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20,800 | Atrioventricular dyssynchrony from empiric device settings is common in cardiac resynchronization therapy and adversely impacts left ventricular morphology and function. | Echocardiographic atrioventricular (AV) optimization after cardiac resynchronization therapy (CRT) is uncommon due to time constraints and the use of vendor-specific device algorithms. It remains unclear whether optimization of mitral inflow velocities can still be useful. We aimed to investigate post implantation left ventricular (LV) inflow patterns to determine the incidence of AV dyssynchrony from empirically set devices.</AbstractText>This was a retrospective study of patients undergoing CRT using empiric device settings. Forty-eight patients with clinical, echocardiographic, and pacemaker follow-up were grouped by their post implantation LV filling pattern. Baseline characteristics and echocardiographic measurements were compared with post implantation findings at median 6.3 months (interquartile range [IQR], 3.9-17.0).</AbstractText>Twenty-four patients demonstrated AV dyssynchrony (Group 1) after CRT, and 24 patients did not (Group 2). Group 1 patients had less LV reverse remodeling compared to Group 2 patients (ΔLV end-diastolic volume: -3.6 mL vs -49.5 mL, P<.05; ΔLV end-systolic volume: -16.9 mL vs -53.5 mL, P<.05) and did not experience significant improvements in LV outflow tract velocity time integral, stroke volume, or LV ejection fraction. There were no differences in new-onset atrial fibrillation, heart failure readmissions, or mortality between groups.</AbstractText>Our study suggests that up to 50% of patients with empiric device settings have AV dyssynchrony at 6 months despite atrioventricular delay optimization (AVO) algorithms. As AV dyssynchrony is common and has proven to be modifiable, a strategic approach to Doppler echocardiography-guided AVO after CRT is warranted, particularly in nonresponders where the LV filling pattern is fused or truncated.</AbstractText>© 2017, Wiley Periodicals, Inc.</CopyrightInformation> |
20,801 | Association of left atrial enlargement with ventricular remodeling in hypertensive Chinese elderly. | It is not well known whether left atrial (LA) enlargement is associated with left ventricular (LV) remodeling in Asian subjects with preserved LV ejection fraction (LVEF ≥50%). Therefore, we studied whether LA enlargement is related to ventricular remodeling in hypertensive Chinese elderly with preserved LVEF.</AbstractText>Data of 480 hypertensive Chinese elderly (age from 65 to 94 years) with LVEF ≥50% were consecutively included in the study.</AbstractText>We observed a total of 248 patients (51.7%) with increased LA size. Univariate analysis showed that LA size was positively related to duration of hypertension, prevalence of coronary heart disease and atrial fibrillation, interventricular septal thickness, LV posterior wall thickness, LV end-diastolic and end-systolic diameter, LV mass index, right ventricular (RV) diameter and aortic diameter; meanwhile, LA size was inversely related to LVEF and relative wall thickness of LV. Multivariate regression analysis showed that LA enlargement was positively related to duration of hypertension (P=.012) and RV diameter (P<.001).</AbstractText>Left atrial enlargement is independently associated with a longer duration of hypertension and RV dilative remodeling in hypertensive elderly with preserved LVEF. LA enlargement is an early sign of RV eccentric remodeling in hypertensive elderly.</AbstractText>© 2017, Wiley Periodicals, Inc.</CopyrightInformation> |
20,802 | Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial. | To evaluate whether a clinical aid providing precalculated medication doses decreases prescribing errors among residents during pediatric simulated cardiopulmonary arrest and anaphylaxis.</AbstractText>A crossover randomized trial was conducted in a tertiary care hospital simulation center with residents rotating in the pediatric emergency department. The intervention was a reference book providing weight-based precalculated doses. The control group used a card providing milligram-per-kilogram doses. The primary outcome was the presence of a prescribing error, defined as a dose varying by ≥20% from the recommended dose or by incorrect route. Residents were involved in 2 sets of paired scenarios and were their own control group. Primary analysis was the difference in mean prescribing error proportions between both groups.</AbstractText>Forty residents prescribed 1507 medications or defibrillations during 160 scenarios. The numbers of prescribing errors per 100 bolus medications or defibrillations were 5.1 (39 out of 762) and 7.5 (56 out of 745) for the intervention and control, respectively, a difference of 2.4 (95% confidence interval [CI], -0.1 to 5.0). However, the intervention was highly associated with lower risk of 10-fold error for bolus medications (odds ratio 0.27; 95% CI, 0.10 to 0.70). For medications administered by infusion, prescribing errors occurred in 3 out of 76 (4%) scenarios in the intervention group and 13 out of 76 (22.4%) in the control group, a difference of 13% (95% CI, 3 to 23).</AbstractText>A clinical aid providing precalculated medication doses was not associated with a decrease in overall prescribing error rates but was highly associated with a lower risk of 10-fold error for bolus medications and for medications administered by continuous infusion.</AbstractText>Copyright © 2017 by the American Academy of Pediatrics.</CopyrightInformation> |
20,803 | Benefit of the Wearable Cardioverter-Defibrillator in Protecting Patients After Implantable-Cardioverter Defibrillator Explant: Results From the National Registry. | This study reports on the time course of reimplantation and benefits of the wearable cardioverter-defibrillator (WCD) in patients post implantable cardioverter-defibrillator (ICD) explantation.</AbstractText>The WCD is used to treat patients at high risk for ventricular tachycardia (VT) and ventricular fibrillation (VF), including patients with ICD-related infections who undergo device removal and cannot be immediately reimplanted.</AbstractText>This retrospective study included consecutive patients from 2002 to 2014 who underwent ICD removal because of device-related infection and were prescribed a WCD. WCD-stored electrocardiograms were reviewed. Event outcome was assessed through either the manufacturer WCD registry or the Social Security death index search.</AbstractText>A total of 8,058 patients (mean age 62 ± 14 years, 75% male) were included in the analysis. Median time to reimplantation of an ICD was 50 days (interquartile range: 24 to 83 days). While wearing the WCD, 334 patients (4%) experienced 406 VT/VF events, of which 348 events were treated. Shocks were averted in 54 events by conscious patients. The overall 24-h survival, both treated and nontreated, was 93% (312 of 334). VT/VF occurrence was the highest in the initial weeks after ICD removal (0.9%, 0.7%, and 0.7% per week for weeks 1, 2, and 3, respectively). The 12-month cumulative event rate was 10%. For all patients, the 30-day post-event survival was 81%. An ICD was reimplanted in 80% of patients.</AbstractText>The risk of VT/VF reaches 4% during the first 2 months and 10% at 1 year after ICD removal. WCD demonstrated a high efficacy for protecting patients from VT/VF. Clinicians may use the WCD as an ICD alternative when reimplantation is medically delayed.</AbstractText>Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,804 | Characterization of rate and regularity of ventricular response during atrial tachyarrhythmias. Insight on atrial and nodal determinants. | Ventricular rate and regularity affect hemodynamic stability and are targets of rate control therapy in patients with atrial flutter (AFL) and atrial fibrillation (AF). Nevertheless, the characteristics and determinants of ventricular response during these atrial arrhythmias are poorly understood. This work aims to investigate the effects of changes in atrial activity and atrioventricular (AV) conduction patterns on ventricular response in patients with atrial tachyarrhythmias by a combined quantitative analysis of atrial and ventricular time series.</AbstractText>Time series were determined in patients during 24 episodes of AFL and 13 episodes of AF. Ventricular response was characterized in terms of mean ventricular interval, time-domain variability parameters, and entropy-based irregularity measures (quadratic entropy rate, QSE, and coefficient of sample entropy, COSEn). Atrial activity was characterized in terms of mean atrial rate and variability. AV conduction was analyzed by AV synchrogram method, quantifying the stability of AV coupling and the average AV conduction ratio. The dependence of ventricular features on atrial/AV determinants was investigated by correlation analysis.</AbstractText>The analysis showed ventricular response to display a wide spectrum of variability and irregularity features at changing atrial and AV properties. The ventricular interval was significantly correlated with the AV conduction ratio (Spearman correlation coefficient ρ  =  -0.76, p  <  0.005), while it did not correlate with atrial rate. The variability and irregularity of ventricular response were influenced by both atrial and AV parameters. QSE and COSEn significantly increased at shorter atrial cycle lengths (ρ  =  -0.67 and  -0.71, p  <  0.005), at higher atrial variability (ρ  =  0.80 and 0.77, p  <  0.005), at reduced AV coupling (ρ  =  -0.91, p  <  0.005) and at smaller AV conduction ratios (ρ  =  -0.65 and  -0.52, p  <  0.005).</AbstractText>The identification of the determinants of ventricular rate and regularity may have significant implications in the development of efficacious rate control strategies in patients with atrial tachyarrhythmias.</AbstractText> |
20,805 | Surface ECG and Fluoroscopy are Not Predictive of Right Ventricular Septal Lead Position Compared to Cardiac CT. | Controversy exists regarding the optimal lead position for chronic right ventricular (RV) pacing. Placing a lead at the RV septum relies upon fluoroscopy assisted by a surface 12-lead electrocardiogram (ECG). We compared the postimplant lead position determined by ECG-gated multidetector contrast-enhanced computed tomography (MDCT) with the position derived from the surface 12-lead ECG.</AbstractText>Eighteen patients with permanent RV leads were prospectively enrolled. Leads were placed in the RV septum (RVS) in 10 and the RV apex (RVA) in eight using fluoroscopy with anteroposterior and left anterior oblique 30° views. All patients underwent MDCT imaging and paced ECG analysis. ECG criteria were: QRS duration; QRS axis; positive or negative net QRS amplitude in leads I, aVL, V1, and V6; presence of notching in the inferior leads; and transition point in precordial leads at or after V4.</AbstractText>Of the 10 leads implanted in the RVS, computed tomography (CT) imaging revealed seven to be at the anterior RV wall, two at the anteroseptal junction, and one in the true septum. For the eight RVA leads, four were anterior, two septal, and two anteroseptal. All leads implanted in the RVS met at least one ECG criteria (median 3, range 1-6). However, no criteria were specific for septal position as judged by MDCT. Mean QRS duration was 160 ± 24 ms in the RVS group compared with 168 ± 14 ms for RVA pacing (P = 0.38).</AbstractText>We conclude that the surface ECG is not sufficiently accurate to determine RV septal lead tip position compared to cardiac CT.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,806 | Clinical presentation of patients with spontaneous coronary artery dissection. | Spontaneous coronary artery dissection (SCAD) is an infrequent but important cause of myocardial infarction (MI) especially in younger women. However, the clinical presentation and the acuity of symptoms prompting invasive management in SCAD patients have not been described. Understanding these presenting features may improve SCAD diagnosis and management.</AbstractText>We reviewed SCAD patients who were prospectively followed at the Vancouver General Hospital SCAD Clinic. Their presenting symptoms and unstable features were obtained from detailed clinical histories and hospital admission documentation. Baseline characteristics, predisposing and precipitating conditions, angiographic findings, management strategies, in-hospital, and long-term events were recorded prospectively.</AbstractText>We included 196 SCAD patients who had complete documentation of their presenting symptoms. The majority were women (178/196; 90.8%) and all presented with MI (24.0% STEMI). The most frequent presenting symptom was chest discomfort, reported by 96%. Other symptoms included arm pain (49.5%), neck pain (22.1%), nausea or vomiting (23.4%), diaphoresis (20.9%), dyspnea (19.3%), and back pain (12.2%). Ventricular tachycardia/fibrillation occurred in 8.1% (16/196), with 1.0% having cardiac arrest. The time from symptom onset to hospital presentation was 1.1 ± 3.0 days. NSTEMI patients had longer delay for coronary angiography compared with STEMI (2.0 ± 2.5 days vs. 0.8 ± 1.7 days, P = 0.002). Overall, 34.2% had unstable symptoms upon arrival for coronary angiography. Those with unstable symptoms were more likely to undergo repeat angiography (65.7% vs. 50.4%, P = 0.049), and repeat or unplanned revascularization (14.9% vs. 5.4%, P = 0.033) during acute hospitalization.</AbstractText>Chest discomfort was the most frequent presenting symptom with SCAD and one-third had unstable symptoms prompting urgent invasive angiography. © 2017 Wiley Periodicals, Inc.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,807 | Ventricular Fibrillation and Tachycardia detection from surface ECG using time-frequency representation images as input dataset for machine learning. | To safely select the proper therapy for Ventricullar Fibrillation (VF) is essential to distinct it correctly from Ventricular Tachycardia (VT) and other rhythms. Provided that the required therapy would not be the same, an erroneous detection might lead to serious injuries to the patient or even cause Ventricular Fibrillation (VF). The main novelty of this paper is the use of time-frequency (t-f) representation images as the direct input to the classifier. We hypothesize that this method allow to improve classification results as it allows to eliminate the typical feature selection and extraction stage, and its corresponding loss of information.</AbstractText>The standard AHA and MIT-BIH databases were used for evaluation and comparison with other authors. Previous to t-f Pseudo Wigner-Ville (PWV) calculation, only a basic preprocessing for denoising and signal alignment is necessary. In order to check the validity of the method independently of the classifier, four different classifiers are used: Logistic Regression with L2 Regularization (L2 RLR), Adaptive Neural Network Classifier (ANNC), Support Vector Machine (SSVM), and Bagging classifier (BAGG).</AbstractText>The main classification results for VF detection (including flutter episodes) are 95.56% sensitivity and 98.8% specificity, 88.80% sensitivity and 99.5% specificity for ventricular tachycardia (VT), 98.98% sensitivity and 97.7% specificity for normal sinus, and 96.87% sensitivity and 99.55% specificity for other rhythms.</AbstractText>Results shows that using t-f data representations to feed classifiers provide superior performance values than the feature selection strategies used in previous works. It opens the door to be used in any other detection applications.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,808 | A method to differentiate between ventricular fibrillation and asystole during chest compressions using artifact-corrupted ECG alone. | In recent years, numerous adaptive filtering techniques have been developed to suppress the chest compression (CC) artifact for reliable analysis of the electrocardiogram (ECG) rhythm without CC interruption. Unfortunately, the result of rhythm diagnosis during CCs is still unsatisfactory in many studies. The misclassification between corrupted asystole (ASY) and corrupted ventricular fibrillation (VF) is generally regarded as one of the major reasons for the poor performance of reported methods. In order to improve the diagnosis of VF/ASY corrupted by CCs, a novel method combining a least mean-square (LMS) filter and an amplitude spectrum area (AMSA) analysis was developed based only on the analysis of the surface of the corrupted ECG episode. This method was tested on 253 VF and 160 ASY ECG samples from subjects who experienced cardiac arrest using a porcine model and was compared with six other algorithms. The validation results indicated that this method, which yielded a satisfactory result with a sensitivity of 93.3%, a specificity of 96.3% and an accuracy of 94.8%, is superior to the other reported techniques. After improvement using the human ECG records in real cardiopulmonary resuscitation (CPR) scenarios, the algorithm is promising for corrupted VF/ASY detection with no hardware alterations in clinical practice. |
20,809 | Value of Cardiovascular Magnetic Resonance Imaging in Noninvasive Risk Stratification in Tetralogy of Fallot. | Adults late after total correction of tetralogy of Fallot (TOF) are at risk for major complications. Cardiovascular magnetic resonance (CMR) imaging is recommended to quantify right ventricular (RV) and left ventricular (LV) function. However, a commonly used risk model by Khairy et al requires invasive investigations and lacks CMR imaging to identify high-risk patients.</AbstractText>To implement CMR imaging in noninvasive risk stratification to predict major adverse clinical outcomes.</AbstractText><AbstractText Label="DESIGN, SETTING, AND PARTICIPANTS">This multicenter study included 575 adult patients with TOF (4.083 patient-years at risk) from a prospective nationwide registry in whom CMR was performed. This study involved 5 tertiary referral centers with a specialized adult congenital heart disease unit. Multivariable Cox hazards regression analysis was performed to determine factors associated with the primary end point. The CMR variables were combined with the noninvasive components of the Khairy et al risk model, and the C statistic of the final noninvasive risk model was determined using bootstrap sampling. The data analysis was conducted from January to December 2016.</AbstractText>The composite primary outcome was defined as all-cause mortality or ventricular arrhythmia, defined as aborted cardiac arrest or documented ventricular fibrillation and ventricular tachycardia (lasting ≥30 seconds or recurrent symptomatic).</AbstractText>Of the 575 patients with TOF, 57% were male, and the mean (SD) age was 31 (11) years. During a mean (SD) follow-up of 7.1 (3.5) years, the primary composite end point occurred in 35 patients, including all-cause mortality in 13 patients. Mean (SD) RV ejection fraction (EF) was 44% (10%), and mean (SD) LV EF was 53% (8%). There was a correlation between RV EF and LV EF (R, 0.36; 95% CI, 0.29-0.44; P < .001). Optimal thresholds for ventricular function (RV EF <30%: hazard ratio, 3.90; 95% CI, 1.84-8.26; P < .001 and LV EF <45%: hazard ratio, 3.23; 95% CI, 1.57-6.65; P = .001) were independently predictive in multivariable analysis. Both thresholds were included in a point-based noninvasive risk model (C statistic, 0.75; 95% CI, 0.63-0.85) and combined with the noninvasive components of the Khairy et al risk model.</AbstractText>In patients with repaired TOF, biventricular dysfunction on CMR imaging was associated with major adverse clinical outcomes. The quantified thresholds (RV EF <30% and LV EF <45%) may be implemented in noninvasive risk stratification.</AbstractText> |
20,810 | Pattern of initiation of monomorphic ventricular tachycardia and implications on tachycardia mechanism. | The incidence of sudden cardiac death, predominantly caused by ventricular tachycardia and ventricular fibrillation, is high in patients with congestive heart failure. Implantable cardiac defibrillators have improved survival in this population but defibrillator shocks can lead to low quality of life and heart failure progression. The current management of recurrent ventricular tachycardia includes ablation and anti-arrhythmic drugs and both are associated with high recurrence rates. Better understanding the mechanism of ventricular tachycardia allowing individualization of treatment may improve outcomes. Re-entry is currently accepted as the mechanism of the majority of monomorphic ventricular tachycardias in patients with congestive heart failure, being responsible for more than 90% of the ventricular tachycardia in patients with ischemic cardiomyopathy. On the other hand, some studies show a greater participation of focal arrhythmias in the genesis of ventricular tachycardia in this population. The pattern of initiation of ventricular tachycardia is divided into sudden, when the first beat of the tachycardia is morphologically similar to the rest of the tachycardia, and non-sudden, when its morphology is dissimilar. An association between the pattern of the initiation and the mechanism of ventricular tachycardia has been proposed. The pattern of initiation of ventricular tachycardia is a readily available from data stored in current generation implantable cardiac defibrillators. The association with tachycardia mechanism may allow individualization of the therapy, however evidence is lacking and further research is required. |
20,811 | Ventricular Tachyarrhythmias in Patients With Hypertrophic Cardiomyopathy and Defibrillators: Triggers, Treatment, and Implications. | Triggers and ICD interventions of ventricular arrhythmias in patients with hypertrophic cardiomyopathy (HCM) offer insight into mechanisms and treatment.</AbstractText>Intracardiac ICD electrograms from 71 HCM patients in the HCM I and II studies were analyzed by three individuals. Rhythms were defined as VF (polymorphic ventricular arrhythmia), VT (monomorphic ventricular tachycardia), and ventricular flutter (VFL; VT ≥ 240 bpm). Physical activity and rhythm preceding the arrhythmia were ascertained. Of 149 arrhythmias, VF was present in 74, VT in 57, and VFL in 18. In those whose activity was known, moderate or intense physical activity was associated with over 50% of the tachycardias (57 of 111). Rhythms preceding ventricular arrhythmias were often sinus tachycardia (49 of 149; 33%) or rapid atrial fibrillation (7 of 149; 5%). VF and VFL were more likely preceded by supraventricular rhythms >100 bpm (30 of 68 with VF; 44%; 12 of 16 with VFL 75%, vs. 14 of 50 with VT 28%; P = 0.001). Antitachycardia pacing (ATP) was successful in 39 of 53 (74%). Multiple shocks were more often required to terminate VFL (10 of 18; 56%) compared to VF (10 of 72; 14%) and VT (2 of 25; 8%; P < 0.0001). Of arrhythmias requiring more than one shock to terminate, 16 of 22 were preceded by sinus tachycardia and/or moderate or extreme physical activity.</AbstractText>Rapid supraventricular rhythms, and at least moderate activity, frequently precede VT and VF, and when they occur in these situations often require multiple ICD shocks to restore sinus rhythm. ATP is successful in terminating VT and VFL, and should be a programmed in all HCM patients with ICDs.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,812 | Assessment of left atrial mechanical function and synchrony in paroxysmal atrial fibrillation with two-dimensional speckle tracking echocardiography. | The aim of this study was to investigate left atrial (LA) function and synchrony in paroxysmal atrial fibrillation (PAF) patients using two-dimensional speckle tracking echocardiography (STE).</AbstractText>Forty-five PAF patients and 30 healthy controls were enrolled. LA peak ventricular systolic longitudinal strain (LAS</sub>-S</sub> ) and strain rate (LASR</sub>-S</sub> ) and left atrial longitudinal strain (LAS</sub>-A</sub> ) and strain rate (LASR</sub>-A</sub> ) during late diastole were determined using STE, and the standard deviation of the time to peak (TPSD) of the regional strains was calculated to quantify LA dyssynchrony. TPSD during ventricular systole and late diastole were named SDs and SDa, respectively.</AbstractText>Left atrial peak longitudinal strain during ventricular systole (LAS</sub>-S</sub> ) (29.34±8.57 vs 36.73±6.13), LASR</sub>-S</sub> (1.27±0.311 vs 1.57±0.25), LAS</sub>-A</sub> (13.11±4.91 vs 17.86±3.57), and LASR</sub>-A</sub> (-1.51±0.58 vs -1.90±0.30) were reduced in the PAF group compared with the controls (P<.05 for all). SDs (8.11±3.00% vs 4.67±1.48%) and SDa (5.57±2.26% vs 3.11±1.13%) were greater in PAF patients than in the controls (P<.05 for both). Furthermore, PAF patients with normal LA sizes exhibited lower LAS</sub>-S</sub> (P<.05), LASR</sub>-S</sub> (P<.05), LAS</sub>-A</sub> (P<.05), and LASR</sub>-A</sub> (P<.05) values and increased SDs (P<.05) and SDa (P<.05) values compared with the controls. Multivariate regression confirmed that SDs and SDa were powerful parameters for differentiating PAF patients from controls (SDs: sensitivity, 83%; specificity, 72%; SDa: sensitivity, 81%; specificity, 76%).</AbstractText>Left atrial (LA) dysfunction and dyssynchrony in PAF patients can be detected with STE even in the absence of LA enlargement. STE-derived SDs and SDa were powerful parameters for identifying PAF patients.</AbstractText>© 2017, Wiley Periodicals, Inc.</CopyrightInformation> |
20,813 | Minimal Invasive Left Ventricular Lead Repositioning is Safe and Effective in Distal Left Ventricular Lead Positions. | Treatment of left ventricular electrode dislocation and phrenic nerve stimulation remains an issue in the era of new electrode designs.</AbstractText>Safety and efficacy of minimal invasive lead repositioning and pocket opening reposition procedures were evaluated between December 2005 and December 2012 at our center. Minimal invasive method was developed and widely utilized at our center to treat phrenic nerve stimulation. The distally positioned left ventricular lead is looped around by a deflectable catheter in the right atrium introduced from the femoral vein access and then pulled back. Coronary stent implantation was used afterwards for lead stabilization in some patients.</AbstractText>42 minimal invasive and 48 electrode repositions with pacemaker pocket opening were performed at 77 patients for left ventricular lead problems. Minimal invasive reposition could be carried out successfully in 69% of (29 patients) cases. Note that in 14.3% of the cases (six patients) minimal invasive procedures were acutely unsuccessful and crossover was necessary. In 16.6% of the cases (seven patients) lead issues were noted later during follow-up. Opening of the pocket could be carried out successfully in 81.2% (39 patients) and was unsuccessful acutely in 6.25% (three patients). Repeated dislocation was noticed, 12.5%, in this group (six patients). Complication during minimal invasive procedures was electrode injury in one case. Pocket openings were associated with several complications: atrial fibrillation, pericardial effusion, fever, hematoma, and right ventricular electrode dislodgement.</AbstractText>Minimal invasive procedure-as the first line approach-is safe and feasible for left ventricular electrode repositioning in selected cases.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,814 | Defibrillation before EMS arrival in western Sweden. | Bystanders play a vital role in public access defibrillation (PAD) in out-of-hospital cardiac arrest (OHCA). Dual dispatch of first responders (FR) alongside emergency medical services (EMS) can reduce time to first defibrillation. The aim of this study was to describe the use of automated external defibrillators (AEDs) in OHCAs before EMS arrival.</AbstractText>All OHCA cases with a shockable rhythm in which an AED was used prior to the arrival of EMS between 2008 and 2015 in western Sweden were eligible for inclusion. Data from the Swedish Register for Cardiopulmonary Resuscitation (SRCR) were used for analysis, on-site bystander and FR defibrillation were compared with EMS defibrillation in the final analysis.</AbstractText>Of the reported 6675 cases, 24% suffered ventricular fibrillation (VF), 162 patients (15%) of all VF cases were defibrillated before EMS arrival, 46% with a public AED on site. The proportion of cases defibrillated before EMS arrival increased from 5% in 2008 to 20% in 2015 (p<0.001). During this period, 30-day survival increased in patients with VF from 22% to 28% (p=0.04) and was highest when an AED was used on site (68%), with a median delay of 6.5min from collapse to defibrillation. Adjusted odds ratio for on-site defibrillation versus dispatched defibrillation for 30-day survival was 2.45 (95% CI: 1.02-5.95).</AbstractText>The use of AEDs before the arrival of EMS increased over time. This was associated with an increased 30-day survival among patients with VF. Thirty-day survival was highest when an AED was used on site before EMS arrival.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,815 | Left cardiac sympathetic denervation: case series and technical report. | Left cardiac sympathetic denervation (LCSD) is a surgical procedure that has been shown to have an antiarrhythmic and antifibrillatory effect. Evidence indicating its antiarrhythmic effect has been available for over 100 years. It involves the removal of the lower half of the stellate ganglion and T2-T4 of the sympathetic ganglia and is carried out as either a unilateral or bilateral procedure. With advancements in thoracic surgery, it can be safely performed via a minimally invasive Video-Assisted Thoracoscopic Surgery (VATS) approach resulting in significantly less morbidity and a shortened inpatient stay. LCSD provides a valuable treatment option for patients with life-threatening channelopathies and cardiomyopathies.</AbstractText>This case series reports the preliminary paediatric and adult experience in the Republic of Ireland with LCSD and describes five cases recently treated in addition to an outline of the operative procedure employed. Of the five cases included, two were paediatric cases and three were adult cases.</AbstractText>One of the paediatric patients had a diagnosis of the rare catecholaminergic polymorphic ventricular tachycardia (CPVT) and the other a diagnosis of long-QT syndrome. Both paediatric patients experienced excellent outcomes. Of the three adult patients, two benefitted greatly and remain well at follow-up (one inappropriate sinus tachycardia and one CPVT). One patient with idiopathic ventricular fibrillation unfortunately passed away from intractable VF despite all attempts at resuscitation.</AbstractText>In this case series, we highlight that LCSD provides a critical adjunct to existing medical therapies and should be considered for all patients with life-threatening refractory arrhythmias especially those patients on maximal medical therapy.</AbstractText> |
20,816 | The occurrence of atrial fibrillation in dialysis patients and its association with left atrium volume before and after dialysis. | Atrial fibrillation is a serious problem, especially in patients on dialysis. The prevalence of AF in this group of patients is higher than in general population and associated with increased mortality. The aim of this study was to assess the risk of the occurrence of atrial fibrillation related to intradialysis hypotension and left atrium volume enlargement associated with dialysis. The influence of dialysis session on: E/E', V LA, E/A, E', V RA and the width of inferior vena cava of RV was analyzed.</AbstractText>This study included 40 patients on hemodialysis. Echocardiographic examination was performed to assess heart condition and function, the presence of LVH and systolic and diastolic function disturbances, LV mass, LA size, LAV, RAV, E/A, E', E/E, ejection fraction in all patients before and after dialysis. Moreover, all patients had ECG Holter continuously recording heart's rhythm before and after dialysis to assess the occurrence of atrial fibrillation related to dialysis session.</AbstractText>The analysis of differences in echocardiographic parameters before and after dialysis demonstrated significantly greater left atrium volume, right atrium volume, width of inferior vena cava and e' parameter before dialysis in comparison with post-dialysis state. Significantly higher incidence of AF after dialysis was seen. Volume of left atrium exceeding 32 mm (cutoff value) was observed significantly more often in patients before dialysis. No association was observed between left ventricle mass and left atrium volume.</AbstractText>The dialysis procedure may be a trigger for atrial fibrillation and thus AF preventive measures should be introduced in dialysis patients.</AbstractText> |
20,817 | Esophagopericardial fistula, septic shock and intracranial hemorrhage with hydrocephalus after lung transplantation. | A 57-year old woman underwent lung transplantation for non-specific interstitial pneumonia. Primary graft dysfunction was diagnosed requiring continued use of extracorporeal membrane oxygenation (ECMO). Within three days she developed recurring hemothoraces requiring two surgical evacuations. After ECMO removal a series of complications occurred within four months: femoral thrombosis, persisting tachycardic atrial fibrillation, pneumopericardium with an esophagopericardial fistula and purulent pericarditis, septic shock, multiorgan failure and intracerebral hemorrhage with ventricular involvement requiring external ventricular drainage. Interdisciplinary management coordinated by the intensive care specialist, transplant surgeon and pulmonologist with various interventions by the respective specialists followed by intensive physical rehabilitation allowed for discharge home on day 235 post transplant. Subsequently quality of life was considered good by the patient and family. |
20,818 | Biomarkers of Atrial Cardiopathy and Atrial Fibrillation Detection on Mobile Outpatient Continuous Telemetry After Embolic Stroke of Undetermined Source. | Biomarkers of atrial dysfunction or "cardiopathy" are associated with embolic stroke risk. However, it is unclear if this risk is mediated by undiagnosed paroxysmal atrial fibrillation or flutter (AF). We aim to determine whether atrial cardiopathy biomarkers predict AF on continuous heart-rhythm monitoring after embolic stroke of undetermined source (ESUS).</AbstractText>This was a single-center retrospective study including all patients with ESUS undergoing 30 days of ambulatory heart-rhythm monitoring to look for AF between January 1, 2013 and December 31, 2015. We reviewed medical records for clinical, radiographic, and cardiac variables. The primary outcome was a new diagnosis of AF detected during heart-rhythm monitoring. The primary predictors were atrial biomarkers: left atrial diameter on echocardiography, P-wave terminal force in electrocardiogram (ECG) lead V1, and P wave - R wave (PR) interval on ECG. A multiple logistic regression model was used to assess the relationship between atrial biomarkers and AF detection.</AbstractText>Among 196 eligible patients, 23 (11.7%) were diagnosed with AF. In unadjusted analyses, patients with AF were older (72.4 years versus 61.4 years, P < .001) and had larger left atrial diameter (39.2 mm versus 35.7 mm, P = .03). In a multivariable model, the only predictor of AF was age ≥ 60 years (odds ratio, 3.0; 95% CI, 1.06-8.5; P = .04).</AbstractText>Atrial biomarkers were weakly associated with AF after ESUS. This suggests that previously reported associations between these markers and stroke may reflect independent cardiac pathways leading to stroke. Prospective studies are needed to investigate these mechanisms.</AbstractText>Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,819 | Anticoagulation Therapy and NOACs in Heart Failure. | Current evidence indicates that heart failure (HF) confers a hyper-coagulable state that is associated with adverse events including stroke, systemic embolism, and mortality. This may be due to the elevated levels of pro-thrombotic and pro-inflammatory cytokines that are seen in patients with acute and chronic HF. Left ventricular wall motion abnormalities in patients with systolic dysfunction predispose to local thrombosis due to blood stasis as does atrial fibrillation (AF) which leads to blood stasis in regions of the atria. The high risk of thromboemboli in HF patients with AF has resulted in the use anticoagulation therapy to prevent the occurrence of catastrophic events. There is evidence, however, that the pro-inflammatory, pro-thrombotic state that exists in HF puts patients who are in sinus rhythm at risk. The novel oral anticoagulants (NOACs) have been shown in RCT to have at least equivalent efficacy in reducing stroke as warfarin while exposing patients to a lower risk of bleeding. The fact that the NOACs don't require routine monitoring to assure that patients remain within the therapeutic range and have relatively simple dosing requirements and a safer risk profile makes them attractive substitutes to warfarin in HF patients with atrial fibrillation and other conditions (e.g. deep venous thrombosis). Post hoc analyses from a subset of HF patients from the RCTs in AF patients have demonstrated similar findings as were reported in the entire populations that were included in the trials. As a result, NOACS are commonly used now in HF patients with AF. For HF patients with reduced ejection fraction in sinus rhythm, the use of warfarin in randomized clinical trials (RCT) to reduce stroke has been disappointing and associated with increase bleeding risk when compared to aspirin. The advantages of the NOACs over warfarin, however, raise the question of whether they might improve outcomes in HF patients who are in sinus rhythm. The currently ongoing COMMANDER-HF trial has been designed to address this issue. In this chapter we review evidence of existence of a prothombotic state in HF, the pharmacodynamics and clinical trials of the NOACs and the outcomes from NOAC substudies in the HF subgroup. We also discuss the rationale for using anticoagulation in HF independent of arrhythmia burden. |
20,820 | In-hospital management and outcomes in patients with peripartum cardiomyopathy: a descriptive study using a national inpatient database in Japan. | Peripartum cardiomyopathy (PPCM) is a rare but life-threatening cardiac disorder characterized by maternal systolic heart failure. Although PPCM is a major cause of maternal mortality, little is known about the acute-phase management of PPCM in real-world clinical settings. We retrospectively identified patients hospitalized with PPCM from 2007 to 2014 using the Diagnosis Procedure Combination database in Japan. We investigated patient characteristics, in-hospital examinations and treatment, and in-hospital outcomes. The study patients were 283 patients hospitalized with PPCM at 177 hospitals. The mean age was 32.7 ± 5.5 years. Of the eligible patients, 134 (47.3%) patients had a hypertensive disorder, including 48 (17.0%) patients with pre-eclampsia, and 111 (39.2%) patients were admitted to the intensive care unit or emergency center. Coronary angiography, cardiac magnetic resonance imaging, and endomyocardial biopsy were performed during hospitalization in 69 (24.4%), 42 (14.8%), and 43 (15.2%) patients, respectively. Invasive pulmonary artery pressure monitoring was used in 14 (4.9%) patients. Mechanical circulatory support was used in 13 (4.6%) patients (intra-aortic balloon pumping, n = 12; extracorporeal membrane oxygenation, n = 5; ventricular assist device, n = 0). Catecholamine therapy and phosphodiesterase-III inhibitor therapy were used in 79 (27.9%) and 13 (4.6%) patients, respectively. Prolactin blockade therapy was used in 78 (27.6%) patients. During hospitalization, four (1.4%) patients died and nine (3.2%) patients developed ventricular tachycardia or fibrillation. Two (0.7%) patients received an implantable cardioverter defibrillator, but no patient received other permanent cardiac devices. This retrospective cohort study suggests that attending physicians should be ready to provide intensive care for patients with PPCM during the acute phase. |
20,821 | Hybrid Surgery Options for Complex Clinical Scenarios in Adult Patients with Congenital Heart Disease: Three Case Reports. | The strategy for the management of adult patients with congenital heart disease (CHD) often represents a challenge for cardiac surgeons and cardiologists due to complex anatomy, wide range of clinical presentations, and a high-risk profile. However, hybrid approach may represent an attractive solution. We report three cases of adult patients previously operated for CHD and recently treated with a hybrid approach in our institution. Case 1: a 76-year-old woman with permanent atrial fibrillation, lung disease, chronic kidney disease, microcytic anemia, and type II diabetes mellitus, previously operated for atrial septal defect closure and pulmonary valvotomy, presented with severe pulmonary regurgitation and advanced right ventricular failure. In order to minimize the surgical risk, a hybrid approach was used: an extensive right ventricular outflow tract (RVOT) plication was followed by implantation of an Edwards Sapien XT prosthesis in the RVOT through the right ventricular apex, without cardiopulmonary bypass. Case 2: a 64-year-old man with previous atrial septum excision and pericardial baffle for partial anomalous pulmonary venous drainage with intact interatrial septum, presented with worsening dyspnea, right ventricular failure, and pulmonary hypertension caused by baffle stenosis. His comorbidities included coronary artery disease, atrial flutter, and previous left pneumonectomy. After performing a redo longitudinal median sternotomy, a 20-mm stent was implanted in the baffle with access through the superior vena cava. Case 3: a 50-year-old man, with previous atrioventricular septal defect repair, followed by mitral valve replacement with a mechanical prosthesis, subsequently developed a paravalvular leak (PVL) with severe mitral regurgitation and severe left ventricular dysfunction. He underwent a transapical PVL device closure with two Amplatzer Vascular Plugs. In our opinion, hybrid surgery is a promising therapeutic modality that increases the available treatment options for this patient population. A multidisciplinary and patient-tailored approach is crucial in these complex clinical scenarios. |
20,822 | Progression of paroxysmal to persistent atrial fibrillation: 10-year follow-up in the Canadian Registry of Atrial Fibrillation. | Progression from paroxysmal to persistent atrial fibrillation (AF) has important clinical implications and is relevant to the management of patients with AF.</AbstractText>The purpose of this study was to define the long-term rate of progression from paroxysmal to persistent AF and the relevant clinical variables.</AbstractText>The Canadian Registry of Atrial Fibrillation enrolled patients after a first electrocardiographic diagnosis of paroxysmal AF. Associations between baseline characteristics and clinical outcomes were evaluated using a multivariable Cox proportional hazard model and a competing risk model accounting for death as a competing risk, where appropriate.</AbstractText>We enrolled 755 patients (61.7% men) aged between 14 and 91 years (mean age 61.2 ± 14.2 years). The median follow-up was 6.35 years (interquartile range 2.93-10.04 years), with a rate of progression to persistent AF at 1, 5, and 10 years was 8.6%, 24.3%, and 36.3%, respectively. All-cause mortality was 30.3% at 10 years. Factors associated with AF progression were increasing age (hazard ratio [HR] 1.40; 95% confidence interval [CI] 1.23-1.60, for each 10-year increment), mitral regurgitation (HR 1.87; 95% CI 1.28-2.73), left atrial dilatation (HR 3.01; 95% CI 2.03-4.47), aortic stenosis (HR 2.40; 95% CI 1.05-5.48), and left ventricular hypertrophy (HR .47; 95% CI 1.04-2.08). Factors associated with a lower rate of progression were a faster heart rate during AF (HR 0.94; 95% CI 0.92-0.96 per 5-beat/min increment) and angina (HR 0.54; 95% CI 0.38-0.77). After accounting for death as a competing risk, left ventricular hypertrophy and aortic stenosis were no longer significant.</AbstractText>Within 10 years of presenting with paroxysmal AF, >50% of patients will progress to persistent AF or be dead. Increasing age, mitral regurgitation, aortic stenosis, left ventricular hypertrophy, and left atrial dilatation were associated with progression to persistent AF.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,823 | Effects of Na+ channel blockers on the restitution of refractory period, conduction time, and excitation wavelength in perfused guinea-pig heart. | Na+ channel blockers flecainide and quinidine can increase propensity to ventricular tachyarrhythmia, whereas lidocaine and mexiletine are recognized as safe antiarrhythmics. Clinically, ventricular fibrillation is often precipitated by transient tachycardia that reduces action potential duration, suggesting that a critical shortening of the excitation wavelength (EW) may contribute to the arrhythmic substrate. This study examined whether different INa blockers can produce contrasting effects on the rate adaptation of the EW, which would explain the difference in their safety profile. In perfused guinea-pig hearts, effective refractory periods (ERP), conduction times, and EW values were determined over a wide range of cardiac pacing intervals. All INa blockers tested were found to flatten the slope of ERP restitution, indicating antiarrhythmic tendency. However, with flecainide and quinidine, the beneficial changes in ERP were reversed owing to the use-dependent conduction slowing, thereby leading to significantly steepened restitution of the EW. In contrast, lidocaine and mexiletine had no effect on ventricular conduction, and therefore reduced the slope of the EW restitution, as expected from their effect on ERP. These findings suggest that the slope of the EW restitution is an important electrophysiological determinant which can discriminate INa blockers with proarrhythmic and antiarrhythmic profile. |
20,824 | Routine <sup>18</sup>F-FDG PET/CT does not detect inflammation in the left atrium in patients with atrial fibrillation. | Increasing evidence supports a role of inflammation in the development of atrial fibrillation (AF). However, direct evidence of persistent inflammatory activity in the atria of AF patients is scarce. In this study, we used 18-Fluor-Deoxyglucose positron emission tomography computed tomography (<sup>18</sup>F-FDG PET/CT) to determine atrial inflammation in patients with and without AF. Retrospectively, <sup>18</sup>F-FDG PET/CT scans were analyzed. 37 patients with a history of AF were compared to an age and sex matched control group with no history of AF. Standardized uptake values were obtained in the atrial walls, in the left ventricular wall, and in the right ventricular blood pool, respectively. Target to background ratios (TBR) were determined in the atrial and left ventricular walls and compared between the two groups. TBR values of the left atrial wall were slightly but not significantly higher in patients with AF (1.21 ± 0.27) compared to those without AF (1.14 ± 0.29; p = 0.85). Likewise, a weak but not significant difference was observed in signal intensities in the right atrial wall between patients in the AF (1.14 ± 0.45) and the control group (0.96 ± 0.2; p = 0.41). TBR values of the left ventricular myocardium did not differ between the groups; no significant correlation was found between the TBR in the left and right atrial wall and blood glucose levels. <sup>18</sup>F-FDG PET/CT performed under routine conditions did not detect a significant difference in inflammatory activity in the left or right atrium between patients with and without AF. Contrary to previous reports, these results therefore do not clearly support a role for ongoing atrial inflammation in patients with AF. Prospective clinical studies using myocardial glucose uptake suppression strategies may be helpful to clarify these issues. |
20,825 | Acquired prolongation of QT interval as a risk factor for torsade de pointes ventricular tachycardia: a narrative review for the anesthesiologist and intensivist. | More than 70% of intensive care unit (ICU) patients experience heart rhythm disturbances, and these patients have correspondingly higher mortality rates. Consequently, one of the standards of care in ICUs is continuous electrocardiography monitoring. One of the potentially preventable dysrhythmic events is the occurrence of torsade de pointes ventricular tachycardia in the setting of acquired prolonged QT interval. This type of ventricular tachycardia can be malignant because it often progresses to ventricular fibrillation. Many factors predispose to lengthening of the QT interval, the most important of which are electrolyte abnormalities and the administration of specific medications. In this review, we discuss the pathophysiology of acquired long QT interval, stressing the medication-induced acquired long QT-interval and factors present in ICU patients that promote prolongation of the QT interval. We also propose guidelines to avoid the occurrence of torsade de pointes ventricular tachycardia. |
20,826 | Findings of transoesophageal echocardiogram in appropriately anticoagulated patients with persistent atrial fibrillation prior to planned cardioversion. | To evaluate a diagnostic value of transoesophageal echocardiogram (TEE) in appropriately anticoagulated patients with a non-valvular atrial fibrillation (AF) and to establish possible additional indications for TEE; to evaluate the incidence of left atrial (LA) thrombi in appropriately anticoagulated patients in daily clinical practice.</AbstractText>This retrospective study analyses data of 432 patients who had been anticoagulated by means of oral anticoagulants (OACs) prior to planned cardioversion during the period from 2012 to 2015. Thromboembolic (TE) and bleeding risks were assessed using CHA2DS2-VASc and HAS-BLED scores. Transthoracic and transoesophageal echocardiograms were evaluated. TE complications during 30 days after discharge were assessed.</AbstractText>432 patients were selected, aged from 22 to 89 years (mean 65.0 ±11.5), 277 (64.1%) males and 155 (35.9%) females, 306 (70.8%) on warfarin and 126 (29.2%) on non-vitamin K antagonist oral anticoagulants (NOAC). Mean CHA2DS2-VASc score was 3.5 ±1.5. TEE was performed for 120 (27.8%) patients, more frequently for patients on NOACs and for ones with III° LA enlargement. TEE revealed LA thrombi in seven (5.8%) of the patients. In warfarin and NOACs groups thrombi were revealed in five (7.0%) and two (4.1%) patients, respectively. TEE did not reveal any thrombi in patients with normal left ventricular (LV) function; however, thrombi were found in two (6.1%) patients with slightly decreased LV function, and in five (17.9%) patients with markedly decreased LV function. In patients with decreased left ventricular ejection fraction (LVEF) thrombi in LA were found more frequently than in patients with normal and slightly decreased LVEF (17.9% vs 2.2%, p=0.008). CHA2DS2-VASc score of all 7 patients was ≥5. None of the patients after cardioversion had TE complications 30 days after discharge.</AbstractText>The risk of LA thrombi in patients prepared for scheduled cardioversion in line with the guidelines is low. Higher risk of thrombi was present in patients with decreased LVEF (≤40%), CHA2DS2-VASc ≥5. In order to assess more accurately indications to perform TEE for appropriately anticoagulated patients prior to scheduled cardioversion a study with larger number of patients is required.</AbstractText> |
20,827 | Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillator. | The presence of a cardiovascular implantable electronic device has long been a contraindication for the performance of magnetic resonance imaging (MRI). We established a prospective registry to determine the risks associated with MRI at a magnetic field strength of 1.5 tesla for patients who had a pacemaker or implantable cardioverter-defibrillator (ICD) that was "non-MRI-conditional" (i.e., not approved by the Food and Drug Administration for MRI scanning).</AbstractText>Patients in the registry were referred for clinically indicated nonthoracic MRI at a field strength of 1.5 tesla. Devices were interrogated before and after MRI with the use of a standardized protocol and were appropriately reprogrammed before the scanning. The primary end points were death, generator or lead failure, induced arrhythmia, loss of capture, or electrical reset during the scanning. The secondary end points were changes in device settings.</AbstractText>MRI was performed in 1000 cases in which patients had a pacemaker and in 500 cases in which patients had an ICD. No deaths, lead failures, losses of capture, or ventricular arrhythmias occurred during MRI. One ICD generator could not be interrogated after MRI and required immediate replacement; the device had not been appropriately programmed per protocol before the MRI. We observed six cases of self-terminating atrial fibrillation or flutter and six cases of partial electrical reset. Changes in lead impedance, pacing threshold, battery voltage, and P-wave and R-wave amplitude exceeded prespecified thresholds in a small number of cases. Repeat MRI was not associated with an increase in adverse events.</AbstractText>In this study, device or lead failure did not occur in any patient with a non-MRI-conditional pacemaker or ICD who underwent clinically indicated nonthoracic MRI at 1.5 tesla, was appropriately screened, and had the device reprogrammed in accordance with the prespecified protocol. (Funded by St. Jude Medical and others; MagnaSafe ClinicalTrials.gov number, NCT00907361 .).</AbstractText> |
20,828 | Impact of right ventricular function on outcome of severe aortic stenosis patients undergoing transcatheter aortic valve replacement. | Right ventricular (RV) dysfunction was shown to be associated with adverse outcomes in a variety of cardiac patients and is considered a risk factor for adverse outcome according to the updated Valve Academic Research Consortium criteria.</AbstractText>Our goal was to assess the impact of RV function at baseline on 1-year mortality among patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).</AbstractText>All patients with severe AS treated with TAVR from May 2007 to March 2015 at our center were included in the present study, and baseline and procedural characteristics were recorded for each patient. The patients were categorized according to RV function at baseline as assessed by current guidelines, and a comparison of mortality rates up to 1 year was performed.</AbstractText>Among 650 patients, 606 had adequate echocardiogram quality and 146 (24%) had RV dysfunction. There were significant differences between the 2 groups, as patients with RV dysfunction were younger (81±9 vs 84±7 years, P=.01) and were more likely to be male (65% vs 42%, P<.001). In addition, patients with RV dysfunction had higher rates of prior myocardial infarction (26% vs 16%, P=.02) and atrial fibrillation (51% vs 39%, P=.02). Echocardiographic parameters demonstrated higher rates of left ventricular ejection fraction <40% (40% vs 18%, P<.001), tricuspid regurgitation above moderate (16% vs 9%, P=.04), and higher pulmonary artery systolic pressure (50±17 vs 44±16 mm Hg, P<.001) among patients with severe AS and RV dysfunction compared with patients with normal RV function. Despite the unfavorable cardiac function, patients with severe AS undergoing TAVR have similar functional class (P=.22) and mortality rates at 1year (27% vs 23%, log-rank P=.45).</AbstractText>Patients with severe AS and RV dysfunction have similar 1-year mortality and functional class after TAVR to patients with normal RV function. The presence of RV dysfunction does not correlate with outcome in patients with severe AS.</AbstractText>Copyright © 2016 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,829 | [A patient with severe digoxin toxicity]. | Digoxin is a cardiac glycoside that is frequently prescribed in atrial fibrillation and heart failure. Symptoms such as nausea, hyperkalaemia, cardiac arrhythmias and cardiac arrest are seen in digoxin toxicity. The treatment focuses on reduction of digoxin absorption, prevention of hypokalaemia and hyperkalaemia, treatment of symptoms and, in severe toxicity, administration of digoxin antibodies.</AbstractText>A 73-year-old man with a history of extensive cardiac disease was seen 45 minutes after ingesting 20 mg of digoxin. The patient developed ventricular fibrillation within 3 hours of ingestion, before arrival of the digoxin antibodies. The patient passed away despite resuscitation and administration of an insufficient amount of digoxin antibodies.</AbstractText>The national supply of digoxin antibodies in the Netherlands proved to be too limited for the treatment of a patient with severe digoxin toxicity. An increase in the supply, and central storage, of digoxin antibodies could promote faster administration of an adequate amount of the antibodies. Timely transportation to an extra corporeal membrane oxygenation centre should also be considered.</AbstractText> |
20,830 | Performance of the New BioMonitor 2-AF Insertable Cardiac Monitoring System: Can Better be Worse? | Implantable loop recorders (ILR) are valuable tools for the investigation of patients with suspected arrhythmias. The BioMonitor 2-AF is a novel insertable ILR with enhanced atrial fibrillation (AF) detection algorithm and remote monitoring capability.</AbstractText>The objective of this first-in-human study with the BioMonitor 2-AF was to analyze course of P-wave sensing performance and R-wave amplitude, prevalence of false and correctly sensed and classified episodes, and effectiveness of remote monitoring.</AbstractText>All 19 patients who underwent ILR insertion were included in the BIOTRONIK Home Monitoring® system (BIOTRONIK GmbH, Berlin, Germany). Daily changes in P-wave and R-wave sensing were analyzed over 6 weeks. A breathing test (in- and expiration) was performed in two different body positions at baseline and during a 6-week in-house follow-up to investigate alterations of P-wave and R-wave sensing.</AbstractText>R-wave amplitude and the high P-wave visibility (94.4%) remained unchanged during the follow-up period. In most patients both an increase and decrease of R-wave amplitude, and in some cases a complete R-wave vector change (31.6%), was documented during the "breathing test." Change of body position did not alter R-wave sensing amplitude mostly. "Breathing test" and change of body position had no effect on P-wave sensing performance. In 15.8% of the patients, misclassification of episodes as AF or high ventricular rates due to P-wave oversensing occurred. No ILR-related complication occurred. Automatic transmission via BIOTRONIK Home Monitoring® was successful 100% of the time.</AbstractText>This study demonstrates that the BioMonitor 2-AF is a safe and effective tool for continuous cardiac monitoring.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,831 | Renal denervation for resistant hypertension. | Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications, or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, renal sympathetic ablation (renal denervation) has been recently proposed as a possible therapeutic alternative to treat this condition.</AbstractText>We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile, and kidney function, as well as the potential adverse events related to the procedure.</AbstractText>We searched the following databases to 17 February 2016 using relevant search terms: the Cochrane Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ClinicalTrials.gov SELECTION CRITERIA: We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction.</AbstractText>Two authors independently extracted data and assessed study risks of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI).</AbstractText>We found 12 eligible studies (1149 participants). In four studies, renal denervation was compared to sham procedure; one study compared a proximal ablation to a complete renal artery denervation; in the remaining, renal denervation was tested against standard or intensified antihypertensive therapy.None of the included trials was designed to look at hard clinical end points as primary outcomes.When compared to control, there was low quality evidence that renal denervation did not reduce the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (4 studies, 823 participants; RR 1.15, 95% CI 0.36 to 3.72), or unstable angina (2 studies, 201 participants; RR 0.63, 95% CI 0.08 to 5.06), and moderate quality evidence that it had no effect on 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (5 studies, 797 participants; MD 0.28 mmHg, 95% CI -3.74 to 4.29), diastolic BP (4 studies, 756 participants; MD 0.93 mmHg, 95% CI -4.50 to 6.36), office measured systolic BP (6 studies, 886 participants; MD -4.08 mmHg, 95% CI -15.26 to 7.11), or diastolic BP (5 studies, 845 participants; MD -1.30 mmHg, 95% CI -7.30 to 4.69). Furthermore, low quality evidence suggested that this procedure produced no effect on either serum creatinine (3 studies, 736 participants, MD 0.01 mg/dL; 95% CI -0.12 to 0.14), estimated glomerular filtration rate (eGFR), or creatinine clearance (4 studies, 837 participants; MD -2.09 mL/min, 95% CI -8.12 to 3.95). Based on low-quality evidence, renal denervation significantly increased bradycardia episodes compared to control (3 studies, 220 participants; RR 6.63, 95% CI 1.19 to 36.84), while the risk of other adverse events was comparable or not assessable.Data were sparse or absent for all cause mortality, hospitalisation, fatal cardiovascular events, quality of life, atrial fibrillation episodes, left ventricular hypertrophy, sleep apnoea severity, need for renal replacement therapy, and metabolic profile.The quality of the evidence was low for cardiovascular outcomes and adverse events and moderate for lack of effect on blood pressure and renal function.</AbstractText><AbstractText Label="AUTHORS' CONCLUSIONS">In patients with resistant hypertension, there is low quality evidence that renal denervation does not change major cardiovascular events, and renal function. There was moderate quality evidence that it does not change blood pressure and and low quality evidence that it caused an increaseof bradycardia episodes. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardized procedural methods are necessary to clarify the utility of this procedure in this population.</AbstractText> |
20,832 | Perspectives and Challenges of Pluripotent Stem Cells in Cardiac Arrhythmia Research. | The promises of human-induced pluripotent stem cells (hiPSCs) for modeling arrhythmogenic disease, but also for drug discovery and toxicity tests, are straightforward and exciting. However, the full potential of this new technology has not been fully realized yet. The purpose of this review is to provide an overview of the state-of-the-art research in arrhythmogenic disease modeling and drug discovery and an outlook of what can be expected from the second decade of hiPSC-based arrhythmia research.</AbstractText>Remarkable advances in genomic discoveries, stem cell biology, and genome editing via sequence-specific nucleases have been made in recent years. Together, these breakthroughs have allowed us to progress from studying monogenetic diseases with a direct genotype-phenotype relationship to genetically more complex diseases such as arrhythmogenic right ventricular dysplasia and atrial fibrillation. In addition, newly developed tools for arrhythmia research such as optical action potential recordings have facilitated the use of hiPSCs for drug and toxicity screening and their eventual clinical use. These advances in in vitro assay development, genome editing, and stem cell biology will soon enable the implementation of hiPSC-based findings into clinical practice and provide us with unprecedented insights into mechanisms of complex arrhythmogenic diseases.</AbstractText> |
20,833 | Targeted temperature management after intraoperative cardiac arrest: a multicenter retrospective study. | Few outcome data are available about temperature management after intraoperative cardiac arrest (IOCA). We describe targeted temperature management (TTM) (32-34 °C) modalities, adverse events, and association with 1-year functional outcome in patients with IOCA.</AbstractText>Patients admitted to 11 ICUs after IOCA in 2008-2013 were studied retrospectively. The main outcome measure was 1-year functional outcome.</AbstractText>Of the 101 patients [35 women and 66 men; median age, 62 years (interquartile range, 42-72)], 68 (67.3%) were ASA PS I to III and 57 (56.4%) had emergent surgery. First recorded rhythms were asystole in 44 (43.6%) patients, pulseless electrical activity in 36 (35.6%), and ventricular fibrillation/tachycardia in 20 (19.8%). Median times from collapse to cardiopulmonary resuscitation and return of spontaneous circulation (ROSC) were 0 min (0-0) and 10 min (4-20), respectively. The 30 (29.7%) patients who received TTM had an increased risk of infection (P = 0.005) but not of arrhythmia, bleeding, or metabolic/electrolyte disorders. By multivariate analysis, one or more defibrillation before ROSC was positively associated with a favorable functional outcome at 1-year (OR 3.06, 95% CI 1.05-8.95, P = 0.04) and emergency surgery was negatively associated with 1-year favorable functional outcome (OR 0.36; 95% CI 0.14-0.95, P = 0.038). TTM use was not independently associated with 1-year favorable outcome (OR 0.82; 95% CI 0.27-2.46, P = 0.72).</AbstractText>TTM was used in less than one-third of patients after IOCA. TTM was associated with infection but not with bleeding or coronary events in this setting. TTM did not independently predict 1-year favorable functional outcome after IOCA in this study.</AbstractText> |
20,834 | Enhanced Late Na and Ca Currents as Effective Antiarrhythmic Drug Targets. | While recent advances clarified the molecular and cellular modes of action of antiarrhythmic drugs (AADs), their link to suppression of dynamical arrhythmia mechanisms remains only partially understood. The current classifications of AADs (Classes I, III, and IV) rely on blocking peak Na, K and L-type calcium currents (I<sub>Ca,L</sub>), with Class II with dominant beta receptor blocking activity and Class V including drugs with diverse classes of actions. The discovery that the calcium and redox sensor, cardiac Ca/calmodulin-dependent protein kinase II (CaMKII) enhances both the late Na (I<sub>Na-L</sub>) and the late I<sub>Ca,L</sub> in patients at high risk of VT/VF provided a new and a rational AAD target. Pathological rise of either or both of I<sub>Na-L</sub> and late I<sub>Ca,L</sub> are demonstrated to promote cellular early afterdepolarizations (EADs) and EAD-mediated triggered activity that can initiate VT/VF in remodeled hearts. Selective inhibition of the I<sub>Na-L</sub> without affecting their peak transients with the highly specific prototype drug, GS-967 suppresses these EAD-mediated VT/VFs. As in the case of I<sub>Na-L</sub>, selective inhibition of the late I<sub>Ca,L</sub> without affecting its peak with the prototype drug, roscovitine suppressed oxidative EAD-mediated VT/VF. These findings indicate that specific blockers of the late inward currents without affecting their peaks (gating modifiers), offer a new and effective AAD class action i.e., "Class VI." The development of safe drugs with selective Class VI actions provides a rational and effective approach to treat VT/VF particularly in cardiac conditions associated with enhanced CaMKII activity such as heart failure. |
20,835 | Atrial fibrillation in hypertrophic cardiomyopathy: A turning point towards increased morbidity and mortality. | Atrial fibrillation (AF) is the most common arrhythmic event in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to identify the clinical impact and prognostic significance of AF on a large cohort of patients with HCM.</AbstractText>Echocardiographic and clinical correlates, risk factors for AF and thromboembolic stroke and the prognostic significance of AF were evaluated in 509 patients with an established diagnosis of HCM.</AbstractText>A total of 119 patients (23.4%) were diagnosed with AF during the index evaluation visit. AF patients had a higher prevalence of stroke and presented with worse functional impairment. Left atrial diameter (LA size) was a common independent predictor of the arrhythmia (OR: 2.2, 95% CI 1.6-3.3) and thromboembolic stroke (OR: 1.6, 95% CI 1.01-2.40). AF was an important risk factor for overall mortality (HR=3.4, 95% CI: 1.7-6.5), HCM-related mortality (HR=3.9, 95% CI: 1.8-8.2) and heart failure-related mortality (HR=6.0, 95% CI: 2.0-17.9), even after adjusting for statistically significant clinical and demographic risk factors. However, AF did not affect the risk for sudden death.</AbstractText>LA size is an independent predictor of both AF and thromboembolic stroke. Moreover, patients with AF, regardless of type, have significantly higher mortality rates than patients without AF.</AbstractText>Copyright © 2017 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,836 | Hypertension-induced remodelling: on the interactions of cardiac risk factors. | Hypertension induces considerable cardiac remodelling, such as hypertrophy, interstitial fibrosis, and abnormal activity of the cardiac sympathetic nervous system, which are established risk factors in several highly dangerous heart diseases, such as ventricular fibrillation and congestive heart failure. All these risk factors and heart diseases are studied extensively in isolation, but to our knowledge, there is no comprehensive review of their interactions. At the same time, there is growing evidence suggesting that such interactions are numerous and that a successful therapy against a particular condition may have unexpectedly weak effects on mortality, as treated patients may die of a different cause exacerbated by the therapy. In this article, we present a multiscale review of the literature focusing on the relationships between the above-mentioned risk factors and heart diseases, and introduce a framework that gives insight into their possible interactions. We use this framework to demonstrate that conditions such as fibrosis and elevated activity of the sympathetic nervous system may be compensatory, rather than purely pathological, mechanisms in certain contexts. Finally, we show why the described mechanisms are relevant not only in hypertension, but also in the case of healed myocardial infarction. |
20,837 | QRS duration versus morphology and survival after cardiac resynchronization therapy. | The prognostic implications of QRS duration and morphology in heart failure patients treated with cardiac resynchronization therapy (CRT) remains debated. The present evaluation investigated the association between QRS duration (<150 vs. ≥150 ms) and QRS morphology (left bundle brand block [LBBB] vs. non-LBBB) and long-term prognosis of a large cohort of unselected heart failure patients treated with CRT according to contemporary guidelines.</AbstractText>Of 973 heart failure patients treated with CRT (mean age 66.1 ± 9.8 years, 76% male), 658 patients (68%) showed QRS duration ≥150 ms, and 772 patients (79%) had LBBB configuration. Compared with patients with QRS duration <150 ms, patients with QRS duration ≥150 ms had less frequently ischaemic cardiomyopathy and atrial fibrillation and showed larger left ventricular volumes and lower left ventricular ejection fraction. Compared with patients with non-LBBB configuration, patients with LBBB morphology were younger, less often males and less often had ischaemic cardiomyopathy and atrial fibrillation. On multivariable analysis, after correcting for relevant clinical and echocardiographic variables, LBBB morphology was significantly associated with better survival [hazard ratio (HR) 0.737; 95% confidence interval (CI) 0.584-0.931; P</i> = 0.010], whereas there was no statistically significant association between QRS duration ≥150 ms and survival (HR 0.889; 95% CI 0.726-1.088; P</i> = 0.252).</AbstractText>In this large population of heart failure patients treated with CRT, QRS morphology was independently associated with long-term survival. The association between QRS duration and long-term survival was not statistically significant.</AbstractText> |
20,838 | Inappropriate shocks from a subcutaneous implantable cardioverter-defibrillator due to oversensing during periods of rate-related bundle branch block. | The subcutaneous implantable cardioverter-defibrillator (S-ICD) is a novel technology with proven efficacy in sudden cardiac death prevention; however, there is a lack of long-term safety data. We describe the case of a 55-year-old female patient implanted with an S-ICD due to idiopathic ventricular fibrillation, who subsequently presented with inappropriate shocks leading to ventricular fibrillation that was successfully terminated by another shock. Inappropriate shocks were due to intermittent T wave oversensing during periods of rate-dependent right bundle branch block. Assessment of the S-ICD electrograms during an exercise test allowed successful reprogramming of the device׳s sensing vector with no further events. |
20,839 | Role of Right Ventricular Dysfunction and Diabetes Mellitus in N-terminal pro-B-type Natriuretic Peptide Response of Patients With Severe Mitral Regurgitation and Heart Failure After MitraClip. | MitraClip (MC) is an alternative therapeutic option for patients with severe mitral regurgitation (MR) who are at high surgical risk. Most candidates for MC have severe heart failure (HF) with increased N-terminal pro-B-type natriuretic peptide (NT-pro BNP) levels. We sought to clarify the response of NT-pro BNP after MC and to identify the determinants of NT-pro BNP nonresponders. Among 136 consecutive patients successfully treated with MC, we excluded 20 patients due to low baseline NT-pro BNP levels and therefore examined 116 patients. NT-pro BNP responders were defined as patients whose NT-pro BNP levels decreased by > 30% at 6 months after MC. Mean NT-pro BNP levels significantly decreased from 6,117 pg/mL at baseline to 4,143 pg/mL at 6 months after MC (P < 0.001); 61 patients (53%) were responders. Diabetes mellitus (DM) (51% versus 25%; P = 0.003) and atrial fibrillation (67% versus 49%; P = 0.049) were more common in nonresponders. Baseline New York Heart Association (NYHA) class and NT-proBNP levels were higher in responders. Right ventricular systolic dysfunction (RVSD) defined as tricuspid annular plane systolic excursion (TAPSE) < 15 mm was more common in nonresponders (41% versus 18%; P = 0.008). Multivariable logistic regression analysis revealed that DM (odds ratio [OR], 2.966; P = 0.014), RVSD (OR, 3.948; P = 0.006), and baseline NT-proBNP > 5,000 pg/mL (OR, 0.204; P = 0.001) were independent determinants of nonresponders. All-cause death tended to be less common in responders to NT-pro BNP (20% versus 31%; P = 0.163). In conclusion, NT-pro BNP levels significantly decreased after MC. DM and RVSD were determinants of NT-pro BNP nonresponse after the MC procedure. |
20,840 | Altered mental status in the emergency department - Can an electrocardiogram show the right way to go? | A 38-year-old African American male patient with a past medical history of human immunodeficiency virus and schizophrenia who was noncompliant with medications presented to the emergency department (ED) after activation of the local crisis response center for altered mental status. Upon arrival he was lethargic and uncooperative, unable to provide any significant details apart from pleuritic chest pain. His blood pressure was 133/88 mmHg, heart rate 43 beats per minute and initial body temperature 36.1 °C which prompted an electrocardiogram (EKG). This initial EKG was compared to a prior one obtained six months earlier during an ER visit for an acute psychotic episode. Three hours of being admitted he started shivering. Patient was found to be hypothermic with a rectal temperature of 28.9 °C. He was also hypoglycemic, pancytopenic and had positive urine cultures with >100,000 CFU/ml coagulase-negative Staphylococcus. There was no evidence of medication overdose. His CT scan of the brain did not show evidence of intracranial bleeding and his serum calcium was normal. |
20,841 | The effect of resuscitation position on cerebral and coronary perfusion pressure during mechanical cardiopulmonary resuscitation in porcine cardiac arrest model. | It is unknown whether patient position is associated with the optimal cerebral (CePP) and coronary (CoPP) perfusion pressure.</AbstractText>This study utilized a randomized experimental design and anesthetized, intubated and paralyzed female pigs (n=12) (mean 42, SD 3kg). After 6min of untreated ventricular fibrillation, mechanical CPR with was performed for 3min in 0° supine position. The CPR was then performed for 5min in a position randomly assigned to either 1) head-up tilt (HUT) by three angles (30°, 45°, or 60°) or 2) head-down tilt (HDT) by three angles (30°, 45°, or 60°) and at 3) supine position between HUT and HDT positions. 4 Pigs were assigned to each angle of HUT or HDT position and 12 pigs were assigned to supine position. CePPs and CoPPs were measured and compared using MIXED procedure with pig as a random effect among angles and compared between angles with Tukey post-hoc analysis.</AbstractText>With 60°, 45°, 30° head-down, 0° (supine), and 30°, 45°, 60° head-up positioning, mean(SD) CePPs increased consistently as follows: 2.4(0.4), 9.3(1.6), 16.5(1.6), 27.0(1.5), 35.1(0.4), 39.4(0.6), and 39.9(0.3) mmHg, respectively. CoPPs were followings according to same angle: 12.9(2.5), 13.3(2.5), 12.8(0.4), 18.1(0.7), 30.3(0.4), 24.1(0.6), and 26.5(0.9) mmHg, respectively. The CePPs were peak at HUT(45°) and HUT(60°), but CoPP was peak in HUT(30°) and higher than HUT(45°) and HUT(60°).</AbstractText>Cerebral perfusion pressure during mechanical CPR were similar and highest in the HUT(45° and 60°) positions whereas the peak coronary perfusion pressure was observed with HUT(30°).</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,842 | Application of computer models on atrial fibrillation research. | Atrial fibrillation (AF) is a multifactorial and multiscale disease, where electrical, structural, anatomical and genetic factors contribute to the emergence of a complex and dynamic macroscopic phenotype. The incomplete understanding of AF mechanisms and the diversity and multiplicity of factors promoting the arrhythmia in humans have hampered the development of effective therapeutic approaches. Computer models and simulation of atrial arrhythmias may represent a unique ally to investigate AF mechanisms and direct therapeutic strategies, being able to merge and provide interpretation for multiscale data from cellular to entire organ scale levels. This review presents a broad overview of the principal modeling approaches applied in AF research to model atrial activity and ventricular response. The description of methodological aspects is followed by representative contributions of modeling to the dissection of AF mechanisms at both the atrial and atrioventricular level. A specific focus is given to controversial themes in AF research, such as calcium dynamics, fibrosis, multiple wavelets versus rotors propagation patterns, and AF heritability. Following modeling mechanistic insights, the review showcases modeling contributions in the domain of AF management and therapy, including the development of antiarrhythmic agents for rate and rhythm control, the optimization of ablation strategy, and the validation of mapping techniques and signal processing tools for the investigation of AF. A summary of current challenges and future developments necessary to improve the model capability at different scales and to transfer modeling results into clinical practice is finally presented. |
20,843 | Efficiency of ranolazine in the patient with microvascular angina, atrial fibrillation and migraine. | Microvascular angina (MVA) is rather a common form of stable ischemic coronary disease (CAD) as that such diagnosis is made in 20-30% of patients who previously underwent coronary angiography. The disease occurs three times more frequently in women than in men irrespective of age. Most of these patients are 45-60 years old. According to available data, the long-term outcome in patients with MVA is comparable with that in general population. MVA characterizes great variability of its course and low response to conventional antianginal therapy. However, patients with MVA experience chest pain, which in most cases tend to strengthen and increase the number of pain episodes, significantly deteriorating the quality of life of these patients. In view of this, the problem of antianginal drugs which can be used in addition to standard therapy remains to be solved. The major role in MVA development plays the decreased coronary flow reserve resulting from evident endothelial dysfunction of small coronary arteries. Ranolazine is a new original antianginal drug which improves left ventricular diastolic filling by selective inhibition of late sodium current leading to more effective coronary vessel filling in diastole. The article presents the case of the successful administration of ranolazine in a woman with MVA and persistent atrial fibrillation. |
20,844 | Suppression of Tumorigenicity 2 in Heart Failure With Preserved Ejection Fraction. | Soluble suppression of tumorigenicity 2 (sST2) receptor is a biomarker that is elevated in certain systemic inflammatory diseases. Comorbidity-driven microvascular inflammation is postulated to play a key role in heart failure with preserved ejection fraction (HFpEF) pathophysiology, but data on how sST2 relates to clinical characteristics or inflammatory conditions or biomarkers in HFpEF are limited. We sought to determine circulating levels and clinical correlates of sST2 in HFpEF.</AbstractText>At enrollment, patients (n=174) from the Phosphodiesterase-5 Inhibition to Improve Clinical Status And Exercise Capacity in Diastolic Heart Failure (RELAX) trial of sildenafil in HFpEF had sST2 levels measured. Clinical characteristics; cardiac structure and function; exercise performance; and biomarkers of neurohumoral activation, systemic inflammation and fibrosis, and myocardial necrosis were assessed in relation to sST2 levels. Median sST2 levels in male and female HFpEF patients were 36.7 ng/mL (range 30.9-49.2 ng/mL; reference range 4-31 ng/mL) and 30.8 ng/mL (range 25.3-39.3 ng/mL; reference range 2-21 ng/mL), respectively. Among HFpEF patients, higher sST2 levels were associated with the presence of diabetes mellitus; atrial fibrillation; renal dysfunction; right ventricular pressure overload and dysfunction; systemic congestion; exercise intolerance; and biomarkers of systemic inflammation and fibrosis, neurohumoral activation, and myocardial necrosis (P</i><0.05 for all). sST2 was not associated with left ventricular structure or left ventricular systolic or diastolic function.</AbstractText>In HFpEF, sST2 levels were associated with proinflammatory comorbidities, right ventricular pressure overload and dysfunction, and systemic congestion but not with left ventricular geometry or function. These data suggest that ST2 may be a marker of systemic inflammation in HFpEF and potentially of extracardiac origin.</AbstractText>URL: http://www.clinicaltrials.gov. Unique identifier: NCT00763867.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.</CopyrightInformation> |
20,845 | Contemporary animal models of cardiac arrest: A systematic review. | Animal models are widely used in cardiac arrest research. This systematic review aimed to provide an overview of contemporary animal models of cardiac arrest.</AbstractText>Using a comprehensive research strategy, we searched PubMed and EMBASE from March 8, 2011 to March 8, 2016 for cardiac arrest animal models. Two investigators reviewed titles and abstracts for full text inclusion from which data were extracted according to pre-defined definitions.</AbstractText>Search criteria yielded 1741 unique titles and abstracts of which 490 full articles were included. The most common animals used were pigs (52%) followed by rats (35%) and mice (6%). Studies favored males (52%) over females (16%); 17% of studies included both sexes, while 14% omitted to report on sex. The most common methods for induction of cardiac arrest were either electrically-induced ventricular fibrillation (54%), asphyxia (25%), or potassium (8%). The median no-flow time was 8min (quartiles: 5, 8, range: 0-37min). The majority of studies used adrenaline during resuscitation (64%), while bicarbonate (17%), vasopressin (8%) and other drugs were used less prevalently. In 53% of the studies, the post-cardiac arrest observation time was ≥24h. Neurological function was an outcome in 48% of studies while 43% included assessment of a cardiac outcome.</AbstractText>Multiple animal models of cardiac arrest exist. The great heterogeneity of these models along with great variability in definitions and reporting make comparisons between studies difficult. There is a need for standardization of animal cardiac arrest research and reporting.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,846 | Relation Between Ventricular Premature Complexes and Incident Heart Failure. | Ventricular premature complexes (VPCs) may represent a reversible cause of heart failure (HF); however, the type of patients most prone remains unknown. This study leverages a large population-based database to examine interactions that might prove clinically useful in risk-stratifying patients with VPCs. We used the California Healthcare Cost and Utilization Project to identify patients with VPCs and incident systolic HF from January 1, 2005, to December 31, 2009. We calculated hazard ratios for predictors of incident systolic HF using multivariable Cox proportional hazard models. Interactions with known risk factors were studied. Of the 16.8 million patients experiencing 48.1 million hospitalizations, 35,817 (0.2%) had a VPC diagnosis and 198,818 (1.2%) developed systolic HF. Incidence of systolic HF was 62.8 per 1,000 patient-years (95% confidence interval [CI] 61.2 to 64.4) in those with and 6.1 per 1,000 patient-years (95% CI 6.1 to 6.2) in those without VPCs (p <0.001). After adjusting for potential confounders, VPCs were associated with a nearly twofold risk of systolic HF (HR 1.8, 95% CI 1.8 to 1.9, p <0.001). Interaction analyses revealed a stronger relation between VPCs and HF among those with fewer cardiovascular risk factors. A VPC diagnosis in younger patients (<65 years) without coronary artery disease, hypertension, diabetes, or atrial fibrillation exhibited a sixfold increased risk of systolic HF (HR 6.5, 95% CI 5.5 to 7.7, p <0.001). In conclusion, these results suggest that a diagnosis of VPCs independently predicts incident systolic HF. This effect is most pronounced in younger patients without co-morbidities, suggesting that VPCs may be an important cause of "idiopathic" HF. |
20,847 | Comparison of Pulmonary Venous and Left Atrial Remodeling in Patients With Atrial Fibrillation With Hypertrophic Cardiomyopathy Versus With Hypertensive Heart Disease. | Left ventricular diastolic dysfunction in hypertrophic cardiomyopathy (HC) increases susceptibility to atrial fibrillation. Although phenotypical characteristics of the hypertrophied left ventricle are clear, left atrial (LA) and pulmonary venous (PV) remodeling has rarely been investigated. This study aimed to identify differences in LA and PV remodeling between HC and hypertensive heart disease (HHD) using 3-dimensional computed tomography. Included were 33 consecutive patients with HC, 25 with HHD, and 29 without any co-morbidities who were referred for catheter ablation of atrial fibrillation. Pre-ablation plasma atrial and brain natriuretic peptide levels, post-ablation troponin T level, and LA pressure were measured, and LA and PV diameters were determined 3 dimensionally. LA transverse diameter in the control group was smaller than that in the HHD or HC group (55 ± 6 vs 63 ± 9 vs 65 ± 12 mm, p = 0.0003). PV diameter in all 4 PVs was greatest in the HC group and second greatest in the HHD group (21.0 ± 3.1 vs 23.8 ± 2.8 vs 26.8 ± 4.1 mm, p <0.0001 for left superior PV). Differences in PV size between the HHD and HC groups were enhanced by indexing to the body surface area (12.4 ± 1.9 vs 13.1 ± 1.4 vs 16.1 ± 3.3 mm/m<sup>2</sup>, p <0.0001). The PV/LA diameter ratio was greater in the HC than in the other groups (0.38 ± 0.06 vs 0.38 ± 0.05 vs 0.42 ± 0.07, p = 0.01). Atrial natriuretic peptide, brain natriuretic peptide, troponin T levels, and LA pressure were highest in the HC group (all p <0.05). In conclusion, the stiff LA caused from atrial hypertrophy may account for higher levels of biomarkers, higher LA pressure, and PV-dominant remodeling in HC. |
20,848 | Correlations between electrocardiogram and biomarkers in acute pulmonary embolism: Analysis of ZATPOL-2 Registry. | Electrocardiography (ECG) is still one of the first tests performed at admission, mostly in patients (pts) with chest pain or dyspnea. The aim of this study was to assess the correlation between electrocardiographic abnormalities and cardiac biomarkers as well as echocardiographic parameter in patients with acute pulmonary embolism.</AbstractText>We performed a retrospective analysis of 614 pts. (F/M 334/280; mean age of 67.9 ± 16.6 years) with confirmed acute pulmonary embolism (APE) who were enrolled to the ZATPOL-2 Registry between 2012 and 2014.</AbstractText>Elevated cardiac biomarkers were observed in 358 pts (74.4%). In this group the presence of atrial fibrillation (p = .008), right axis deviation (p = .004), S1</sub> Q3</sub> T3</sub> sign (p < .001), RBBB (p = .006), ST segment depression in leads V4</sub> -V6</sub> (p < .001), ST segment depression in lead I (p = .01), negative T waves in leads V1</sub> -V3</sub> (p < .001), negative T waves in leads V4</sub> -V6</sub> (p = .005), negative T waves in leads II, III and aVF (p = .005), ST segment elevation in lead aVR (p = .002), ST segment elevation in lead III (p = .0038) was significantly more frequent in comparison to subjects with normal serum level of cardiac biomarkers. In multivariate regression analysis, clinical predictors of "abnormal electrocardiogram" were as follows: increased heart rate (OR 1.09, 95% CI 1.02-1.17, p = .012), elevated troponin concentration (OR 3.33, 95% CI 1.94-5.72, p = .000), and right ventricular overload (OR 2.30, 95% CI 1.17-4.53, p = .016).</AbstractText>Electrocardiographic signs of right ventricular strain are strongly related to elevated cardiac biomarkers and echocardiographic signs of right ventricular overload. ECG may be used in preliminary risk stratification of patient with intermediate- or high-risk forms of APE.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,849 | Emergency extracorporeal life support and ongoing resuscitation: a retrospective comparison for refractory out-of-hospital cardiac arrest. | In refractory cardiac arrest, with cardiopulmonary resuscitation (CPR) for more than 30 min, chances of survival are small. Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for certain patients with cardiac arrest. The aim of this study was to evaluate characteristics of patients selected for ECPR.</AbstractText>Anonymised data of adult patients suffering refractory cardiac arrest, transported with ongoing CPR to an ED of a tertiary care centre between 2002 and 2012 were analysed. Outcome measure was the selection for ECPR. Secondary outcome was 180 days survival in good neurological condition.</AbstractText>Overall, 239 patients fulfilled the inclusion criteria. ECPR was initiated in seven patients. Patients treated with ECPR were younger (46 vs 60 years; p=0.04), had shorter intervals before CPR was started (0 vs 1 min; p=0.013), faster admissions at the ED (38 vs 56 min; p=0.31) and lower blood glucose levels on admission (14 vs 21 mmol/L; p=0.018). Survival to discharge in good neurological condition was achieved in 14 (6%) of all patients. One patient in the ECPR group survived in excellent neurological condition. Age was independently associated with the selection for ECPR (OR 0.07; 95% CI 0.01 to 0.85; p=0.037).</AbstractText>Emergency extracorporeal life support was used for a highly selected group of patients in refractory cardiac arrest. Several parameters were associated with the decision, but only age was independently associated with the selection for ECPR. The patient selection resulting in a survival of one patient out of seven treated seems reasonable. Randomised controlled trials evaluating the age limit as selection criteria are urgently needed to confirm these findings.</AbstractText>© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.</CopyrightInformation> |
20,850 | Role of Apamin-Sensitive Calcium-Activated Small-Conductance Potassium Currents on the Mechanisms of Ventricular Fibrillation in Pacing-Induced Failing Rabbit Hearts. | Ventricular fibrillation (VF) during heart failure is characterized by stable reentrant spiral waves (rotors). Apamin-sensitive small-conductance calcium-activated potassium currents (I</i>KAS</sub>) are heterogeneously upregulated in failing hearts. We hypothesized that I</i>KAS</sub> influences the location and stability of rotors during VF.</AbstractText>Optical mapping was performed on 9 rabbit hearts with pacing-induced heart failure. The epicardial right ventricular and left ventricular surfaces were simultaneously mapped in a Langendorff preparation. At baseline and after apamin (100 nmol/L) infusion, the action potential duration (APD80</sub>) was determined, and VF was induced. Areas with a >50% increase in the maximum action potential duration (ΔAPD) after apamin infusion were considered to have a high I</i>KAS</sub> distribution. At baseline, the distribution density of phase singularities during VF in high I</i>KAS</sub> distribution areas was higher than in other areas (0.0035±0.0011 versus 0.0014±0.0010 phase singularities/pixel; P</i>=0.004). In addition, high dominant frequencies also colocalized to high I</i>KAS</sub> distribution areas (26.0 versus 17.9 Hz; P</i>=0.003). These correlations were eliminated during VF after apamin infusion, as the number of phase singularities (17.2 versus 11.0; P</i>=0.009) and dominant frequencies (22.1 versus 16.2 Hz; P</i>=0.022) were all significantly decreased. In addition, reentrant spiral waves became unstable after apamin infusion, and the duration of VF decreased.</AbstractText>The I</i>KAS</sub> current influences the mechanism of VF in failing hearts as phase singularities, high dominant frequencies, and reentrant spiral waves all correlated to areas of high I</i>KAS</sub>. Apamin eliminated this relationship and reduced VF vulnerability.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,851 | A novel method of standardized myocardial infarction in aged rabbits. | The incidence of both myocardial infarction (MI) and sudden cardiac death increases with age. Here, we describe the development of a minimally invasive large animal model of MI that can be applied to young or aged animals. We demonstrate that rabbit coronary anatomy is highly variable, more so than described in previous literature. In this work, we categorize the coronary pattern of 37 young rabbits and 64 aged rabbits. Aged rabbits had a higher degree of branching from the left main coronary artery. Standardizing the model across age cohorts required a new approach, targeting an area of myocardium rather than a specific vessel. Here, we present a method for achieving a reproducible infarct size, one that yielded a consistent scar encompassing ~30% of the apical left ventricular free wall. The model's consistency allowed for more valid comparisons of MI sequelae between age cohorts.<b>NEW & NOTEWORTHY</b> This study describes the coronary angiographic imaging of young and aged rabbits. We developed and improved a novel minimally invasive approach for coil embolization that targets a specific area of myocardium and yielded a consistent scar encompassing ~30% of the left ventricular free wall of young and aged rabbit hearts. |
20,852 | Interleukin-1β levels predict long-term mortality and need for heart transplantation in ambulatory patients affected by idiopathic dilated cardiomyopathy. | The prognostic stratification of patients with Idiopathic Dilated Cardiomyopathy (iDCM) is a difficult task. Here, we assessed the additive value of the evaluation of biomarkers of inflammasome activation and systemic inflammation for the long-term risk stratification of iDCM patients.</AbstractText>We studied 156 ambulatory iDCM patients (mean age 58 years, 77% men, 79% in NYHA class 1-2, median Left Ventricular Ejection Fraction (LVEF) 35%, mean sodium 139 mEq/L, median BNP 189 pg/mL, median IL-1 beta (IL-1β) 1.08 pg/mL, median IL-6 1.7 pg/mL and median IL-10 2.7 pg/mL).During the follow-up period of 89.6 months, 35 patients (22%) died/underwent heart transplantation. Patients who died/underwent heart transplantation were more likely to be male, to be in NYHA class III, to have atrial fibrillation, to have lower LVEF and higher BNP levels. IL-1β, IL-6 and IL-10 levels did not differ significantly between the groups of patients with good or bad prognosis. IL-1β levels did not vary significantly among either the different NYHA classes or the quartiles of LVEF. In a multivariable model, however, IL-1β was a strong and independent predictor of all-cause mortality (HR 1.193, 95% CI 1.056 - 1.349, p=0.005 for log squared transformed values). Other factors associated with the outcome were: male gender, presence of atrial fibrillation and sodium concentration. The estimated time-dependent ROC curve of the multivariable model showed an AUC 0.74 (95% CI 0.65-0.86).</AbstractText>Serum levels of IL-1β could be useful to predict the long-term outcome of patients with iDCM.</AbstractText> |
20,853 | Long-term prognosis after acute heart failure: a differential impact of age in different age strata. | Increasing age predicts ominous prognosis in heart failure. Age influences the success of therapeutic approaches and interacts with other prognostic predictors. We aimed to study the impact of age in long-term survival in different age strata.</AbstractText>Patients were prospectively included in an acute heart failure registry; those with acute coronary syndromes and those with primary valvular disease were excluded. Outcome studied was all-cause mortality. Follow-up was 5 years. A receiver-operating characteristic curve was used to define the age cut-off for 5-year death prediction. A multivariate Cox regression analysis was used to study mortality predictors. Analysis was stratified according to the 75-year-age cut-off.</AbstractText>We studied 473 patients. Mean age was 75 ± 12 years, 48.4% were men and 68.7% had reduced ejection fraction. Older patients were more often women, with preserved ejection fraction, history of arterial hypertension and atrial fibrillation; they were discharged in higher NYHA classes and with lower haemoglobin. Older patients were less often discharged with evidence-based heart failure therapy. In 5 years, 339 (71.7%) patients died. Patients aged more than 75 years had a multivariate-adjusted hazard ratio of mortality of 1.87 (95% confidence interval 1.46-2.38). In older patients, there was a 5% mortality increase per each 1-year increase in age; 75 years or less, age had no prognostic impact; and P for interaction (age continuous and age dichotomized) was 0.01.</AbstractText>Age is a strong long-term prognostic determinant in acute heart failure. The prognostic impact of age was significantly different between age subgroups: it was an independent predictor of mortality in patients aged more than 75 years and had no impact in those aged 75 years or less.</AbstractText> |
20,854 | Pharmacologic cardioversion with intravenous amiodarone is likely safe in neurocritically Ill patients. | Neurological injury is often associated with cardiac abnormalities, including electrophysiological issues. Cardioversion of acute atrial fibrillation (<48h' duration) without anticoagulation carries about a 0.7% risk of thromboembolism. There is limited data on managing acute atrial fibrillation specifically in the neuroscience intensive care unit (NSICU) setting. We sought to determine the safety of using intravenous (IV) amiodarone for restoring sinus rhythm in patients with presumed new onset atrial or ventricular tachycardia after neurological injury. We conducted a retrospective review of consecutive patients admitted to our NSICU between June 2011 and March 2015 with a primary neurological diagnosis and new onset tachyarrhythmias who received IV amiodarone. Baseline demographics and presence of known risk factors for atrial fibrillation were recorded. The primary end point was new onset stroke. 48 patients were included for the final analysis. No patients developed new stroke after receiving IV amiodarone. The average follow up period was 14.0days. The majority of patients did not have the pre identified risk factors for atrial fibrillation. Ischemic stroke and traumatic brain injury were the most common admitting diagnoses. We conclude that in patients with primary neurological injury, use of IV amiodarone for rhythm control of acute onset atrial fibrillation carries a low risk of cardioembolic stroke in the first 2weeks. Further investigation, including prospective studies, with larger samples and longer follow up periods is warranted. |
20,855 | [Acute chest pain and new ECG changes in pacemaker patients : A clinical challenge]. | We report the case of a 82-year-old woman who was admitted to our institution with acute chest pain, nausea, and vomiting. Because of atrial fibrillation with intermittent bradycardia, a single-chamber pacemaker was implanted 4 years ago. The initial 12-lead ECG showed atrial fibrillation with a heart rate of 70 bpm, narrow QRS, and T‑wave inversions in the inferolateral leads. Coronary artery disease was excluded by immediate cardiac catheterization. A subsequent ECG three hours later showed a ventricular paced rhythm. During the subsequent clinical course, cardiac injury markers remained normal. However, serum amylase and lipase levels were 5 times above the normal range. According to these clinical findings, acute pancreatitis was the most likely diagnosis. Abdominal ultrasound excluded pancreatic necrosis and gallstones. Initial treatment consists of fasting, pain control, and intravenous fluids with resolution of symptoms after a few days. The patient could be discharged 7 days later. In conclusion, the observed ECG findings in combination with chest pain are suggestive for myocardial ischemia mandating immediate cardiac catheterization. However, acute pancreatitis might present with the aforementioned ECG changes and symptoms. The case was further complicated by a distinct electrocardiographic memory effect due to intermittent ventricular pacing. |
20,856 | Effects of Upgrade Versus De Novo Cardiac Resynchronization Therapy on Clinical Response and Long-Term Survival: Results from a Multicenter Study. | Benefits of cardiac resynchronization therapy (CRT) on morbidity and mortality in selected patients are well known. Although the number of upgrade procedures from single- or dual-chamber devices to CRT is increasing, there are only sparse data on the outcomes of upgrade procedures compared with de novo CRT. This study aimed to evaluate clinical response and survival in patients receiving de novo versus upgrade CRT defibrillator therapy.</AbstractText>Prospectively collected outcome data were compared in patients undergoing de novo or upgrade CRT defibrillator implantation at 3 implant centers in Germany and Hungary. Clinical response was defined as an improvement by at least one New York Heart Association (NYHA) functional class. CRT implantation was performed in 552 consecutive patients of whom 375 underwent a de novo and 177 an upgrade procedure. Upgrade patients were more often implanted for secondary prevention, suffered more often from atrial fibrillation, chronic kidney disease, diabetes mellitus, and dyslipidemia, and had more often a non-LBBB (left bundle branch block) wide QRS complex, and lower left ventricular ejection fraction. Upgrade procedures were associated with a lower response rate compared to the de novo group (57% versus 69%, P</i> univariate=0.008, P</i> multivariate=0.021). During the follow-up of 37±28 months, survival was worse after upgrade compared with de novo CRT defibrillator implantations (hazard ratio, 1.65; 95% confidence interval, 1.22-2.24; P</i>=0.001) even after careful adjustment for important baseline variables (adjusted hazard ratio, 1.68; 95% confidence interval, 1.20-2.34; P</i>=0.002) and after propensity-score matching (propensity-adjusted hazard ratio, 1.79; 95% confidence interval, 1.08-2.95; P</i>=0.023).</AbstractText>Both clinical response and long-term survival were less favorable in patients undergoing CRT upgrade compared to de novo implantations.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,857 | Therapeutic hypothermia attenuates brain edema in a pig model of cardiac arrest: Possible role of the angiopoietin-Tie-2 system. | This study aimed to clarify whether therapeutic hypothermia protects against cerebral edema following cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) in a porcine model via regulating the angiopoietin-Tie-2 ligand-receptor system.</AbstractText>Male pigs were randomized into the therapeutic hypothermia group, the normothermia group or the sham control group. CA was induced in pigs by untreated ventricular fibrillation for 8min. Brain edema was determined by measuring the cerebral cortical water content at 24h after the return of spontaneous circulation (ROSC). The serum levels of angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), tyrosine kinase with immunoglobulin-like loop epidermal growth factor homology domain 2 (Tie-2), and S100B were measured using enzyme immunoassay kits at 0.5, 6, 12 and 24h after ROSC. The levels of the Ang-1, Ang-2, phosphorylated Tie-2 and Tie-2 proteins in the cerebral cortex at 24h after ROSC were determined by Western blotting.</AbstractText>Therapeutic hypothermia lessened brain cortex edema, alleviated histopathology injury, and improved neurologic outcomes at 24h after ROSC. Therapeutic hypothermia inhibited the CA- and CPR-induced increases in serum Ang-2 protein expression and the Ang-2/Ang-1 ratio and attenuated the decrease in serum Ang-1 expression. Therapeutic hypothermia also increased the protein expression of Ang-1 and the phosphorylated Tie-2/Tie-2 ratio and inhibited the expression of Ang-2 in the cerebral cortex at 24h after ROSC.</AbstractText>Based on our experiment, therapeutic hypothermia decreased cerebral edema after CA, which may be, at least in part, related to its ability to modulate the expression of components of the Ang-Tie-2 system.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,858 | Predictors of Permanent Pacemaker Implantation After Coronary Artery Bypass Grafting and Valve Surgery in Adult Patients in Current Surgical Era. | Permanent pacemaker (PPM) implantation after cardiac surgery is required in 0.4-6% of patients depending on cardiac surgery type. PPM implantation in the early postoperative period may reduce morbidity and postoperative hospital stay. We performed a retrospective review of electronic medical records of adult patients with coronary artery bypass grafting (CABG), valve surgery, or both, over a 3-year period. Our aim was to identify predictors of PPM requirements and PPM dependency on follow-up in the current surgical era.</AbstractText>After exclusion of patients with congenital heart disease, patients who already had a PPM or implantable cardioverter defibrillator (ICD), and patients with an indication for PPM or ICD before surgery, we identified 1,234 adult patients who underwent cardiac surgery between January 2007 and December 2009. A retrospective review of electronic medical records and pacemaker clinic data was performed.</AbstractText>Patients' mean age was 46.65 ± 16 years, and 59% were males. CABG was performed in 575 (46.6%) cases, aortic valve replacement in 263 (21.3%), mitral valve replacement in 333 (27%), and tricuspid valve replacement in 76 patients (6.2%). Twenty patients (1.6%) required implantation of a PPM postoperatively. Indications for PPM implantation included complete atrioventricular (AV) block in 13 (65%), sick sinus syndrome in three (15%), and atrial fibrillation (AF) with a slow ventricular rate in four (20%). Predictors for PPM requirement by multivariate analysis were the presence of pulmonary hypertension (P-HTN), reoperation, and left bundle branch block (LBBB) (P < 0.05). Late follow-up was available in 18 patients, at 84.5 ± 30 months. Eleven patients (61%) were PPM dependent on long-term follow-up.</AbstractText>Patients at high risk for PPM implantation after cardiac surgery include those with P-HTN, reoperation, and pre-existing LBBB. Of those receiving a PPM, about one-third will recover at least partially at long-term follow-up. We recommend preoperative assessment for risk of requiring postoperative PPM, to counsel patients about this risk and early PPM implantation in high-risk patients who are PPM dependent after surgery.</AbstractText> |
20,859 | Left Atrial Structure in Relationship to Age, Sex, Ethnicity, and Cardiovascular Risk Factors: MESA (Multi-Ethnic Study of Atherosclerosis). | Left atrial (LA) size is a marker of diastolic function and is associated with atrial fibrillation and cardiovascular outcomes. However, there are no large population studies measuring LA structure. The relationship of demographics and cardiovascular risk factors to LA size is largely unknown. This study aimed to determine associations of LA size with demographic factors, cardiac structure and function, and cardiovascular risk factors.</AbstractText>LA volume indexed to body surface area was measured by cardiovascular magnetic resonance steady-state free precession and fast gradient echo cine long- and short-axis images in 2576 asymptomatic participants of MESA ([Multi-Ethnic Study of Atherosclerosis] 68.7 years, 53.0% women, white 42.2%, Chinese American 12.0%, black 24.5%, and Hispanic 21.2%) using biplane and short-axis images. The mean LA volume index was 36.5±11.4 mL/m2</sup> in the entire cohort and 35.5±10.1 mL/m2</sup> in subjects free of cardiovascular risk factors (n=283). Multivariable analysis included adjustment for demographics, ethnicity, cardiovascular risk factors, serological studies, socioeconomic status, left ventricular structure, and medications. In the adjusted analysis, age (β=0.2 mL/m2</sup> per year, P</i><0.0001), male sex (β=-4.2 mL/m2</sup>, P</i><0.0001), obesity (β=1.3 mL/m2</sup>, P</i><0.01), end-diastolic volume index (β=0.4 mL/m2</sup>, P</i><0.0001), Chinese American (β=-2.6 mL/m2</sup>, P</i><0.0001), and Hispanic (β=1.1 mL/m2</sup>, P</i><0.05) ethnicities were associated with LA volume index. Diabetes mellitus and smoking were not associated with LA volume index. LA volumes measured by steady-state free precession were 3% larger than by fast gradient echo cine cardiovascular magnetic resonance (P</i><0.001).</AbstractText>Age, sex, ethnicity and left ventricular structural parameters were associated with LA size. Importantly, the study provides reference values of normal LA volume index.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,860 | Renal sympathetic stimulation and ablation affect ventricular arrhythmia by modulating autonomic activity in a cesium-induced long QT canine model. | Our previous studies showed that renal sympathetic stimulation (RS) may facilitate ischemic ventricular arrhythmia (VA) by increasing left stellate ganglion (LSG) nerve activity, whereas renal sympathetic ablation (RA) may suppress VA.</AbstractText>The purpose of this study was to investigate whether renal sympathetic interventions also can affect VA by modulating LSG activity in a cesium-induced long QT canine model.</AbstractText>Twenty-four dogs were randomly divided into RS group (n = 8), RA group (n = 8), or control group (n = 8). Serum norepinephrine, LSG function, and LSG neural activity were measured before and 3 hours after RS or RA. Increasing doses of cesium chloride then were administered until a "threshold dose" produced sustained ventricular tachycardia or ventricular fibrillation. Early afterdepolarization amplitude, VA prevalence, and tachycardia threshold dose were compared among these groups. Nerve growth factor and c-fos protein expressed in the LSG also were examined.</AbstractText>Serum norepinephrine, LSG function, and LSG neural activity were all significantly increased after 3 hours of RS and all were decreased 3 hours after RA. In addition, RS significantly decreased the tachycardia threshold dose, increased the early afterdepolarization amplitude, facilitated the incidence of VAs, and increased the expression of nerve growth factor and c-fos protein. In contrast, RA induced the opposite effects.</AbstractText>RS promotes, whereas RA suppresses, the incidence of VAs in a canine model of cesium-induced long QT. Modulation of LSG neural activity by RS and RA may be responsible for these different effects.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,861 | The clinical utility of normal findings on noninvasive cardiac assessment in the prediction of atrial fibrillation. | The absence of abnormalities on noninvasive cardiac assessment possibly confers a reduced risk of atrial fibrillation (AF) despite the presence of traditional risk factors.</AbstractText>Normal findings on noninvasive cardiac assessment are associated with a lower risk of AF development.</AbstractText>We examined the clinical utility of normal findings on routine noninvasive cardiac assessment in 5331 participants (85% white; 57% women) from the Cardiovascular Health Study who were free of baseline AF. The combination of a normal electrocardiogram (ECG) + normal echocardiogram was assessed for the development of AF events. A normal ECG was defined as the absence of major or minor Minnesota code abnormalities. A normal echocardiogram was defined as the absence of contractile dysfunction, wall motion abnormalities, or abnormal left ventricular mass. Cox regression was used to compute the 10-year risk of developing AF.</AbstractText>During the 10-year study period, a total of 951 (18%) AF events were detected. A normal ECG (multivariable hazard ratio [HR]: 0.80, 95% confidence interval [CI]: 0.69-0.92) and normal echocardiogram (multivariable HR: 0.75, 95% CI: 0.65-0.87) were associated with a reduced risk of AF in isolation. This association improved in those with normal ECG + normal echocardiogram (multivariable HR: 0.66, 95% CI: 0.55-0.79) compared with participants who had abnormal ECG + abnormal echocardiogram (referent).</AbstractText>Normal findings on routine noninvasive cardiac assessment identify persons in whom the risk of AF is low. Further studies are needed to explore the utility of this profile regarding the decision to implement certain risk factor modification strategies in older adults to reduce AF burden.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,862 | Apical left ventricular myocardial dysfunction is an early feature of cardiac involvement in myotonic dystrophy type 1. | Left ventricular (LV) dysfunction is a major prognostic determinant in myotonic dystrophy type 1 (DM1). Therefore, markers of early-stage LV impairment may be useful. The aim of this study was to evaluate 2D echocardiographic LV strain in a cohort of DM1 patients with preserved left ventricular ejection fraction (LVEF) and to compare the results with matched controls.</AbstractText>This prospective single-center study included 33 consecutive DM1 patients between February 2014 and February 2015. Mean age was 38.2±12.9 years, and 17 (52%) were males. Exclusion criteria were LVEF <55%, QRS >120 milliseconds, history of atrial fibrillation, and presence of a pacemaker with ventricular pacing. DM1 patients were matched to healthy controls according to sex and age.</AbstractText>DM1 patients showed significant impairment of global longitudinal strain (GLS) as compared to controls (-18.0±1.9 vs -19.1±2.4; P=.03), characterized by a marked alteration at the apex (-20.0±3.3 vs -22.7±3.1; P<.001). DM1 patients had also global radial strain impairment (20.0±9.8 vs 27.5±14.9; P=.024) compared to controls while global circumferential strain was not statistically different between groups (P=.94). Intra- and inter-observer analysis showed good reproducibility of GLS.</AbstractText>Despite preserved LVEF, DM1 patients exhibited significantly altered LV GLS, particularly at the apex, as compared with controls. The detection of impaired myocardial deformation at early stages of the disease might help to screen high-risk patients who need closer follow-up.</AbstractText>© 2017, Wiley Periodicals, Inc.</CopyrightInformation> |
20,863 | MEMS-Based Flexible Force Sensor for Tri-Axial Catheter Contact Force Measurement. | Atrial fibrillation (AFib) is a significant healthcare problem caused by the uneven and rapid discharge of electrical signals from pulmonary veins (PVs). The technique of radiofrequency (RF) ablation can block these abnormal electrical signals by ablating myocardial sleeves inside PVs. Catheter contact force measurement during RF ablation can reduce the rate of AFib recurrence, since it helps to determine effective contact of the catheter with the tissue, thereby resulting in effective power delivery for ablation. This paper presents the development of a three-dimensional (3D) force sensor to provide the real-time measurement of tri-axial catheter contact force. The 3D force sensor consists of a plastic cubic bead and five flexible force sensors. Each flexible force sensor was made of a PEDOT:PSS strain gauge and a PDMS bump on a flexible PDMS substrate. Calibration results show that the fabricated sensor has a linear response in the force range required for RF ablation. To evaluate its working performance, the fabricated sensor was pressed against gelatin tissue by a micromanipulator and also integrated on a catheter tip to test it within deionized water flow. Both experiments simulated the ventricular environment and proved the validity of applying the 3D force sensor in RF ablation. |
20,864 | Electrocardiographic intervals associated with incident atrial fibrillation: Dissecting the QT interval. | Prolongation of the QT interval has been associated with an increased risk of developing atrial fibrillation (AF), but the responsible mechanism remains unknown.</AbstractText>The aims of this study were to subdivide the QT interval into its components and identify the resultant electrocardiographic interval(s) responsible for the association with AF.</AbstractText>Predefined QT-interval components were assessed for association with incident AF in the Atherosclerosis Risk in Communities study using Cox proportional hazards models. Hazard ratios (HRs) were calculated per 1-SD increase in each component. Among QT-interval components exhibiting significant associations, additional analyses evaluating long extremes, defined as greater than the 95th</sup> percentile, were performed.</AbstractText>Of the 14,625 individuals, 1505 (10.3%) were diagnosed with incident AF during a mean follow-up period of 17.6 years. After multivariable adjustment, QT-interval components involved in repolarization, but not depolarization, exhibited significant associations with incident AF, including a longer ST segment (HR 1.27; 95% confidence interval [CI] 1.14-1.41; P < .001) and a prolonged T-wave onset to T-wave peak (T-onset to T-peak) (HR 1.13; 95% CI 1.07-1.20; P < .001). Marked prolongation of the ST segment (HR 1.31; 95% CI 1.04-1.64; P = .022) and T-onset to T-peak (HR 1.36; 95% CI 1.09-1.69; P = .006) was also associated with an increased risk of incident AF.</AbstractText>The association between a prolonged QT interval and incident AF is primarily explained by components involved in ventricular repolarization: prolongation of the ST segment and T-onset to T-peak. These observations suggest that prolongation of phases 2 and 3 of the cardiac action potential drives the association between the QT interval and AF risk.</AbstractText>Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,865 | Outcomes of ventricular tachycardia ablation in patients with structural heart disease: The impact of electrical storm. | To investigate predictors of long-term outcomes after catheter ablation (CA) for ventricular tachycardia (VT) and the impact of electrical storm (ES) prior to index ablation procedures.</AbstractText>We studied consecutive patients with structural heart disease and VT (n = 328; age: 63±12 years; 88% males; 72% ischaemic cardiomyopathy; LVEF: 32±12%) who had undergone CA. According to presenting arrhythmia at baseline, they were divided into ES (n = 93, 28%) and non-ES groups. Clinical predictors of all-cause mortality were investigated and a clinically useful risk score (SCORE) was constructed.</AbstractText>During a median follow-up of 927 days (IQR: 564-1626), 67% vs. 60% of patients (p = 0.05) experienced VT recurrence in the ES vs. the non-ES group, respectively; and 41% vs. 32% patients died (p = 0.02), respectively. Five factors were independently associated with mortality: age >70 years (hazard ratio (HR): 1.6, 95% confidence interval (CI): 1.1-2.4, p = 0.01), NYHA class ≥3 (HR: 1.9, 95% CI: 1.2-2.9, p = 0.005), a serum creatinine level >1.3 mg/dL (HR: 1.6, 95% CI: 1.1-2.3, p = 0.02), LVEF ≤25% (HR: 2.4, 95% CI: 1.6-3.5, p = 0.00004), and amiodarone therapy (HR: 1.5, 95% CI: 1.0-2.2, p = 0.03). A risk SCORE ranging from 0-4 (1 point for either high-risk age, NYHA, creatinine, or LVEF) correlated with mortality. ES during index ablation independently predicted mortality only in patients with a SCORE ≤1.</AbstractText>Advanced LV dysfunction, older age, higher NYHA class, renal dysfunction, and amiodarone therapy, but not ES, were predictors of poor outcomes after CA for VT in the total population. However, ES did predict mortality in a low-risk sub-group of patients.</AbstractText> |
20,866 | Comparison of different inspiratory triggering settings in automated ventilators during cardiopulmonary resuscitation in a porcine model. | Mechanical ventilation via automated in-hospital ventilators is quite common during cardiopulmonary resuscitation. It is not known whether different inspiratory triggering sensitivity settings of ordinary ventilators have different effects on actual ventilation, gas exchange and hemodynamics during resuscitation.</AbstractText>18 pigs enrolled in this study were anaesthetized and intubated. Continuous chest compressions and mechanical ventilation (volume-controlled mode, 100% O2, respiratory rate 10/min, and tidal volumes 10ml/kg) were performed after 3 minutes of ventricular fibrillation. Group trig-4, trig-10 and trig-20 (six pigs each) were characterized by triggering sensitivities of 4, 10 and 20 (cmH2O for pressure-triggering and L/min for flow-triggering), respectively. Additionally, each pig in each group was mechanically ventilated using three types of inspiratory triggering (pressure-triggering, flow-triggering and turned-off triggering) of 5 minutes duration each, and each animal matched with one of six random assortments of the three different triggering settings. Blood gas samples, respiratory and hemodynamic parameters for each period were all collected and analyzed.</AbstractText>In each group, significantly lower actual respiratory rate, minute ventilation volume, mean airway pressure, arterial pH, PaO2, and higher end-tidal carbon dioxide, aortic blood pressure, coronary perfusion pressure, PaCO2 and venous oxygen saturation were observed in the ventilation periods with a turned-off triggering setting compared to those with pressure- or flow- triggering (all P<0.05), except when compared with pressure-triggering of 20 cmH2O (respiratory rate 10.5[10/11.3]/min vs 12.5[10.8/13.3]/min, P = 0.07; coronary perfusion pressure 30.3[24.5/31.6] mmHg vs 27.4[23.7/29] mmHg, P = 0.173; venous oxygen saturation 46.5[32/56.8]% vs 41.5[33.5/48.5]%, P = 0.575).</AbstractText>Ventilation with pressure- or flow-triggering tends to induce hyperventilation and deteriorating gas exchange and hemodynamics during CPR. A turned-off patient triggering or a pressure-triggering of 20 cmH2O is preferred for ventilation when an ordinary inpatient hospital ventilator is used during resuscitation.</AbstractText> |
20,867 | Utility of CHA2DS2-VASc and HAS-BLED Scores as Predictor of Thromboembolism and Bleeding After Left Ventricular Assist Device Implantation. | Ischemic and hemorrhagic events are the common causes of morbidity and mortality after continuous-flow left ventricular assist device (CF-LVAD) implantation. CHA2DS2-VASc score predicts thromboembolic (TE) event risk and HAS-BLED score predicts bleeding risk in patients on anticoagulant with atrial fibrillation (AF). We aimed to evaluate whether these scoring systems would be predictive of TE and bleeding complications after CF-LVAD implantation. From December 2010 to December 2014, 145 patients who underwent CF-LVAD implantation at a single center were included. Mean age was 50.7 ± 11.2 years, and 85.5% were male. Baseline CHA2DS2-VASc and HAS-BLED scores were retrospectively determined for patients with CF-LVADs. After device implantation, all patients were on warfarin (target international normalized ratio 2-3) as well as 300 mg of aspirin daily. Median length of support was 316 days (range 31-1,060), with 22 TE events (15.2%) and 32 bleeding (22.1%) events. The mean CHA2DS2-VASc score was 2.3 ± 1.4 and 2.5 ± 1.2 (p = 0.2) in patients with and without TE event, respectively. The mean HAS-BLED score was 1.8 ± 0.8 and 1.42 ± 0.6 (p = 0.004) in patients with and without bleeding, respectively. Baseline high HAS-BLED score was predictive of bleeding events after CF-LVAD implantation, whereas baseline CHA2DS2-VASc score was not predictive of TE events. |
20,868 | Discrimination between QRS and T Waves Using a Right Parasternal Lead for S-ICD in a Patient with a Single Ventricle. | The subcutaneous implantable cardioverter-defibrillator (S-ICD) is a useful option for patients with a single ventricle (SV) in which transvenous leads are contraindicated because of intracardiac shunts. We report a case in which a right parasternal lead placement was indicated for an S-ICD in a resuscitated patient with an SV. There were significant changes in the magnitude of R to T waves ratio in the right compared to the left parasternal lead position. Screening in the right parasternal position is effective for selecting appropriate patients with congenital heart disease for S-ICD implantations. |
20,869 | [A life-saving shock from a subcutaneous ICD during skydiving]. | We report the case of a 38-year-old man who was implanted a subcutaneous implantable cardioverter-defibrillator (S-ICD) and then performed a skydive from a height of 3000 m. During the jump, he lost consciousness due to ventricular fibrillation (VF). The S‑ICD detected the VF properly and successfully shocked the arrhythmia. Our illustrative case emphasizes the S‑ICD as an appropriate therapy in patient with life-threatening arrhythmias even under extreme conditions. |
20,870 | Local Left Ventricular Epicardial J Waves and Late Potentials in Brugada Syndrome Patients with Inferolateral Early Repolarization Pattern. | <b>Background:</b> Brugada syndrome (BrS) is characterized by J-point or ST-segment elevation on electrocardiograms (ECGs) and increased risk of ventricular fibrillation (VF). In BrS, epicardial depolarization abnormality with delayed potential on the right ventricular outflow tract is reportedly the predominant mechanism underlying VF. Yet VF occurrence is also associated with early repolarization (ER) pattern in the inferolateral ECG leads, which may represent the inferior and/or left lateral ventricular myocardium. The aim of this study was to examine epicardial electrograms recorded directly at the left ventricle (LV) in BrS patients after VF episodes. <b>Methods:</b> In 12 BrS patients who had experienced VF episodes and 17 control subjects, a multipolar catheter was introduced into the left lateral coronary vein for unipolar and bipolar electrogram recordings at the LV epicardium. Both inferior and lateral ER patterns on ECG were observed in three BrS patients and six control subjects. <b>Results:</b> In the epicardium, prominent J waves were detected using unipolar recording, and potentials after the QRS complex were detected using bipolar recording in three of the 12 BrS patients. These three patients also showed both inferior and lateral ER patterns on ECG. Neither prominent J waves nor potentials after the QRS complex were recorded at the endocardium of the LV in any of these three patients; nor were they seen at the epicardium in any of the control subjects. These features were accentuated on pilsicainide administration (<i>n</i> = 2) but diminished on constant atrial pacing (<i>n</i> = 3) and isoproterenol administration (<i>n</i> = 1). The J waves observed through unipolar recording coincided with the potentials after QRS complex observed through bipolar recording and with the inferolateral ER patterns on ECG. <b>Conclusions:</b> We recorded prominent J waves in unipolar electrogram and potentials after QRS complex in bipolar electrogram at the LV epicardium in BrS patients with global ER pattern. The prominent J waves coincided with the potentials after QRS complex and the inferolateral ER pattern on ECG. The characteristics of the inferolateral ER pattern on ECG in these patients primarily represent depolarization feature. |
20,871 | Cervical sympathetic blockade for the management of electrical storm. | A 75-year-old man presented with dizziness and fatigue secondary to ventricular and supraventricular arrhythmias. He underwent an elective ablation but continued to suffer from ventricular tachycardia with cardiovascular instability despite antiarrhythmic therapy with multiple agents. The patient continued to develop episodes of ventricular tachycardia and an episode of ventricular fibrillation. Electrical storm encompasses a situation of cardiac instability which may present as several episodes of ventricular tachycardia or ventricular fibrillation in a short period. We performed an ultrasound-guided left stellate ganglion block at the bedside which resulted in abolition of electrical storm. The patient demonstrated sinus rhythm with episodes of sinus tachycardia. Left stellate ganglion block has proven to be a successful mode of treatment for those patients with ventricular tachyarrhythmia resistant to medical management or those who fail atrioventricular node ablation. Ultrasound-guided left stellate ganglion block is a valuable and effective means to providing sympathectomy in the management of electrical storm or ventricular tachyarrhythmias. |
20,872 | Ranolazine Added to Amiodarone Facilitates Earlier Conversion of Atrial Fibrillation Compared to Amiodarone-Only Therapy. | Amiodarone (AMIO) is for many years effectively used to control ventricular rate during atrial fibrillation (AF) and to convert it into sinus rhythm. However, due to its delayed onset of action, ranolazine (RAN), a new antianginal agent with atrial-selective electrophysiologic properties, has recently been attempted as add-on therapy with AMIO to facilitate AF conversion.</AbstractText>To establish the role of this combination therapy, we enrolled 173 consecutive patients (68 ± 10 years, 54% male) with recent-onset (<48-hour duration) AF who were eligible for pharmacologic cardioversion. Patients were randomized to intravenous AMIO (loading dose 5 mg/kg in 1 hour followed by 50 mg/h; n = 81), or AMIO plus a single oral dose of RAN 1 g (n = 92).</AbstractText>Mean left atrial diameter did not significantly differ between groups, AMIO and AMIO + RAN (4.2 ± 0.5 cm vs 4.1 ± 0.4 cm, P = 0.18). The AMIO + RAN group compared with the AMIO-only group showed significantly shorter time to conversion (8.6 ± 2.8 hours vs 19.4 ± 4.4 hours, P < 0.0001) and higher conversion rate at 24 hours (98% vs 58%, P < 0.001). Left ventricular ejection fraction did not markedly vary between the two groups and ranged within moderately reduced values. No serious clinically evident adverse effects were observed in any of the patients receiving either AMIO or the combination treatment.</AbstractText>Our data demonstrate faster sinus rhythm restoration and enhanced conversion rate of AF after AMIO plus RAN in patients with preserved ejection fraction and left atrial size, implicating a synergistic effect of the two agents.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,873 | Modulation of Autonomic Nervous Activity in the Termination of Paroxysmal Atrial Fibrillation. | Autonomic nervous activity plays a critical role in the genesis of paroxysmal atrial fibrillation (AF, PAF). However, the role of autonomic nervous activity on AF termination has not been elucidated. Heart rate variability (HRV) is widely used to evaluate autonomic nervous activity in humans. The purpose of this study was to assess whether autonomic nervous activity assessed by HRV contributes to AF termination.</AbstractText>Electrocardiograms (ECGs) and HRV were studied in patients with termination of sustained (>30 s) PAF by 24-hour ambulatory Holter monitoring. The 20-minute interval after termination of AF was divided into four segments of 5 minutes each, and a frequency analysis was applied to each 5-minute segment.</AbstractText>In 52 AF episodes, the ultra-low-frequency power, very-low-frequency power, low-frequency power (LF), high-frequency power (HF), and total power significantly decreased with time after episodes of AF termination. The LF/HF (L/H) ratio, normalized LF (LFnu), and normalized HF (HFnu) significantly changed after AF termination. Eighteen (35%) episodes had decreased LFnu and increased HFnu (sympathetic withdrawal and vagal activation), which had slower average AF ventricular responses (92 ± 16 beats/min vs 105 ± 24 beats/min, P < 0.05) than the AF termination episodes (n = 34, 65%) with increased LFnu and decreased HFnu (sympathetic activation and vagal withdrawal). Moreover, older patients (aged >65 years) had a higher incidence (n = 27, 75%) of AF termination with increased LFnu and decreased HFnu than did younger patients (aged ≤65 years, n = 7, 44%, P < 0.05).</AbstractText>Autonomic changes critically regulate termination of PAF, which is modulated by aging.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,874 | Is there a role of inducible nitric oxide synthase activation in the delayed antiarrhythmic effect of sodium nitrite? | This study aimed to examine whether inducible nitric oxide synthase (iNOS) plays a role in the delayed antiarrhythmic effect of sodium nitrite. Twenty-one dogs were infused intravenously with sodium nitrite (0.2 μmol·kg<sup>-1</sup>·min<sup>-1</sup>) for 20 min, either in the absence (n = 12) or in the presence of the iNOS inhibitor S-(2-aminoethyl)-isothiourea (AEST) (total dose 2.0 mg·kg<sup>-1</sup> i.v., n = 9). Control dogs (n = 12) were given saline. Twenty-four hours later, all of the dogs were subjected to a 25 min period occlusion of the left anterior descending coronary artery followed by rapid reperfusion. Dogs treated with AEST and nitrite received again AEST prior to the occlusion. Compared with the controls, sodium nitrite markedly reduced the number of ectopic beats, the number and incidence of ventricular tachycardia, and the incidence of ventricular fibrillation during occlusion and increased survival (0% versus 50%) from the combined ischaemia and reperfusion insult. Although AEST completely inhibited iNOS activity, the nitrite-induced increase in NO bioavailability during occlusion was not substantially modified. Furthermore, AEST attenuated but did not completely abolish the antiarrhythmic effect of nitrite. The marked delayed antiarrhythmic effect of sodium nitrite is not entirely due to the activation of iNOS; other mechanisms may certainly play a role. |
20,875 | True idiopathic ventricular fibrillation in out-of-hospital cardiac arrest survivors in the Swiss Canton Ticino: prevalence, clinical features, and long-term follow-up. | Out-of-hospital cardiac arrest (OHCA) in the absence of evident structural heart disease is rare and can be due to subclinical cardiomyopathy and primary electrical disorders, including idiopathic ventricular fibrillation (IVF) with early repolarization (ER) pattern. Aim of this study was to investigate prevalence, clinical features, and long-term prognosis of IVF in OHCA survivors with otherwise normal 12-lead electrocardiograms (ECGs).</AbstractText>Patients with IVF in the absence of ER pattern or atrioventricular conduction abnormalities were considered eligible for this study. A total of 3407 OHCAs occurred in our region from 2000 to 2014. Out-of-hospital cardiac arrests of presumed cardiac origin were 2192; of them, 644 presented with a ventricular arrhythmia (VT/VF) as first shockable rhythm. Among them, a total of 74 implantable cardioverter-defibrillators were implanted for secondary prevention. Ventricular arrhythmia was considered idiopathic in 11 (15%) of these patients. Over a mean follow-up time of 85 ± 47 months (median: 42 months), ECG was found abnormal in three cases. In the remaining eight patients (6 males; median age: 45 years), no ECG or structural abnormalities were detected during the follow-up. Prevalence of IVF in OHCA survivors with first-shockable rhythm was 1.2%. During the long-term follow-up, no patient died or experienced ICD interventions. No new echocardiographic abnormal findings were revealed.</AbstractText>Idiopathic ventricular fibrillation is rare occurring in 1.2% of OHCA survivors presenting with a shockable rhythm. The initial diagnosis can change in up to 27% of cases. Patients with IVF and no ER pattern or AV conduction disturbances have a good prognosis during a long-term follow-up.</AbstractText> |
20,876 | Chronic total occlusion of an infarct-related artery: a new predictor of ventricular arrhythmias in primary prevention implantable cardioverter defibrillator patients. | The aim of this article is to evaluate the impact of a coronary chronic total occlusion in an infarct-related artery (IRA-CTO) on the occurrence of ventricular arrhythmias (VAs) in patients implanted with an implantable cardioverter defibrillator (ICD) for primary prevention.</AbstractText>The study includes a prospective cohort of 108 consecutive patients with ischaemic cardiomyopathy, in whom an ICD was implanted for primary prevention and a coronary angiography performed before ICD implantation. About 49 patients (45%) had a CTO and 34 (31%) had an IRA-CTO. Patients with IRA-CTO did not differ from the rest of the population in terms of basal characteristics and severity of cardiac disease. Median follow-up was 33 months (interquartile range 46). Infarct-related artery-CTO was associated with higher rates of any VA (53 vs. 26%, P = 0.006) and fast ventricular tachycardia (fast VT, cycle length <300 ms) or ventricular fibrillation (VF) (47 vs. 19%, P = 0.002). At multivariate Cox regression, IRA-CTO was the only independent predictor of any VA [hazard ratio (HR) 3.64, P = 0.002] and fast VT/VF (HR 3.36, P = 0.008). On the contrary, CTO not associated with a prior infarction in their territory did not increase the risk of VA. Infract-related artery-CTO was also an independent predictor of cardiac mortality or heart transplantation (HR 3.46, P = 0.022).</AbstractText>In ischaemic patients implanted with an ICD for primary prevention, a CTO associated with a previous infarction in its territory is an independent predictor of VA and, especially, of fast VT/VF, identifying a subgroup of patients with a very high rate of arrhythmic events at follow-up.</AbstractText> |
20,877 | Reduction in unnecessary ventricular pacing fails to affect hard clinical outcomes in patients with preserved left ventricular function: a meta-analysis. | Several pacing modalities across multiple manufacturers have been introduced to minimize unnecessary right ventricular pacing. We conducted a meta-analysis to assess whether ventricular pacing reduction modalities (VPRM) influence hard clinical outcomes in comparison to standard dual-chamber pacing (DDD).</AbstractText>An electronic search was performed using Cochrane Central Register, PubMed, Embase, and Scopus. Only randomized controlled trials (RCT) were included in this analysis. Outcomes of interest included: frequency of ventricular pacing (VP), incident persistent/permanent atrial fibrillation (PerAF), all-cause hospitalization and all-cause mortality. Odds ratios (OR) were reported for dichotomous variables. Seven RCTs involving 4119 adult patients were identified. Ventricular pacing reduction modalities were employed in 2069 patients: (MVP, Medtronic Inc.) in 1423 and (SafeR, Sorin CRM, Clamart) in 646 patients. Baseline demographics and clinical characteristics were similar between VPRM and DDD groups. The mean follow-up period was 2.5 ± 0.9 years. Ventricular pacing reduction modalities showed uniform reduction in VP in comparison to DDD groups among all individual studies. The incidence of PerAF was similar between both groups {8 vs. 10%, OR 0.84 [95% confidence interval (CI) 0.57; 1.24], P = 0.38}. Ventricular pacing reduction modalities showed no significant differences in comparison to DDD for all-cause hospitalization or all-cause mortality [9 vs. 11%, OR 0.82 (95% CI 0.65; 1.03), P= 0.09; 6 vs. 6%, OR 0.97 (95% CI 0.74; 1.28), P = 0.84, respectively].</AbstractText>Novel VPRM measures effectively reduce VP in comparison to standard DDD. When actively programmed, VPRM did not improve clinical outcomes and were not superior to standard DDD programming in reducing incidence of PerAF, all-cause hospitalization, or all-cause mortality.</AbstractText> |
20,878 | A Randomised tRial of Expedited transfer to a cardiac arrest centre for non-ST elevation ventricular fibrillation out-of-hospital cardiac arrest: The ARREST pilot randomised trial. | Wide variation exists in inter-hospital survival from out-of-hospital cardiac arrest (OHCA). Regionalisation of care into cardiac arrest centres (CAC) may improve this. We report a pilot randomised trial of expedited transfer to a CAC following OHCA without ST-elevation. The objective was to assess the feasibility of performing a large-scale randomised controlled trial.</AbstractText>Adult witnessed ventricular fibrillation OHCA of presumed cardiac cause were randomised 1:1 to either: (1) treatment: comprising expedited transfer to a CAC for goal-directed therapy including access to immediate reperfusion, or (2) control: comprising current standard of care involving delivery to the geographically closest hospital. The feasibility of randomisation, protocol adherence and data collection of the primary (30-day all-cause mortality) and secondary (cerebral performance category (CPC)) and in-hospital major cardiovascular and cerebrovascular events (MACCE) clinical outcome measures were assessed.</AbstractText>Between November 2014 and April 2016, 118 cases were screened, of which 63 patients (53%) met eligibility criteria and 40 of the 63 patients (63%) were randomised. There were no protocol deviations in the treatment arm. Data collection of primary and secondary outcomes was achieved in 83%. There was no difference in baseline characteristics between the groups: 30-day mortality (Intervention 9/18, 50% vs. Control 6/15, 40%; P=0.73), CPC 1/2 (Intervention: 9/18, 50% vs. Control 7/14, 50%; P>0.99) or MACCE (Intervention: 9/18, 50% vs. Control 6/15, 40%; P=0.73).</AbstractText>These findings support the feasibility and acceptability of conducting a large-scale randomised controlled trial of expedited transfer to CAC following OHCA to address a remaining uncertainty in post-arrest care.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,879 | Emergency Medicine Myths: Epinephrine in Cardiac Arrest. | Sudden cardiac arrest accounts for approximately 15% of deaths in developed nations, with poor survival rate. The American Heart Association states that epinephrine is reasonable for patients with cardiac arrest, though the literature behind its use is not strong.</AbstractText>To review the evidence behind epinephrine for cardiac arrest.</AbstractText>Sudden cardiac arrest causes over 450,000 deaths annually in the United States. The American Heart Association recommends epinephrine may be reasonable in patients with cardiac arrest, as part of Advanced Cardiac Life Support. This recommendation is partly based on studies conducted on dogs in the 1960s. High-dose epinephrine is harmful and is not recommended. Epinephrine may improve return of spontaneous circulation, but does not improve survival to discharge or neurologic outcome. Literature suggests that three phases of resuscitation are present: electrical, circulatory, and metabolic. Epinephrine may improve outcomes in the circulatory phase prior to 10 min post arrest, though further study is needed. Basic Life Support measures including adequate chest compressions and early defibrillation provide the greatest benefit.</AbstractText>Epinephrine may improve return of spontaneous circulation, but it does not improve survival to discharge or neurologic outcome. Timing of epinephrine may affect patient outcome, but Basic Life Support measures are the most important aspect of resuscitation and patient survival.</AbstractText>Published by Elsevier Inc.</CopyrightInformation> |
20,880 | Increasing age does not affect time to appropriate therapy in primary prevention ICD/CRT-D: a competing risks analysis. | To evaluate the impact of age on the clinical outcomes in a primary prevention implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) population.</AbstractText>A retrospective, multicentre analysis of patients aged 60 years and over with primary prevention ICD/CRT-D devices implanted between 1 January 2006 and 1 November 2014 was performed. Survival to follow-up with no therapy (T1), death prior to follow-up with no therapy (T2), delivery of appropriate therapy with survival to follow-up (T3), and delivery of appropriate therapy with death prior to follow-up (T4) were measured. In total, 424 patients were eligible for inclusion in the analysis, mean follow-up of 32.6 months during which time 44 patients (10.1%) received appropriate therapy. The sub-hazard ratio (SHR) for the cumulative incidence of appropriate therapy (T3) according to age at implant was 1.00 (P = 0.851; 95% CI 0.96–1.04). The SHR for cumulative incidence of death (T2) according to age at implant was 1.06 (P < 0.001; 95% CI 1.03–1.01). Age at implant, ischaemic aetiology, baseline haemoglobin, and the presence of diabetes mellitus were predictors of all-cause mortality.</AbstractText>Age has no impact on the time to appropriate therapy, but risk of death prior to therapy increases by 6% for every year increment. As the ICD population ages, the proportion who die without receiving appropriate therapy increases due to competing risks. Characterizing competing risks predictive of death independent of ICD indication would focus therapy on those with potential to benefit and reduce unnecessary exposure to ICD-related morbidity.</AbstractText> |
20,881 | Alternative Approaches for Ablation of Resistant Ventricular Tachycardia. | Ventricular tachycardia (VT) ablation is usually performed with an ablation catheter that delivers unipolar radiofrequency (RF) energy to eliminate the re-entry circuit responsible for VT. However, there are some instances when unipolar RF ablation fails, notably in VTs with a deep intramural origin, or cases in which epicardial access is not attainable due to prior cardiac surgery. To overcome these limitations, several alternative approaches have been used in clinical practice, including alcohol ablation or coil embolization, simultaneous unipolar or bipolar RF ablation, surgical ablation, or noninvasive ablation with stereotactic radiosurgery. This review article describes some of these alternative techniques. |
20,882 | Fluoroless Catheter Ablation of Cardiac Arrhythmias: A 5-Year Experience. | Catheter ablations have been traditionally performed with the use of fluoroscopic guidance, which exposes the patient and staff to the inherent risks of radiation. We have developed techniques to eliminate the use of fluoroscopy during cardiac ablations and have been performing completely fluoroless catheter ablations on our patients for over 5 years.</AbstractText>We present a retrospective analysis of the safety, efficacy, and feasibility data from 500 consecutive patients who underwent nonfluoroscopic catheter ablation, targeting a total of 639 arrhythmias, including atrioventricular reciprocating tachycardia (AVRT), atrioventricular nodal reentrant tachycardia (AVNRT), atrial tachycardia (AT), atrial fibrillation (AF), premature ventricular contractions (PVCs), and ventricular tachycardia (VT). We perform fluoroless ablations using intracardiac electrograms, electroanatomic mapping, and for most cases intracardiac echocardiography. Our experience includes exclusively endocardial cardiac ablations.</AbstractText>The mean follow-up was 20.5 months. Recurrence rate for AVRT was 6.5%, for AVNRT 2.5%, for macro-reentrant AT 6.4%, for focal AT 5.4%, for AF 22.6%, for PVC 6.7%, and for VT 21.4%. Major complications occurred in five patients (1.0%); minor complications occurred in three patients (0.6%). No deaths occurred. Fluoroscopy was used in one instance, for 0.3 minutes, to confirm venous access.</AbstractText>Completely fluoroless catheter ablations may be routinely performed for all endocardial ablations without compromising safety, efficacy, or procedural duration.</AbstractText>© 2017 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals, Inc.</CopyrightInformation> |
20,883 | Beta-Blocker Use Is Associated With Impaired Left Atrial Function in Hypertension. | Impaired left atrial (LA) mechanical function is present in hypertension and likely contributes to various complications, including atrial arrhythmias, stroke, and heart failure. Various antihypertensive drug classes exert differential effects on central hemodynamics and left ventricular function. However, little is known about their effects on LA function.</AbstractText>We studied 212 subjects with hypertension and without heart failure or atrial fibrillation. LA strain was measured from cine steady-state free-precession cardiac MRI images using feature-tracking algorithms. In multivariable models adjusted for age, sex, race, body mass index, blood pressure, diabetes mellitus, LA volume, left ventricular mass, and left ventricular ejection fraction, beta-blocker use was associated with a lower total longitudinal strain (standardized β=-0.21; P=0.008), and lower LA expansion index (standardized β=-0.30; P<0.001), indicating impaired LA reservoir function. Beta-blocker use was also associated with a lower positive strain (standardized β=-0.19; P=0.012) and early diastolic strain rate (standardized β=0.15; P=0.039), indicating impaired LA conduit function. Finally, beta-blocker use was associated with a lower (less negative) late-diastolic strain (standardized β=0.15; P=0.049), strain rate (standardized β=0.18; P=0.019), and a lower active LA emptying fraction (standardized β=-0.27; P<0.001), indicating impaired booster pump function. Use of other antihypertensive agents was not associated with LA function.</AbstractText>Beta-blocker use is significantly associated with impaired LA function in hypertension. This association could underlie the increased risk of atrial fibrillation and stroke seen with the use of beta-blockers (as opposed to other antihypertensive agents) demonstrated in recent trials.</AbstractText>© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.</CopyrightInformation> |
20,884 | Changing target temperature from 33°C to 36°C in the ICU management of out-of-hospital cardiac arrest: A before and after study. | In December 2013, our institution changed the target temperature management (TTM) for the first 24h in ventricular fibrillation out-of-hospital cardiac arrest (VF-OHCA) patients from 33°C to 36°C. This study aimed to examine the impact this change had on measured temperatures and patient outcomes.</AbstractText>We conducted a retrospective cohort study of consecutive VF-OHCA patients admitted to a tertiary referral hospital in Melbourne (Australia) between January 2013 and August 2015. Outcomes were adjusted for age and duration of cardiac arrest.</AbstractText>Over the 30-month period, 76 VF-OHCA cases were admitted (24 before and 52 after the TTM change). Patient demographics, cardiac arrest features and hospital interventions were similar between the two periods. After the TTM change, less patients received active cooling (100% vs. 70%, p < 0.001), patients spent less time at target temperature (87% vs. 50%, p < 0.001), and fever rates increased (0% vs. 19%, p = 0.03). ​During the 36°C period, there was a decrease in the proportion of patients who were discharged: alive (71% vs. 58%, p=0.31), home (58% vs. 40%, p=0.08); and, with a favourable neurological outcome (cerebral performance category score 1-2: 71% vs. 56%, p=0.22).</AbstractText>After the change from a TTM target of 33°C to 36°C, we report low compliance with target temperature, higher rates of fever, and a trend towards clinical worsening in patient outcomes. Hospitals adopting a 36°C target temperature to need to be aware that this target may not be easy to achieve, and requires adequate sedation and muscle-relaxant to avoid fever.</AbstractText>Copyright © 2017 Elsevier B.V. All rights reserved.</CopyrightInformation> |
20,885 | Inducibility of Ventricular Arrhythmia 1 Year Following Treatment with Heavy Ion Irradiation in Dogs with Myocardial Infarction. | Targeted external heavy ion irradiation (THIR) of rabbit hearts 2 weeks after myocardial infarction (MI) reduced the vulnerability of fatal ventricular tachyarrhythmias (VT/VF) in association with the increased connexin43 (Cx43). Increased Cx43 was maintained for at least 1 year in normal rabbits, but the long-term antiarrhythmic effects in the MI model are unknown. We investigated the propensity for late potentials and VT/VF inducibility.</AbstractText>Intracoronary injection of microspheres was performed to induce nontransmural MI in anesthetized eight beagles. Four beagles were treated with THIR (12</sup> C6+</sup> , 15 Gy) 2 weeks later (MI + THIR group), and four without THIR served as controls (MI group). Signal-averaged electrocardiography, programmed electrical stimulation, immunohistochemical analysis, and echocardiograms were performed at 1 year.</AbstractText>Filtered QRS duration was exacerbated after MI and remained unchanged for 1 year in the MI group (118 ± 1.4 ms), but significantly returned toward baseline in the MI + THIR group (109 ± 6.9 ms). Similarly, root mean square voltage of the last 40 ms was exacerbated after MI, but recovered after THIR. VT/VF inducibility decreased to 25% in the MI + THIR group compared with 100% in the MI group. Immunostaining Cx43 expression in cardiac tissues significantly increased by 24-45% in the MI + THIR group. Left ventricular ejection fractions remained within the normal range in both groups.</AbstractText>A single exposure of the dog heart to 12</sup> C irradiation attenuated vulnerability to ventricular arrhythmia after the induction of MI for at least 1 year through the modulation of Cx43 expression.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,886 | JAK-STAT signalling and the atrial fibrillation promoting fibrotic substrate. | Left-atrial (LA) fibrosis is an important feature of many atrial fibrillation (AF) substrates. The JAK-STAT system contributes to cardiac remodelling, but its role in AF is unknown. Here we investigated JAK-STAT changes in an AF-model and their potential contributions to LA-fibrosis.</AbstractText>LA-remodelling was studied in dogs with heart failure (HF) induced by ventricular tachypacing (VTP, 240 bpm), and in mice with left-ventricular (LV) dysfunction due to myocardial infarction (MI). The selective STAT-3 inhibitor S3I-201 was administered to fibroblasts in vitro or mice in vivo (10 mg/kg/d, osmotic mini-pump). HF-dogs developed LA-selective fibrosis and AF-susceptibility at 1-week VTP. The mRNA-expression of platelet-derived growth factor (PDGF, a JAK-STAT activator) isoforms A, C and D, as well as JAK2, increased in LA fibroblasts from 1-week VTP. HF upregulated protein-expression of PDGF-receptor-β and phosphorylated (activated) signal transducer and activator of transcription 3 (STAT3) in LA. PDGF-AB stimulation of LA fibroblasts increased PDGFR-α, STAT3 and phosphorylated-STAT3 expression, as well as collagen-1 and fibronectin-1 protein secretion (by 1.6- to 20-fold), with smaller changes in LV fibroblasts. Phosphorylated-STAT3 and collagen upregulation were suppressed by the JAK2 inhibitor AG-490, PDGF receptor inhibitor AG1296 and STAT3-inhibitor SI3-201. In vivo S3I-201 treatment of MI-mice attenuated LA-fibrosis, LA-dilation and P-wave duration changes versus vehicle-control.</AbstractText>HF activates the LA JAK-STAT system and enhances PDGF-signalling. JAK-STAT inhibition reduces the profibrotic effects of PDGF stimulation on canine fibroblasts in vitro while attenuating in vivo LA-fibrosis and remodelling in post-MI mice, suggesting that the JAK/STAT pathway contributes to LA-fibrogenesis and might be a potential target for LA-fibrosis prevention.</AbstractText> |
20,887 | Impaired Mental Health-Related Quality of Life in Patients with Idiopathic Ventricular Fibrillation. | Idiopathic ventricular fibrillation (iVF) is diagnosed in cardiac arrest survivors without an identifiable cause. Data regarding the health-related quality of life (HRQoL) in iVF patients are lacking. The purpose of this study was to investigate the HRQoL of iVF patients and to compare it to patients with an implantable cardioverter defibrillator (ICD) diagnosed with an underlying disease and healthy subjects.</AbstractText>In 61 iVF patients with an ICD (iVF-ICD) and 59 ICD patients with a diagnosis (diagnosis-ICD), HRQoL was assessed using the 12-item Short-Form Health Survey (SF-12), the EuroQoL-5 dimensions (EQ-5D), the 9-item Patient Health Questionnaire, and the ICD Patient Concerns (ICDC) Questionnaire. In addition, 860 healthy subjects completed the SF-12.</AbstractText>IVF-ICD showed similar SF-12 physical summary scores compared with diagnosis-ICD patients (50.8 [interquartile range (IQR) = 42.1-53.9] vs 54.1 [IQR = 46.5-58.3]; P = 0.080) and healthy subjects (51.8 [IQR = 45.9-54.1]; P = 0.691). The mental summary score was impaired in iVF-ICD patients compared with diagnosis-ICD patients (45.9 [IQR = 40.7-49.4] vs 54.6 [IQR = 46.0-57.9]; P < 0.001) and healthy subjects (47.7 [IQR = 43.0-50.4]; P = 0.027). Scores on all five EQ-5D domains were similar between iVF-ICD patients and diagnosis-ICD patients, as well as symptoms of severe depression (19% vs 12%; P = 0.101). ICD concerns were similar between iVF-ICD and diagnosis-ICD patients (ICDC-scores 2 vs 2; P = 0.494).</AbstractText>Data suggest that there is a reduced mental HRQoL in patients with iVF compared to other cardiac arrest survivors. Screening and treatment of psychological distress should therefore be considered in iVF patients.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,888 | A Device Histogram-Based Simple Predictor of Mortality Risk in ICD and CRT-D Patients: The Heart Rate Score. | We hypothesized that survival in implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy defibrillator (CRT-D) patients is predicted by baseline Heart Rate Score.</AbstractText>Heart Rate Score is determined from the atrial paced and sensed histogram of a DDD ICD or CRT-D, and defined as percent of beats in the histogram in the tallest 10 beats/min range bin. It was calculated at initial remote monitoring for patients enrolled in LATITUDE® without persistent atrial fibrillation, and with pulse generators implanted in 2006-2011. Univariate, multivariate, and Kaplan-Meier analyses determined the impact of Heart Rate Score on survival.</AbstractText>Of 57,893 ICDs and 67,929 CRT-Ds followed for 2.4 ± 1.5 years, each 10% increase in Heart Rate Score was associated with decreased survival (CRT-D hazard ratio [HR] 1.07 95%, confidence interval 1.06-1.07, P < 0.0001; ICD HR 1.05, 95% confidence interval 1.04-1.06, P < 0.0001). Multivariate analysis showed survival decreased with increasing age, atrial fibrillation, presence of a shock in first-year follow-up, and increasing programmed lower pacing rate in ICD and CRT-D patients. Increased percent right ventricular pacing predicted mortality in ICD patients, while male gender and lower percent left ventricular pacing predicted mortality in CRT patients. Heart Rate Score predicted survival independent of those variables. Heart Rate Score correlates with heart rate variability (standard deviation of average R-R intervals [SDANN]) when both are obtainable, but SDANN was only present in 6% of patients with Heart Rate Score >70%.</AbstractText>A simple device histogram measure, Heart Rate Score, predicts survival in ICD and CRT-D patients independent of the available variables, and even when SDANN is unavailable.</AbstractText>© 2017 Wiley Periodicals, Inc.</CopyrightInformation> |
20,889 | QT Prolongation due to Graves' Disease. | Hyperthyroidism is a highly prevalent disease affecting over 4 million people in the US. The disease is associated with many cardiac complications including atrial fibrillation and also less commonly with ventricular tachycardia and fibrillation. Many cardiac pathologies have been extensively studied; however, the relationship between hyperthyroidism and rate of ventricular repolarization manifesting as a prolonged QTc interval is not well known. Prolonged QTc interval regardless of thyroid status is a risk factor for cardiovascular mortality and life-threatening ventricular arrhythmia. The mechanism regarding the prolongation of the QT interval in a hyperthyroid patient has not been extensively investigated although its clinical implications are relevant. Herein, we describe a case of prolonged QTc in a patient who presented with signs of hyperthyroidism that was corrected with return to euthyroid status. |
20,890 | Cardiac Resynchronization Therapy Device Implantation in a Patient with Cardiogenic Shock under Percutaneous Mechanical Circulatory Support. | 65-year-old woman was admitted to our hospital with acute decompensated heart failure with reduced left ventricular ejection fraction and severe mitral regurgitation. Electrocardiography revealed a typical left bundle branch block and atrial fibrillation. Her condition deteriorated despite administering high-doses of inotropes and vasopressors. Pending a decision to therapy, venoarterial extracorporeal membrane oxygenation (ECMO) was performed when the patient underwent a cardiogenic shock. Although the hemodynamic status stabilized with ECMO support, weaning the patient from ECMO was not possible. Thus, we decided to perform cardiac resynchronization with defibrillator implantation as a "rescue" therapy. Five days post-implantation, the patient was successfully weaned from ECMO. |
20,891 | Cardioembolic Stroke. | Cardiac embolism accounts for an increasing proportion of ischemic strokes and might multiply several-fold during the next decades. However, research points to several potential strategies to stem this expected rise in cardioembolic stroke. First, although one-third of strokes are of unclear cause, it is increasingly accepted that many of these cryptogenic strokes arise from a distant embolism rather than in situ cerebrovascular disease, leading to the recent formulation of embolic stroke of undetermined source as a distinct target for investigation. Second, recent clinical trials have indicated that embolic stroke of undetermined source may often stem from subclinical atrial fibrillation, which can be diagnosed with prolonged heart rhythm monitoring. Third, emerging evidence indicates that a thrombogenic atrial substrate can lead to atrial thromboembolism even in the absence of atrial fibrillation. Such an atrial cardiomyopathy may explain many cases of embolic stroke of undetermined source, and oral anticoagulant drugs may prove to reduce stroke risk from atrial cardiomyopathy given its parallels to atrial fibrillation. Non-vitamin K antagonist oral anticoagulant drugs have recently expanded therapeutic options for preventing cardioembolic stroke and are currently being tested for stroke prevention in patients with embolic stroke of undetermined source, including specifically those with atrial cardiomyopathy. Fourth, increasing appreciation of thrombogenic atrial substrate and the common coexistence of cardiac and extracardiac stroke risk factors suggest benefits from global vascular risk factor management in addition to anticoagulation. Finally, improved imaging of ventricular thrombus plus the availability of non-vitamin K antagonist oral anticoagulant drugs may lead to better prevention of stroke from acute myocardial infarction and heart failure. |
20,892 | Sudden Cardiac Death in Patients With Ischemic Heart Failure Undergoing Coronary Artery Bypass Grafting: Results From the STICH Randomized Clinical Trial (Surgical Treatment for Ischemic Heart Failure). | The risk of sudden cardiac death (SCD) in patients with heart failure after coronary artery bypass graft surgery (CABG) has not been examined in a contemporary clinical trial of surgical revascularization. This analysis describes the incidence, timing, and clinical predictors of SCD after CABG.</AbstractText>Patients enrolled in the STICH trial (Surgical Treatment of Ischemic Heart Failure) who underwent CABG with or without surgical ventricular reconstruction were included. We excluded patients with prior implantable cardioverter-defibrillator and those randomized only to medical therapy. The primary outcome was SCD as adjudicated by a blinded committee. A Cox model was used to examine and identify predictors of SCD. The Fine and Gray method was used to estimate the incidence of SCD accounting for the competing risk of other deaths.</AbstractText>Over a median follow-up of 46 months, 113 of 1411 patients who received CABG without (n = 934) or with (n = 477) surgical ventricular reconstruction had SCD; 311 died of other causes. The mean left ventricular ejection fraction at enrollment was 28±9%. The 5-year cumulative incidence of SCD was 8.5%. Patients who had SCD and those who did not die were younger and had fewer comorbid conditions than did those who died of causes other than SCD. In the first 30 days after CABG, SCD (n=5) accounted for 7% of all deaths. The numerically greatest monthly rate of SCD was in the 31- to 90-day time period. In a multivariable analysis including baseline demographics, risk factors, coronary anatomy, and left ventricular function, end-systolic volume index and B-type natriuretic peptide were most strongly associated with SCD.</AbstractText>The monthly risk of SCD shortly after CABG among patients with a low left ventricular ejection fraction is highest between the first and third months, suggesting that risk stratification for SCD should occur early in the postoperative period, particularly in patients with increased preoperative end-systolic volume index or B-type natriuretic peptide.</AbstractText>URL: http://www.clinicaltrials.gov. Unique identifier: NCT0002359.</AbstractText>© 2017 American Heart Association, Inc.</CopyrightInformation> |
20,893 | Atrial Fibrillation and Ventricular Arrhythmias: Sex Differences in Electrophysiology, Epidemiology, Clinical Presentation, and Clinical Outcomes. | Sex-specific differences in the epidemiology, pathophysiology, clinical presentation, clinical treatment, and clinical outcomes of atrial fibrillation (AF), sustained ventricular arrhythmias, and sudden cardiac death are recognized. Sex hormones cause differences in cardiac electrophysiological parameters between men and women that may affect the risk for arrhythmias. The incidence and prevalence of AF is lower in women than in men. However, because women live longer and AF prevalence increases with age, the absolute number of women with AF exceeds that of men. Women with AF are more symptomatic, present with more atypical symptoms, and report worse quality of life in comparison with men. Female sex is an independent risk factor for death or stroke attributable to AF. Oral anticoagulation therapy for stroke prevention has similar efficacy for men and women, but older women treated with warfarin have a higher residual risk of stroke in comparison with men. Women with AF are less likely to receive rhythm control antiarrhythmic drug therapy, electric cardioversion, or catheter ablation in comparison with men. The incidence and prevalence of sustained ventricular arrhythmias and sudden cardiac death are lower in women than in men. Women receiving implantable cardioverter defibrillators for primary prevention of sudden cardiac death are less likely to experience sustained ventricular arrhythmias in comparison with men. In contrast, women receiving a cardiac resynchronization therapy implantable cardioverter defibrillator for the treatment of heart failure are more likely to benefit than men. Women are less likely to be referred for implantable cardioverter defibrillator therapy despite current guideline recommendations. Women are more likely to experience a significant complication related to implantable cardioverter defibrillator implantation in comparison with men. Whether sex differences in treatment decisions reflect patient preferences or treatment biases requires further study. |
20,894 | Usefulness of the MrWALLETS Scoring System to Predict First Diagnosed Atrial Fibrillation in Patients With Ischemic Stroke. | Some cryptogenic strokes are caused by undetected paroxysmal atrial fibrillation (AF) and could benefit from oral anticoagulation. In this study, we searched for echocardiographic parameters associated with first diagnosed AF, to form a scoring system for the identification of patients with AF. We examined 571 patients with ischemic stroke (72.7 ± 13.5 years, 50.6% women), subdivided into 4 groups: documented cause without AF, first diagnosed AF, known paroxysmal AF, and permanent AF. All patients underwent transthoracic echocardiography, brain computed tomography scan, carotid/vertebral ultrasound, and continuous electrocardiographic monitoring. Eight factors independently characterized first diagnosed AF and formed the "MrWALLETS" score: mitral regurgitation, mild-to-moderate (+1), white matter lesions (-1), age ≥75 years (+1), left atrium ≥4 cm (+1), cerebral lesion diameter ≥4 cm (+1), left ventricular end-diastolic volume <65 ml (+1), tricuspid regurgitation ≥moderate (+1), carotid stenosis ≥50% (-1). In the patients with ≥3 points, positive predictive value was 80%, specificity 97.5%, and sensitivity 57.1%. In the patients with ≥2 points sensitivity rose to 85.7%, but positive predictive value was 47.1%. The area under the receiver-operating characteristic curve was 0.89 (95% CI 0.83 to 0.95). There were important differences among AF groups, which therefore could not be merged. In conclusion, 4 echocardiographic parameters, 3 additional instrumental parameters, and age allow the identification of stroke patients with first diagnosed AF with high positive predictive value. |
20,895 | Obesity and cardiovascular diseases. | Obesity is increasingly more common in postindustrial societies, and the burden of childhood obesity is increasing. The major effects of obesity on cardiovascular (CV) health are mediated through the risk of metabolic syndrome (insulin-resistance, dyslipidemia, and hypertension), such that an absence of these risk factors in obese individuals may not be associated with increased mortality risk. In individuals already diagnosed with chronic CV disease (CVD), the overweight and class I obese have significant associations with improved survival. However, this effect is attenuated by increases in cardiorespiratory fitness. The negative effects of obesity on CV health manifest as accelerated progression of atherosclerosis, higher rates of ventricular remodeling and a higher risk of associated diseases, including stroke, myocardial infarction, and heart failure. The most effective therapies at reversing CVD risk factors associated with obesity have been dietary changes with exercise, especially through structured exercise programs, such as cardiac rehabilitation. |
20,896 | Supplement of levosimendan to epinephrine improves initial resuscitation outcomes from asphyxial cardiac arrest. | Levosimendan exerted favorable effects on the initial outcome in the treatment of ventricular fibrillation cardiac arrest. This study investigated the efficacy of levosimendan in the treatment of asphyxia-induced cardiac arrest in rats.</AbstractText>Animals underwent asphyxial cardiac arrest/cardiopulmonary resuscitation, randomized to three treatment groups: epinephrine (10 μg/kg) supplemented with levosimendan (bolus 12 μg/kg and infusion for 1 h, EL group); epinephrine only (10 μg/kg, E group), or levosimendan only (bolus 12 μg/kg and infusion for 1 h, L group). The resuscitation success rate, wet-to-dry ratio of lung, and rate of alveolar and blood gas analysis were recorded.</AbstractText>10 rats in the EL group, 8 in the E group, and 2 in the L group showed an initial return of spontaneous circulation (P < 0.001); among them, 10, 4, and 2 rats survived at the end of a 60-min observation period from each group, respectively (P = 0.001). The coronary perfusion pressure in the EL group was higher than that of either the E or L group (P < 0.05). The lung wet-to-dry weight ratio and rate of damaged alveoli were lower in the EL group than the E group (P < 0.05).</AbstractText>In the early stage of resuscitation for asphyxia-induced cardiac arrest in rats, levosimendan supplemented with epinephrine can significantly increase coronary perfusion pressure, reduce lung injury, and ultimately enhance the survival rate.</AbstractText> |
20,897 | Syncope: Outcomes and Conditions Associated with Hospitalization. | Syncope is a perplexing problem for which hospital admission and readmission are contemplated but outcomes remain uncertain. Our purpose was to determine the incidence of admissions and readmissions for syncope and compare associated conditions, in-hospital outcomes, and resource utilization.</AbstractText>The 2005-2011 California Statewide Inpatient Database was utilized. Patients of age ≥18 years admitted under International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 ("syncope or collapse") were selected. Records with a primary discharge diagnosis of syncope were classified as primary syncope. Primary outcome was mortality and secondary outcome measures were cardiopulmonary resuscitation, mechanical ventilation, discharge disposition, length of stay, frequency of readmission and hospital charges.</AbstractText>An estimated 1.52 ± 0.02% admissions every year are related to syncope. Among admissions for syncope, in 42.1%, the cause remained unknown; 23% of syncope admissions were for recurrent episodes. The top 5 associated new diagnoses were hypokalemia (0.24%), ventricular tachycardia (0.17%), atrial fibrillation (0.16%), dehydration (0.12%), and hyponatremia (0.12%). Mortality rates are lower for primary vs secondary syncope (0.2% vs 1.4%; P <.0001). Greatest risk factors for mortality in primary syncope were pulmonary hypertension (odds ratio 12.3; 95% confidence interval, 3.34-45.04) and metastatic cancer (odds ratio 7.22; 95% confidence interval, 4.50-11.58). Major adverse events showed a decreasing trend for patients with multiple syncope admissions. Older patients and defibrillators or pacemaker recipients are admitted more often but experience negligible adverse events. Over a decade, median hospital charge for a single syncope admission has increased by 1.5 times.</AbstractText>Despite a good prognosis, syncope is a frequent cause for hospitalization, particularly in the elderly. Present evaluation strategies are expensive and lack diagnostic value.</AbstractText>Copyright © 2017 Elsevier Inc. All rights reserved.</CopyrightInformation> |
20,898 | A multicenter prospective randomized study comparing the efficacy of escalating higher biphasic versus low biphasic energy defibrillations in patients presenting with cardiac arrest in the in-hospital environment. | Biphasic defibrillation has been practiced worldwide for >15 years. Yet, consensus does not exist on the best energy levels for optimal outcomes when used in patients with ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT).</AbstractText>This prospective, randomized, controlled trial of 235 adult cardiac arrest patients with VF/VT was conducted in the emergency and cardiology departments. One group received low-energy (LE) shocks at 150-150-150 J and the other escalating higher-energy (HE) shocks at 200-300-360 J. If return of spontaneous circulation (ROSC) was not achieved by the third shock, LE patients crossed over to the HE arm and HE patients continued at 360 J. Primary end point was ROSC. Secondary end points were 24-hour, 7-day, and 30-day survival.</AbstractText>Both groups were comparable for age, sex, cardiac risk factors, and duration of collapse and VF/VT. Of the 118 patients randomized to the LE group, 48 crossed over to the HE protocol, 24 for persistent VF, and 24 for recurrent VF. First-shock termination rates for HE and LE patients were 66.67% and 64.41%, respectively (P</i>=0.78, confidence interval: 0.65-1.89). First-shock ROSC rates were 25.64% and 29.66%, respectively (P</i>=0.56, confidence interval: 0.46-1.45). The 24-hour, 7-day, and 30-day survival rates were 85.71%, 74.29%, and 62.86% for first-shock ROSC LE patients and 70.00%, 50.00%, and 46.67% for first-shock ROSC HE patients, respectively. Conversion rates for further shocks at 200 J and 300 J were low, but increased to 38.95% at 360 J.</AbstractText>First-shock termination and ROSC rates were not significantly different between LE and HE biphasic defibrillation for cardiac arrest patients. Patients responded best at 150/200 J and at 360 J energy levels. For patients with VF/pulseless VT, consideration is needed to escalate quickly to HE shocks at 360 J if not successfully defibrillated with 150 or 200 J initially.</AbstractText> |
20,899 | Outcomes of In-Hospital Cardiopulmonary Resuscitation in Morbidly Obese Patients. | This study sought to assess the impact of morbid obesity on outcomes in patients with in-hospital cardiac arrest (IHCA).</AbstractText>Obesity is associated with increased risk of out-of-hospital cardiac arrest; however, little is known about survival of morbidly obese patients with IHCA.</AbstractText>Using the Nationwide Inpatient Sample database from 2001 to 2008, we identified adult patients undergoing resuscitation for IHCA, including those with morbid obesity (body mass index ≥40 kg/m2</sup>) by using International Classification of Diseases 9th edition codes and clinical outcomes. Outcomes including in-hospital mortality, length of stay, and discharge dispositions were identified. Logistic regression model was used to examine the independent association of morbid obesity with mortality.</AbstractText>Of 1,293,071 IHCA cases, 27,469 cases (2.1%) were morbidly obese. The overall mortality was significantly higher for the morbidly obese group than for the nonobese group experiencing in-hospital non-ventricular fibrillation (non-VF) (77% vs. 73%, respectively; p = 0.006) or VF (65% vs. 58%, respectively; p = 0.01) arrest particularly if cardiac arrest happened late (>7 days) after hospitalization. Discharge to home was significantly lower in the morbidly obese group (21% vs. 31%, respectively; p = 0.04). After we adjusted for baseline variables, morbid obesity remained an independent predictor of increased mortality. Other independent predictors of mortality were age and severe sepsis for non-VF and VF group and venous thromboembolism, cirrhosis, stroke, malignancy, and rheumatologic conditions for non-VF group.</AbstractText>The overall mortality of morbidly obese patients after IHCA is worse than that for nonobese patients, especially if IHCA occurs after 7 days of hospitalization and survivors are more likely to be transferred to a skilled nursing facility.</AbstractText>Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</CopyrightInformation> |
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