Continuous Electrocardiographic Monitoring Research Articles

Ventricular Fibrillation in Acute Coronary Syndrome with Elevated ST Segment: Incidence and Predictive Factors.

Background: Ventricular fibrillation is the principal cause of sudden cardiac death; in acute coronary syndrome (ACS) with elevated ST segment, its incidence and predictive factors, have been the subject of several international studies; however, its epidemiological data is lacking in Algeria. Aims: The main objective of our study is the determination of the frequency of ventricular fibrillation in acute coronary syndrome with elevated ST segment, the secondary objective was the analysis of predictive factors of this arrhythmia, and related mortality. Methods and materials: In this prospective study, conducted in the cardiology department of Hussein Dey hospital (Algiers-Algeria), 467 patients with acute coronary syndrome with elevated ST segment (87 women and 380 men) were enrolled between 28 February 2014 and 16 July 2015. The average age is 60 ± 13 years; at admission, a Holter recorder was attached for continuous ECG monitoring during 48 hours Kruskal’s ANNOVA or H tests were used for comparison of quantitative variables, χ2 test or Fisher’s exact test, were used for qualitative variables, all tests were performed with 1st species risk of 5%. Results: The frequency of ventricular fibrillation is 5.8% (27 patients), CI 95%: [3.7%-7.9%], multivariate analysis identified the following independent predictors: low diastolic blood pressure: high ST segment elevation, large diastolic left and right ventricular diameters. The risk of mortality expressed by Hazard Ration (HR) is 12.9 (CI 95%: [4.9-34], p < 0.001), the predictors of mortality are right ventricular failure and failure of thrombolysis. Conclusion: Ventricular fibrillation is the principal cause of sudden cardiac death, during acute coronary syndrome with elevated ST segment, its predictive factors according to our study are: low diastolic blood pressure: high ST segment elevation, large diastolic left and right ventricular diameters, its occurrence increases the risk of hospital mortality, this high risk is partly explained by the therapeutic strategy.

PO-01-032 CLINICAL AND PHYSIOLOGIC OUTCOMES OF COMPUTED TOMOGRAPHY-GUIDED CARDIONEUROABLATION VERSUS STANDARD ABLATION FOR ATRIAL FIBRILLATION

Cardioneuroablation (CNA) of ganglionated plexi (GP) is increasingly recognized for its potential to improve atrial fibrillation (AF) ablation outcomes. Computed tomography (CT)-identified epicardial adipose tissue (EAT) represents a promising approach to localizing GP. However, the clinical efficacy of CT-guided CNA and its utility in combination with standard AF ablation is unclear. To characterize the physiologic and clinical outcomes of CT-guided CNA performed at the time of standard AF ablation. The CNA cohort included patients with AF who underwent CT to identify EAT corresponding with GP anatomic regions, which was merged with electroanatomic right and left atrial maps at the time of the procedure. CNA targeting regions of EAT was performed in addition to standard AF ablation. Vagal-induced AF was defined as the presence of recurrent vagal triggers by history or progressive bradycardia preceding AF on continuous electrocardiographic monitoring. The control group consisted of patients who underwent AF ablation without CNA. AF outcomes were assessed after a 3-month post-procedure blanking period. Mean heart rate and heart rate variability were determined via insertable subcutaneous rhythm monitors. The CNA cohort (n=19), was similar to the standard ablation cohort (n=129) in regard to proportion of females (53% vs. 46%, p=0.6), age (69±6 vs. 69±8 years, p=0.7), rate of prior AF ablation (32% vs. 32%, p=1.0), prevalence of persistent AF (42% vs 39%, p=0.5) and CHA2DS2-VASc scores (3.2±1.1 vs. 2.5±1.5, p=0.1). During follow-up, the mean heart rate did not differ between cohorts, but heart rate variability was significantly lower in the CNA cohort (Figure 1A and 1B). Over a median follow-up period of 430 days (IQR 199-845), atrial flutter or AF recurred at the same rate in the CNA cohort compared to the standard ablation cohort (32% vs. 34%, p=0.8). Patients with a history of vagal-induced AF who underwent CNA (n=8, 42%) had a trend toward a lower rate of recurrence than the control group (13% vs. 34%, p=0.2) and than the CNA patients without vagal-induced AF (13% vs 45%, p=0.1). CT-guided CNA results in reduced heart rate variability without affecting mean heart rate. The rate of AF recurrence overall in the CNA group was not different compared to standard AF ablation. CNA may specifically benefit patients with vagal-induced AF. Further studies are needed to define the role of CT-guided CNA in AF ablation.

Evaluation of premature ventricular complexes during in-hospital ECG monitoring as a predictor of ventricular tachycardia in an intensive care unit cohort.

In-hospital electrocardiographic (ECG) monitors are typically configured to alarm for premature ventricular complexes (PVCs) due to the potential association of PVCs with ventricular tachycardia (VT). However, no contemporary hospital-based studies have examined the association of PVCs with VT. Hence, the benefit of PVC monitoring in hospitalized patients is largely unknown. This secondary analysis used a large PVC alarm data set to determine whether PVCs identified during continuous ECG monitoring were associated with VT, in-hospital cardiac arrest (IHCA), and/or death in a cohort of adult intensive care unit patients. Six PVC types were examined (i.e., isolated, bigeminy, trigeminy, couplets, R-on-T, and run PVCs) and were compared between patients with and without VT, IHCA, and/or death. Of 445 patients, 48 (10.8%) had VT; 11 (2.5%) had IHCA; and 49 (11%) died. Isolated and run PVC counts were higher in the VT group (p = 0.03 both), but group differences were not seen for the other four PVC types. The regression models showed no significant associations between any of the six PVC types and VT or death, although confidence intervals were wide. Due to thesmall number of cases, we were unable to test for associations between PVCs and IHCA. Our findings suggest that we should question the clinical relevance of activating PVC alarms as a forewarning of VT, and more work should be done with larger sample sizes. A more precise characterization of clinically relevant PVCs that might be associated with VT is warranted.

The implantable cardiac monitor in heart failure patient: a possible new indication?

Implantable cardiac monitors (ICMs) have found increasing use in clinical practice over the years, proving, when used in high-risk populations, to facilitate the diagnosis of bradyarrhythmias and tachyarrhythmias requiring treatment. Experience with heart failure patients undergoing pacemaker (PMK) or implantable defibrillator (ICD) implantation, which allow for continuous electrocardiographic monitoring and transthoracic impedance assessment, has made it possible to identify predictors of heart failure flare-ups. In this context, the use of telemonitoring has been shown to ensure better management of patients with heart failure. These benefits cannot be assessed to date in patients with heart failure and left ventricular ejection fraction (LVEF) > 35% who have no indication for PMK or ICD implantation. This population has been shown to have a significant incidence of ventricular arrhythmias and bradyarrhythmias. In addition, a significant number of cerebrovascular events are observed in this population, largely attributable to the high incidence of atrial fibrillation (AF). In this population, the occurrence of AF has also been shown to have a negative impact on patients' prognosis; at the same time, a rhythm control strategy has been shown to be more beneficial in this area than a rate control strategy. Studies also suggest arrhythmias have a negative impact on the cognitive status and quality of life of heart failure patients. These reasons could justify the implantation of ICMs equipped with telemonitoring systems in heart failure patients. The information provided by the monitoring system, if properly managed, could bring benefits in terms of prognosis and quality of life along with a reduction in economic costs. We will try here, by answering a few questions, to assess whether there is an indication for ICM in heart failure, which patients should be candidates and how these patients should be managed.

The accuracy of the Stroke Risk Analysis (SRA) system for predicting atrial fibrillation in patients in the postoperative period of myocardial revascularization.

Postoperative myocardial revascularization atrial fibrillation (POAF) is a clinical complication that affects about 30% of patients and its mechanisms of origin are still poorly understood. This fact makes it difficult to identify the patient at greatest risk for this arrhythmia. This mission seems evident due to the complications it entails, including longer hospital stays, risk of stroke, heart failure, and death. There are reports of preoperative clinical aspects inherent to the patient's condition, such as gender and age, and discontinuation of beta-blockers as risk factors. In addition, additional information obtained by electrocardiogram, echocardiogram, and blood count data, for example, present only modest predictive results. The analysis of heart rate and heart rate variability obtained by the Stroke Risk Analysis System (SRA) is a technique used to predict ambulatory atrial fibrillation (AF), using recordings of only one hour showing good accuracy. This system, however, has not yet been used to predict the emergence of POAF. The rationale for its use is based on the suspicion that the emergence of POAF is strongly related to sympatho-vagal imbalance and the increase in atrial ectopia, that is, changes in heart rhythm, the main variables analyzed by the SRA algorithm. To assess the accuracy of the SRA to identify patients at risk of having POAF after coronary artery bypass graft surgery (CABG). 114 consecutive patients with coronary artery disease underwent coronary artery bypass grafting between the years 2015 and 2018. Between the first and fifth postoperative days, they underwent continuous electrocardiographic monitoring using the Holter system for cardiac rhythm analysis. Patients were divided into two groups: Group I was formed of those with POAF and Group II included patients without POAF. The tracings obtained by Holter were reanalyzed using the CardioManager®/Cardios program, converted and divided into one-hour sections using the SRA®/Cardios and Geratherm Converter program and submitted to the SRA-Apoplex medical/Geratherm® analysis algorithm. The SRA identifies three possibilities for classifying patient risk: a) Risk 0: patient in sinus rhythm; b) Risk 1: patient at increased risk for paroxysmal AF; c) Risk 2: patient with AF already present. For Group I, SRA were considered positive when Risks 1 and 2 were identified. For Group II, those identified as Risk 0 were considered negative SRA. POAF occurred in 33/114 patients (28%). The sensitivity, specificity, positive predictive value, and negative predictive value of the SRA to identify patients with POAF were 69%, 84%, 69%, and 82%, respectively; the positive and negative likelihood ratios, in addition to the accuracy of the SRA were, respectively, 4.3%, 0.36%, and 79%. A subanalysis of the results of the day on which AF occurred was performed on the records obtained in the first three hours of recording and up to three hours before the appearance of POAF. In the first period, the SRA was able to predict POAF in 57% of cases, while in the second period, the system identified the arrhythmia in 83% of cases. a) The SRA presents good accuracy to predict POAF; b) its accuracy is moderate in the first three hours of recording; c) the accuracy increases significantly near the beginning of POAF; d) these findings indicate that electrophysiological changes that precede POAF are acute, occurring a few hours before the event and are identified by the SRA algorithm.

Ergospirometry & body percussion. Case study based on BAPNE FIT method

The purpose of this study is to perform a case study evaluating cardiorespiratory aspects and ergospirometry or stress test with gas analysis using body percussion according to the BAPNE method. A 43-year-old subject with a height of 182 centimeters and 81.7 kilograms was studied in a specialized medical center for athletes directed by the sports medicine specialist Jeroni Llorca at the Sport Clinic Arena in Alicante. The subject underwent an exercise test on an Excite Technogym treadmill where he was given an increase of 0.6 km / h every minute from 4.0 km / h. The slope of the treadmill was applied at a constant gradient of 0.6 km / h every minute. A constant slope of 1% was applied at the same time as continuous ECG monitoring and analysis of ventilatory gas exchange (Blue-Cherry/Geratherm by Ergostix). The BAPNE FIT method sessions last 50 minutes, although the ergospirometry study lasted 2 minutes for each activity to be analyzed. During this process, the subject was evaluated while performing five different activities of the BAPNE FIT program (motor, rhythmic and cognitive activities with dual task) with Step, elastic bands on thighs and ankles, weights on wrist and ankle bracelets and finally body percussion activities with Kangoo Boots shoes. The subject reached a VO2 PEAK maximal oxygen consumption of 2.61 l/min at 32.0 ml/kg/min. A maximum speed of 10.0 km/h was applied, reaching with BAPNE FIT activities an FCM of 189 PPM. This shows that BAPNE FIT activities help and increase the maximum oxygen consumption as well as the heart rate. So far there is no study of this type related to body percussion and this is a first study that can be used for further studies. Keywords: Body percusion, Neuromotricity, BAPNE, Ergospirometry, Dual Task.

Measuring vagal activity in postictal bradycardia

Alterations to cardiac electrical conduction are some of the most frequently observed systemic complications of seizures, with autonomic dysregulation cited as the principal driver for these alterations. In this prospective study, we use 6-lead continuous ECG monitoring in hospitalized patients with epilepsy to trend heart rate patterns in the postictal period. A total of 117 seizures in 45 patients met the criteria for analysis. There was a postictal heart rate increase of 61% (n = 72 seizures), and a decline in heart rate (deceleration) following 38.5% (n = 45). Using 6-lead ECGs for waveform analysis revealed that there was PR prolongation accompanying those seizures that were associated with postictal bradycardia.

Dynamic ECG signal quality evaluation based on persistent homology and GoogLeNet method.

Cardiovascular disease is a serious health problem. Continuous Electrocardiograph (ECG) monitoring plays a vital role in the early detection of cardiovascular disease. As the Internet of Things technology continues to mature, wearable ECG signal monitors have been widely used. However, dynamic ECG signals are extremely susceptible to contamination. Therefore, it is necessary to evaluate the quality of wearable dynamic ECG signals. The topological data analysis method (TDA) with persistent homology, which can effectively capture the topological information of high-dimensional data space, has been widely studied. In this study, a brand-new quality assessment method of wearable dynamic ECG signals was proposed based on the TDA with persistent homology method. The point cloud of an ECG signal was constructed, and then the complex sequence was generated and displayed as a persistent barcode. Finally, GoogLeNet based on the transfer learning model with a 10-fold cross-validation method was used to train the classification model. A total of 12-leads ECGs Dataset and single-lead ECGs Dataset, established based on the 2011 PhysioNet/CinC challenge dataset, were both used to verify the performance of this method. In the study, 773 "acceptable" and 225 "unacceptable" signals were used as 12-leads ECGs Dataset. We relabeled 12,000 ECG signals in the challenge dataset, and treated them as single-lead ECGs Dataset after empty lead detection and balance datasets. Compared with the traditional ECG signal quality assessment method mainly based on waveform characteristics and time-frequency characteristics, the performance of the quality assessment method proposed. In this study, the classification performance of the proposed method are fairly great, mAcc = 98.04%, F1 = 98.40%, Se = 97.15%, Sp = 98.93% for 12-leads ECGs Dataset and mAcc = 98.55%, F1 = 98.62%, Se = 98.37%, Sp = 98.85% for single-lead ECGs Dataset.

Short-term and long-term effects of noninvasive cardiac radioablation for ventricular tachycardia: A single-center case series.

Noninvasive cardiac radioablation is reported to be effective and safe for the treatment of ventricular tachycardia (VT). This study aimed to analyze the acute and long-term effects of VT radioablation. Patients with intractable VT or premature ventricular contraction (PVC)-induced cardiomyopathy were included in this study and treated using a single-fraction 25-Gy dose of cardiac radioablation. To quantitatively analyze the acute response after treatment, continuous electrocardiography monitoring was performed from 24 hours before to 48 hours after irradiation and at the 1-month follow-up. Long-term clinical safety and efficacy were assessed 1-year follow-up. From 2019 to 2020, 6 patients were treated with radioablation for ischemic VT (n = 3), nonischemic VT (n = 2), or PVC-induced cardiomyopathy (n = 1). In the short-term assessment, the total burden of ventricular beats decreased by 49% within 24 hours after radioablation and further decreased by 70% at 1 month. The VT component decreased earlier and more dramatically than the PVC component (decreased by 91% and 57% at 1 month, respectively). In the long-term assessment, 5 patients showed complete (n = 3) or partial (n = 2) remission of ventricular arrhythmias. One patient showed recurrence at 10 months, which was successfully suppressed with medical treatment. The posttreatment PVC coupling interval was prolonged (+38 ms at 1 month). Ischemic VT burden decreased more markedly than nonischemic VT burden after radioablation. In this small case series of 6 patients, without a comparison group, cardiac radioablation appeared to decrease the intractable VT burden. A therapeutic effect was apparent within 1-2 days after treatment but was variable by etiology of cardiomyopathy.

Assessing the use of a noninvasive monitoring system providing multiple cardio-pulmonary parameters following revascularization in STEMI patients.

Continuous monitoring of ECG, respiratory rate, systolic and diastolic blood pressure, pulse rate, cardiac output, and cardiac index is important in patients with ST-elevation myocardial infarction (STEMI) admitted to the intensive cardiac care unit (ICCU). However, monitoring these parameters in this setting and in these patients using noninvasive, wireless devices has not been conducted so far. We aimed to assess the use of a novel noninvasive continuous monitoring device in STEMI patients admitted to the ICCU. Participants included STEMI patients that were admitted to the ICCU after primary percutaneous coronary intervention (PPCI). Patients were continuously monitored using a novel wearable chest patch monitor. Fifteen patients with STEMI who underwent PPCI were included in this study. The median age was 52.8 years, the majority were males, and the median body mass index (BMI) was 25.7. Monitoring lasted for 66 ± 16 hours, and included the automatic collection and recording of all vitals, freeing the nursing staff to focus on other tasks. The user experience of nurses as reflected in filled questionnaires showed high satisfaction rates in all aspects. A novel noninvasive, wireless device showed high feasibility in continuously monitoring multiple crucial parameters in STEMI patients admitted to the ICCU after PPCI.

Incidence and Outcome of Newly Diagnosed Atrial Fibrillation in Medical ICU Patients: An Observational-Descriptive Study

Abstract Introduction: Cardiac arrhythmias frequently occur in critically ill patients in the intensive care unit (ICU), significantly impacting their health outcomes. Among these arrhythmias, supraventricular cardiac arrhythmic tachycardia, particularly atrial fibrillation (AF), is increasing in incidence and spans various medical and surgical contexts. In medical patients, the incidence ranges from 1%–46%. In patients with sepsis, the incidence of acute AF varies with the severity of sepsis, with an incidence of 8–10% in sepsis, 6–22% in severe sepsis, and 23–44% in septic shock. The development of cardiac arrhythmias in critically ill patients poses a substantial risk to both morbidity and mortality. Aim: To study the incidence and outcome of new-onset AF (NOAF) in medical ICU patients. Materials and Methods: NOAF was identified in patients with documented sinus rhythm ECG upon admission to the medical ICU who later developed AF. Results: Four hundred and twenty patients underwent 24-h continuous ECG monitoring, with 68 developing new-onset arrhythmias. Among them, 21 developed AF (5%). AF predominated in patients with preexisting cardiac illness (76.1%), with pneumonia being the primary non-cardiac cause. Notably, among 21 patients with AF, 12 individuals (57.1%) experienced mortality, while 9 patients (42.8%) were discharged from medical care. Notably, among the discharged patients, 5 individuals (45.4%) continued to exhibit persistent AF. Conclusion: It has been observed that there is an increased incidence of AF among critically ill patients, correlating with heightened rates of mortality and morbidity. Early detection and treatment hold promise in altering disease trajectories. Hence, the implementation of 24-h ECG monitoring is advocated for critically ill patients. Furthermore, a significant fraction of acute illness survivors experience new-onset AF after being discharged, which raises their long-term risks of heart failure, ischemic stroke, and death. However, the lack of expert consensus documents or evidence-based guidelines for managing NOAF highlights the need for carefully planned multicenter, prospective randomized trials to address these clinical uncertainties.

Incidence and predictors of atrial fibrillation in a large cohort of implantable cardiac monitors after cryptogenic stroke

Up to 20% of ischemic strokes are associated with overt atrial fibrillation (AF). In addition, silent AF is detected by an implantable cardiac monitor in one in three cryptogenic strokes. After ischemic stroke, ESC guidelines recommend continuous ECG monitoring for at least 72 hours, and additional ECG monitoring with long-term non-invasive ECG monitors or implanted cardiac monitors (ICMs) in cryptogenic stroke. However, in the CRYSTAL AF trial, 70% of implanted cardiac monitors did not record an AF episode during three years of follow-up. To date, no predictors or scores are available to assist in patient selection prior to ICM. We sought to identify factors associated with AF after cryptogenic stroke in a large cohort of ICM patients. All patients implanted with an ICM for cryptogenic stroke between February 2016 and February 2022 at the University Hospital of Dijon and Besançon were retrospectively included. Clinical, electrocardiographic, imaging, biological and follow-up data were collected. Of the 383 patients included, 98 (25.6%) developed AF during a mean follow-up of 23 months. Kaplan-Meier estimates of AF on ICM were 16% at 1 year, 24% at 2 years and 31% at 3 years of follow-up. Compared to patients in sinus rhythm, AF patients were significantly older, more often had previous hypertension and dyslipidemia. In addition, AF patients had larger left atrial index volumes (LAVI), lower creatinine clearance and higher CRP. After multivariable Cox analysis, age > 69 years (HR (95%CI) 3.79 (1.90–7.58), P < 0.001) and LAVI > 34 mL/m2 (HR (95%CI) 2.97 (1.54–5.72) remained independently associated with AF. In a large ICM cohort, we identified two independent predictors of AF, age > 69yo and LAVI > 34 mL/m2, which are readily available in daily practice. Based on these results, we aim to construct a simple score for the diagnostic efficacy of ICM to be validated in another cohort. This score would improve the diagnostic efficiency of ICM and decrease the number of time-consuming and costly implantations.

14-day Holter monitoring for atrial fibrillation after ischemic stroke: The yield of guideline-recommended monitoring duration.

Current European Stroke Organisation (ESO) guidelines recommend >48 h of continuous electrocardiographic monitoring for atrial fibrillation (AF) in all patients with ischemic stroke or transient ischemic attack (TIA) with undetermined origin. We assessed the yield of the guideline-recommended monitoring for AF, as well as of extending monitoring up to 14 days. We included consecutive patients with stroke/TIA without AF in an academic hospital in The Netherlands. We reported AF incidence and number needed to screen (NNS) in the overall sample after 48 h and 14 days of Holter monitoring. Among 379 patients with median age 63 years (IQR 55-73), 58% male, Holter monitoring detected 10 cases of incident AF during a median of 13 (IQR 12-14) days of monitoring. Seven AF cases were detected within the first 48 hours (incidence 1.85%, 95% CI 0.74-3.81; NNS 54), and three additional AF cases were recorded among the 362 patients with >48 h of monitoring and without AF ⩽ 48 h (incidence 0.83%, 95% CI: 0.17-2.42; NNS 121). All AF cases were detected within the first 7 days of monitoring. Our sample was subject to sampling bias favoring inclusion of participants with low AF risk. Strengths of this work were the broad inclusion criteria as recommended by ESO guidelines, and high Holter adherence among participants. The analysis was limited by inclusion of lower-risk cases and a relatively small sample size. In low-risk patients with recent stroke or TIA, ESO guideline-recommended screening for AF resulted in a low AF yield, with limited additional value of monitoring up to 14 days. Our results underline the need for a personalized approach in determining a patient's optimum duration for post-stroke non-invasive ambulatory monitoring.

449 HYPERTROPHIC CARDIOMYOPATHY: A CASE OF CHALLENGING ARRHYTHMIC RISK STRATIFICATION

Abstract Hypertrophic cardiomyopathy (HCM) is a common disease, mostly inherited, with a prevalence of 1:500. Cornerstone of the clinical management of HCM patients is stratifying the risk of sudden cardiac death (SCD) which is the most frightening complication despite its relatively low incidence (0,9% per year). Although mathematical risk scores, as proposed by ESC, are the most used to assess the probability of arrhythmic complications leading to SCD, they have been associated with low sensitivity, precluding some high-risk patients from prophylactic ICD implantation. Among the tools at clinicians’ disposal for risk stratification in HCM patients, the latest AHA/ACC guidelines propose an “individual risk markers strategy”, based on the presence of ≥1 clinical feature such as a family history of SCD, extreme left ventricular hypertrophy (LVH), unexplained recent syncope, NSVT, late gadolinium enhancement (LGE) at CMR, systolic dysfunction and LV apical aneurysm. We present a case that lets us reflect on arrhythmic risk stratification. P.C. is a 58 y.o. male with a history of septal hypertrophy (19 mm) and T wave inversion but without an established diagnosis of HCM. He did not have any familiar history of syncope or SCD. He came to the emergency department for epistaxis and was admitted to the cardiology unit due to the previously mentioned findings, where he underwent cardiac-CTA and CMR showing myocardial bridge of left anterior descending artery, LVH with apical aneurysm and LGE areas localized on the apex (transmural) and on the interventricular septum (subendocardial). No signs of dynamic LVOT obstruction or atrial enlargement emerged from echocardiography. During the observation, asymptomatic NSVT were recorded on continuous ECG monitoring. According to the ESC risk prediction score (3.7%) ICD was not strictly indicated but considering the CMR high-risk profile (according to the suggestions of AHA/ACC) we proposed an ICD implantation anyways. The patient refused any invasive procedure and was implanted with a loop recorder. At 12 months remote monitoring showed a single episode of self-terminated sustained polymorphic ventricular tachycardia (02:23 mm: ss) symptomatic of pre-syncope. The patient was then immediately reached and admitted for ICD implantation in secondary prevention. According to the patient's will, and the no need for bradycardia therapy, an S-ICD was implanted. Figure 1LV apical aneurysm at CMRFigure 2Remote Monitoring

59 THE SHARK-FIN THAT EMERGES AND IMMERGES: A CASE REPORT OF TRANSIENT AND RIPETITIVE TRIANGULAR QRS-ST-T.

Abstract Introduction Shark fin sign, also known as triangular QRS-ST-T waveform (TW), is characterized by a giant R wave (amplitude ≥ 1 mV) resulting from the fusion of the QRS complex, the ST-segment and the T wave and showing triangular morphology. TW pattern is quite uncommon and reveals a life-threatening condition that needs aggressive management. Early recognition is important to prevent acute complications such as ventricular arrhythmias and cardiogenic shock. Case presentation A 45-years old black man with history of arterial hypertension presented with out-of-hospital cardiac arrest (OHCA) at his workplace. Extracorporeal cardiopulmonary resuscitation started immediately and return of spontaneous circulation occurred after 11 minutes and 2 DC shocks. Then he was transferred to our emergency department (ED). At arrival he was hemodynamically stable, ECG showed atrial fibrillation without any repolarization abnormalities and echocardiogram revealed left ventricular hypertrophy (IVS 12mm, PW 12mm) and normal biventricular function. Normal electrolytes and high-sensitivity troponin level of 14 (n.v. 0.01-19.8 ng/L) were found at the blood test. Sedation in the ED was needed due to psychomotor agitation. He was then transferred to the CCU where spontaneous cardioversion to sinus rhythm occurred, and no additional arrhythmias were noted at continuous ECG monitoring. After ten hours, while the patient was still under sedation, ECG monitoring revealed a progressive QRS-ST segment elevation in inferior leads up to a triangular QRS-ST-T giant waveform (“Shark fin sign”), without hemodynamic deterioration. After approximately 3 minutes the ECG showed a progressive and complete regression to a normal waveform. An emergent beside echocardiogram demonstrated inferior wall hypokinesia, but normal pump function. The episode repeated 5 more times in the following hour, waiting for cath lab personnel. Coronary angiography revealed a sub-occlusive mid RCA stenosis without any thrombotic lesion. Percutaneous coronary intervention (PCI) with the implantation of one drug eluting stent (DES) was performed. After the procedure the patient was hemodynamically and electrically stable. ECG did not show any other abnormality and no episodes of recurrent ST-elevation occurred. Sedation was suspended and no focal neurological deficits were noted. Discussion Shark fin sign is the expression of abrupt total deprivation of blood flow in large areas of myocardium that cause massive slowing of transmural electrical conduction. These electrical differences may be at the base of the triangular R waves and predispose to VF induction and cardiogenic shock. This sign is very rare, with an annual incidence of 0.7% in patients admitted for STEMI, and in most of the cases is described in the occlusion of the LAD. In our case we assisted to transient but repetitive inferior triangular ST-elevation with complete regression to normal ECG. The coronary angiogram showed non-obstructive lesion of the RCA. This phenomenon was probably the expression of RCA's plaque coronary vasospasm that caused the ECG shark fin sign and cardiac arrest. Conclusion Shark fin electrocardiographic waveform is an uncommon pattern of STEMI and may be the expression of thrombotic coronary occlusion as well as massive coronary vasospasm. This sign correlates with high risk of cardiogenic shock, electrical instability, and cardiac arrest, thus requiring prompt and aggressive management.

661 TWO CARDIOMYOPATHIES IN ONE HEART: LESSONS FROM CLINICAL CASE

Abstract Case description In November 2020, a 55-years-old female with no significant past medical history, was admitted to our Emergency Department for chest pain after acute stressful event. She had a significant family history of ischemic heart disease, and unclear comatose status of her sister. At admission, she was asymptomatic, blood pressure was 115/80 mmHg, and oxygen saturation was 96%. An electrocardiogram (ECG) showed biphasic T wave in anterolateral leads. Elevated levels of troponin I (hs-TnI of 900 ng/L) and B-type natriuretic peptide (BNP) of 864 pg/mL were detected. Transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 30% with apical ballooning of mid and apical segments of the left ventricle (LV) along with a sizable apical thrombus. Aspirin, iv diuretics, iv nitrates and unfractioned heparin were started. After 13 hours, she suffered a sudden transient neurological sign of decreased level of consciousness. Cranial MRI revealed an ischemic lesion in the territory of the apex of basilar artery (thalamic region). After 7 days from stroke, the patients underwent coronary angiography demonstrating unobstructed coronaries. Thus, the diagnosis of takotsubo syndrome was confirmed. During hospitalization, ECG evolution showed T wave inversion in precordial and lateral leads. Hs-TnI declining within normal values. Of note, ventricular arrhythmias burden with polymorphic ventricular contraction (PVC) emerged on continuous ECG-monitoring. Despite resolution of apical balloning and apical thrombosis, there were persistent wall-motion abnormalities in infero-lateral walls and mild LV dysfunction. This was also confirmed by cardiac magnetic resonance (CMR). Further, CMR also showed an intense myocardial edema with elevated LV mass. The patients was discharged on Warfarin, Bisoprolol 2.5 mg/die, Ramipril 5 mg/die, Eplerenone 25 mg/die. A clinical documentation was required to further investigate history of her sister, and neurological sequelae after cardiac arrest at 28s related to ventricular fibrillation emerged. However, no deeply evaluation of underlining heart disease was available. Despite an early favorable follow-up of patient, after six months, she suffered from palpitations and heart failure requiring diuretic therapy. Persistent repolarization abnormalities in infero-lateral leads, and low-voltage in precordial leads were noted. An extensive wall-motion abnormalities and moderate LV dysfunction were detected. Importantly, significant arrhythmic burden with PVC (13%) at 24-hr ECG monitoring was recorded. CMR was requested to further investigate the possibility of underlining coexisting cardiomyopathy. Mild LV dilation, moderate dysfunction (LVEF 39%), wall motion abnormalities and thinning of the inferior wall middle segments were reported. Surprisingly, fibro-fatty replacement in infero-lateral of LV wall was detected, and unexpectedly, right ventricular (RV) fibro-fatty replacement and mild RV dysfunction were also described. Hence, diagnosis of arrhythmogenic cardiomyopathy was made. Since persistent arrhythmic burden despite optimized medical treatment, biventricular involvement, family history of SCD, an implantable cardioverter defibrillator in primary prevention was placed. Furthermore, genetic testing was required and extensive clinical family screening was suggested. Conclusion According to the clinical data collected, takotsubo and arrhytmogenic cardiomyopathy can coexist. A potential link between two myocardial heart disease may be identified in the future, especially among patients presenting takotsubo and long-term unfavorable outcome.

Understanding how virtual reality forest experience promote physiological and psychological health for patients undergoing hemodialysis.

Growing research has found that exposing patients to forest landscapes through technology improves their health. However, studies on the effects of nature therapy sessions on particularly vulnerable groups that require frequent regular treatment such as patients of chronic kidney disease (CKD) is lacking. This study aims to understand the effects of watching panoramic videos of forest walks through virtual reality (VR) headsets on patients. We also examine the effects of the frequency of virtual exposure to forests on the physiological and psychological parameters of patients undergoing dialysis. Twenty-four dialysis patients with a mean age of 65.11 year underwent a virtual nature intervention over the course of 3 weeks. The intervention consists of 3 numbers of 6-min 360-degree nature videos delivered using VR headsets. We measured heart rate variability (HRV) and heart rate (HR) using continuous electrocardiographic (ECG) monitoring and assessed their emotional states using a questionnaire survey and in-depth interviews. The results showed that the initial 6 min of watching of the panoramic videos through VR headsets resulted in significantly reduced HR and sympathetic nerve activity and increased positive emotional responses. However, repeated VR exposure did not further improve the physiological health of the respondents. Considering these results, the use of VR headsets to watch 6-min nature videos indoors can be used to enhance the positive psychological responses among dialysis and bed-ridden patients. As this study is preliminary, future random controlled trials are needed to compare and determine the best dose, content, and delivery methods of such an intervention.

Long‐term monitoring with an implantable loop recorder detects multiple episodes of paroxysmal atrial fibrillation after electrical cardioversion in a Warmblood horse

SummaryAtrial fibrillation (AF) is a pathological arrhythmia affecting performance horses and is termed paroxysmal (pAF) when self‐terminating to sinus rhythm. Little is known about pAF as its sporadic nature makes it difficult to diagnose. Therefore, continuous electrocardiographic monitoring devices, such as implantable loop recorders (ILR), are necessary to detect the time of onset and episode duration. This case report presents the detection of pAF in a 9‐year‐old Warmblood horse after successful transvenous electrical cardioversion (TVEC). An ILR continuously monitored the heart rhythm over 28 months and detected 12 episodes of pAF of which two episodes were associated with reduced performance, while others occurred asymptomatically at rest. The estimated episode duration ranged from 6 min to 46.5 h. The antiarrhythmic drug sotalol (2 mg/kg bwt BID PO) was given prior to TVEC and then for 4 weeks. As episodes continued to occur, sotalol was prescribed for another 4 weeks, 6 months after TVEC. Continuous monitoring after TVEC allows for detection of AF recurrence and identification of AF burden, approximate time of onset and possible identification of trigger events. Early diagnosis and antiarrhythmic treatment may prevent a progression to persistent AF.

Incremental value of the combined brain-cardiac CT protocol on prediction of atrial fibrillation after stroke.

Atrial fibrillation (AF) is one of the most common causes of ischemic stroke. It is essential to target patients at highest risk of AF detected after stroke (AFDAS), who should benefit from a prolonged rhythm screening strategy. Cardiac-CT angiography (CCTA) was added to the stroke protocol used in our institution in 2018. We sought to assess, for AFDAS, the predictive value of atrial cardiopathy markers by a CCTA performed on admission for acute ischemic stroke. From November 2018 to October 2019, consecutive stroke patients with no history of AF were included. Let atrial volume (LAV), epicardial adipose tissue (EAT) attenuation and volume, and LAA characteristics were measured on CCTA. The primary endpoint was the presence of AFDAS at follow-up, diagnosed by continuous electrocardiographic monitoring, long-term external Holter monitoring during hospital stay, or implantable cardiac monitor (ICM). Sixty of the 247 included patients developed AFDAS. Multivariable analysis shows independent predictors of AFDAS: age >80 years (HR 2.46; 95%CI (1.23-4.92), p = 0.011), indexed LAV >45 mL/m2 (HR 2.58; 95%CI (1.19-5.62), p = 0.017), EAT attenuation > -85HU (HR 2.16; 95%CI (1.13-4.15), p = 0.021) and LAA thrombus (HR 2.50; 95%CI (1.06-5.93), p = 0.037). Added consecutively to AFDAS prediction AS5F score (combining age and NIHSS >5), these markers had an incrementally better predictive value compared with the global Chi2 of the initial model (p = 0.001, 0.035, and 0.015 respectively). Adding CCTA to the acute stroke protocol to assess markers of atrial cardiopathy associated with AFDAS may help to better stratify the AF screening strategy, including the use of an ICM.

Abstract 14604: Arrhythmia Burden With Right-Heart Catheterization: A Systematic Review and Meta-Analysis

Background: Current guidelines cite complete heart block as a complication of invasive hemodynamic monitoring. This was described to be higher in those with existing intraventricular conduction delays. The objective of this meta-analysis was to evaluate the true risk of arrhythmias and pacemaker implantation rates in patients undergoing right-heart catheterization or with pulmonary artery catheter use. Methods: A literature search was performed from inception until May 2022. Studies that reported incidence rates of arrhythmias in those undergoing right-heart catherization or with pulmonary catheter use, including right- (RBBB) and left-bundle branch (LBBB), were included. Some studies described the development of complete heart block (CHB) and need for pacing. Results: Six single-center studies were included in our analysis with a total of 8, 077 right-heart catheter insertions. All patients had continuous ECG monitoring. Most frequently reported arrhythmia was premature ventricular ectopy (56.4%). No fatal ventricular arrhythmias were described and when noted, RBBB was transient in nature (0.2%, n=12/7577). The risk of CHB was 12.8% (n=24) in those with pre-existing LBBB (n=187). Pacing needs were infrequently described, but when reported was 6.3% (n=10) of concordant CHB and LBBB (n=160), and this was 0.2% of all described LBBB patients (n=6292) ( Figure ). Conclusion: Most arrhythmias were benign and transient in nature. The risk of CHB requiring pacing needs was only 0.2%. This begs the question of true burden of the theoretical complication of CHB with invasive hemodynamic monitoring, and most evidence is from decades ago.