrolled in Medicare Part D for the 12 months before 2007 and 2012. Patients were identified through a search for antiarrhythmic medication fills with a supply covering January 1 of the cohort year. Adjusted logistic regression modeling evaluated the association between patient characteristics and antiarrhythmic medication use. The 2007 (n = 2,334) and 2012 (n = 3,892) Medicare Part D cohorts had similar demographics: median age 76 years, 64%-67% male, and 87%-89% white. Of the 2007 cohort, 1,380 (59%) patients were on a beta blocker, and 484 (20.7%) were on an antiarrhythmic medication (70% amiodarone and 20% sotalol). Between 2007 and 2012, there was a statistically significant higher use of any antiarrhythmic medication (p = 0.014), beta blockers (p <0.0001), mexiletine (p = 0.005), and ranolazine (p <0.0001), while amiodarone use remained unchanged (p = 0.53). After multivariable adjustment, male gender and renal disease were associated with higher antiarrhythmic medication use. In conclusion, although antiarrhythmic medication and beta blocker use in patients with VT increased over time, <1 in 4 patients were on an antiarrhythmic medication and only 65% of the patients were on a beta blocker. |
20,696 | Safety of fluoroscopy-guided transseptal approach for ablation of left-sided arrhythmias. | The transseptal approach is used for left atrial access during the ablation of atrial fibrillation (AF) and other left-sided arrhythmia substrates. Transseptal puncture (TP) is commonly performed with fluoroscopic guidance, contrast injection, and pressure monitoring. In many centres, additional techniques [intracardiac echocardiography (ICE), transoesophageal echocardiography (TEE), radiofrequency needle] are used to facilitate TP but its use adds costs. In this retrospective study, we studied the safety and complication rate when TP was routinely done with fluoroscopic guidance, contrast injection, and pressure monitoring using ICE or TEE only in selected cases.</AbstractText>This study analysed 4690 consecutive TP performed between 2000 and 2015: 3408 (72.6%) were ablation of AF, left-sided atrial flutter, or left-sided atrial tachycardia (non-AP group); 1153 (24.6%) were ablation of left-sided accessory pathway, AP group; and 129 (2.8%) were ablation of ventricular tachycardia. Transseptal puncture was done under fluoroscopy, pressure monitoring, and commonly using contrast media injection. In 27 procedures, ICE or TEE was used to guide the TP. We found 34 tamponades (Tx) that required pericardial drainage of which 28 (0.59%) could possibly be TP related and six could not. The total complication rate for all Tx was 0.72%. A higher rate of tamponades was observed in the AF (non-AP) group than in the AP group (0.88 vs. 0.17%, P < 0.02). The highest rate of tamponades was registered during the operators 51-100 cases, 1.3%, and decreased to 0.4% in cases 101-200, P = 0.04.</AbstractText>TP can safely be done under fluoroscopy and pressure monitoring without routine use of additional techniques. With experience, operators should be able to further decrease complication rate.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
20,697 | Long-term outcome of pulmonary vein isolation in patients with paroxysmal atrial fibrillation and Brugada syndrome. | The therapeutical management of atrial fibrillation (AF) in the setting of Brugada syndrome (BS) might be challenging as many antiarrhythmic drugs (AADs) with sodium channel blocking properties might lead to to the development of ventricular arrhythmias. This study sought to evaluate the clinical outcome in a consecutive series of patients with BS having undergone pulmonary vein (PV) isolation by means of radiofrequency (RF) or cryoballoon (CB) ablation and the efficacy of catheter ablation for preventing inappropriate interventions delivered by implantable cardioverter defibrillators (ICD) on a 3-year follow up.</AbstractText>Twenty-three consecutive patients with BS (13 males; mean age was 47 ± 18 years) having undergone PV isolation for drug-resistant paroxysmal AF were enrolled. Eleven patients (48%) had an ICD implanted of whom four had inappropriate shocks secondary to rapid AF. Over a mean follow-up period of 35.0 ± 25.4 months (median 36 months) the freedom from AF recurrence after the index PV isolation procedure was 74% without AADs. Patients with inappropriate ICD interventions for AF did not present futher ICD shocks after AF ablation. No major complications occurred.</AbstractText>Catheter ablation is a valid therapeutic choice for patients with BS and paroxysmal AF considering the high success rates, the limitations of the AADs and the safety of the procedure, and it should be taken into consideration especially in those patients presenting inappropriate ICD shocks due to rapid AF.</AbstractText>Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.</CopyrightInformation> |
20,698 | High rate of subcutaneous implantable cardioverter-defibrillator sensing screening failure in patients with Brugada syndrome: a comparison with other inherited primary arrhythmia syndromes. | Subcutaneous implantable cardioverter-defibrillator (S-ICD) can avoid important complications associated with transvenous leads in patients with inherited primary arrhythmia syndromes, who do not need pacing therapy. Few data are available on the percentage of patients with inherited arrhythmia syndromes eligible for S-ICD implantation. Aim of this study was to analyse the eligibility for S-ICD in a series of patients with Brugada syndrome (BrS), and to compare it with patients with other channelopathies.</AbstractText>Patients presenting with BrS, long-QT syndrome (LQTS), early repolarization syndrome (ERS), and idiopathic ventricular fibrillation (IVF) were considered eligible for this study. ECG screening was performed by analysis of QRS complex and T wave morphology recorded in standing and supine position. Eligibility was defined when ≥1 sense vector was acceptable in both supine and standing position. A total of 100 patients (72 males; mean age: 46 ± 17 years) underwent S-ICD sensing screening. Sixty-one patients presented with BrS, 21 with LQTS, 14 with IVF, and 4 with ERS. Thirty-four patients with BrS (56%) presented with spontaneous type 1 ECG. In the other 27 patients (44%), type 1 ECG was unmasked by ajmaline. Overall, rate of screening failure was 13%. Patients with BrS had a higher rate of inappropriate morphology analysis as compared with other channelopathies (18% vs. 5%, P = 0.07) and had a lower number of suitable sensing vectors (49.6% vs. 84.7% vs. P < 0.001). Ajmaline challenge unmasked sensing failure in 14.8% of drug-induced BrS patients previously considered eligible. In all patients, the reason for sensing inappropriateness was due to the presence of high T wave voltages.</AbstractText>S-ICD screening failure occurs in up to 13% of patients with inherited primary arrhythmia syndromes. Patients with BrS present a higher rate of screening failure as compared with other cardiac channelopathies.</AbstractText> |
20,699 | Single-site ventricular pacing via the coronary sinus in patients with tricuspid valve disease. | To evaluate coronary sinus single-site (CSSS) left ventricular pacing in adult patients with normal left ventricular ejection fraction (LVEF) when traditional right ventricular lead implantation is not feasible or is contraindicated.</AbstractText>We performed a retrospective analysis of 23 patients with tricuspid valve surgery/disease who received a CSSS ventricular pacing lead to avoid crossing the tricuspid valve. Two matched control populations were obtained from patients receiving (i) conventional right ventricular single-site (RVSS) leads and (ii) coronary sinus leads for cardiac resynchronization therapy (CSCRT). Main outcomes of interest were lead stability, electrical lead parameters and change in LVEF during long-term follow-up. Successful CSSS pacing was accomplished in all 23 patients without any procedural complications. During the 5.3 ± 2.8-year follow-up 22/23 (95.7%) leads were functional with stable pacing and sensing parameters, and 1/23 (4.3%) was extracted for unrelated reasons. Compared to CSSS leads, the lead revision/abandonment was similar with RVSS leads (Hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.03, 22.0), but was higher with CSCRT leads (HR 7.41, 95% CI 1.30, 139.0). There was no difference in change in LVEF between CSSS and RVSS groups (-2.4 ± 11.0 vs. 1.5 ± 12.8, P = 0.76), but LVEF improved in CSCRT group (11.2 ± 16.5%, P = 0.002). Fluoroscopy times were longer during implantation of CSSS compared to RVSS leads (25.6 ± 24.6 min vs. 12.3 ± 18.6 min, P = 0.049).</AbstractText>In patients with normal LVEF, single-site ventricular pacing via the coronary sinus is a feasible, safe and reliable alternative to right ventricular pacing.</AbstractText> |
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