Ectopic Atrial Rhythm Research Articles

Meta-analysis of renin angiotensin aldosterone modulators mitigating Atrial Fibrillation risk in hypertensive patients

IntroductionHypertension is associated with left ventricular hypertrophy/enlargement/fibrosis and atrial ectopic rhythm, leading to an increased risk of Atrial Fibrillation (AF). We aimed to stratify the effect of Angiotensin Converting Enzyme Inhibitors (ACEi) and Angiotensin Receptor Blockers (ARB) on the risk of AF. MethodsPubMed, Scopus, and Google Scholar databases were screened, and cross-citation was conducted for studies reporting AF in hypertensive patients on ACEi and ARB. Of 145 studies found till May 2023, 19 were included in this study. Binary random-effects models estimated the pooled odds ratios, I2 statistics assessed heterogeneity and sensitivity analysis was assessed using the leave-one-out method. Results153,559 hypertensive patients met the inclusion criteria. For incidental AF, ACEi and ARB showed a significant decrease in both unadjusted (OR 0.75, 95% CI [0.66-0.85], I² = 20.79%, p=0.29) and adjusted risks (OR 0.76, 95% CI [0.62–0.93], I² = 88.41%, p<0.01). In recurrent AF, the unadjusted analysis showed no significant effect (OR 0.89, 95% CI [0.55–1.42], I² = 78.44%, p<0.01), while the adjusted analysis indicated a reduced risk (OR 0.62, 95% CI [0.50–0.76], I² = 65.71%, p<0.01). Leave-one-out sensitivity analysis confirmed these results. ConclusionsACEi and ARB considerably decrease the risk of incidental and recurrent AF in hypertensive patients, emphasizing the importance of treating clinical hypertension with these drugs.

Electrocardiographic abnormalities in patients with microtia

The main objective of this study was to investigate the incidence and characteristics of electrocardiographic abnormalities in patients with microtia, and to explore cardiac maldevelopment associated with microtia. This retrospective study analyzed a large cohort of microtia patients admitted to Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, from September 2017 to August 2022. The routine electrocardiographic reports of these patients were reviewed to assess the incidence and characteristics of abnormalities. The study included a total of 10,151 patients (5598 in the microtia group and 4553 in the control group) who were admitted to the Plastic Surgery Hospital of Peking Union Medical College. The microtia group had a significantly higher incidence of abnormal electrocardiographies compared to the control group (18.3% vs. 13.6%, P < 0.01), even when excluding sinus irregularity (6.1% vs. 4.4%, P < 0.01). Among the 1025 cases of abnormal electrocardiographies in the microtia group, 686 cases were reported with simple sinus irregularity. After excluding sinus irregularity as abnormal, the most prevalent abnormalities was right bundle branch block (37.5%), followed by sinus bradycardia (17.4%), ST-T wave abnormalities (13.3%), atrial rhythm (9.1%), sinus tachycardia (8.3%), and ventricular high voltage (4.7%). Less common ECG abnormalities included atrial tachycardia (2.1%), ventricular premature contraction (2.4%), and ectopic atrial rhythm (1.8%). atrioventricular block and junctional rhythm were present in 1.2% and 0.9% of the cases, respectively. Wolff Parkinson White syndrome and dextrocardia had a lower prevalence, at 0.6% and 0.9%, respectively. The occurrence of electrocardiographic abnormalities in microtia patients was found to be higher compared to the control group. These findings highlight the potential congenital defect in cardiac electrophysiology beyond the presence of congenital heart defect that coincide with microtia.

Ectopic atrial rhythm after superior septal approach to the mitral valve - an often under-reported entity.

Very few reports elaborate on the changes in P wave following superior septal approach to the mitral valve. We aimed to describe the changes in the P wave axis and other electrocardiographic changes following this approach among patients preoperatively in sinus rhythm. We did a retrospective review of medical records among all our patients undergoing superior septal approach for mitral valve surgery from September 2014 to September 2019. Electrocardiograms during hospital stay and until 6-month follow-up were analyzed. A deviation in P wave axis from the normal range of + 30 to + 60° was classified as ectopic atrial rhythm. In the study population of 47 patients (age 16-75years, 51.3 ± 13.6years; M:F ratio 3.7:1), who were in normal sinus rhythm preoperatively, 34 patients (72.3%) had a visible P wave on electrocardiogram (ECG) at discharge. Among them, the P wave axes of 17 patients (36.2%) were within normal range (normal sinus rhythm), whereas 17 patients (36.2%) had ectopic atrial rhythm at discharge. The most frequent abnormal P wave axis was between 0 and - 30° (12 patients). At 6months, 8 patients (17.0%) had a persistent ectopic atrial rhythm. These patients underwent a Holter test at 6months and were followed up for symptomatic bradycardia for 3years. None of the patients with ectopic atrial rhythm required pacemaker insertion. Persistence of ectopic atrial rhythm at 6months is common (17%) after superior septal approach. Documentation of P wave axis after this approach will help avoid missing it. These patients may be kept on follow-up to look for symptomatic bradycardia.

Premature atrial contractions: A predictor of atrial fibrillation and a relevant marker of atrial cardiomyopathy.

An increased burden of premature atrial contractions (PACs) has long been considered a benign phenomenon. However, strong evidence of their involvement in the occurrence of atrial fibrillation (AF), ischemic stroke, and excess mortality suggests the need for management. The central question to be resolved is whether increased ectopic atrial rhythm is only a predictor of AF or whether it is a marker of atrial cardiomyopathy and therefore of ischemic stroke. After reviewing the pathophysiology of PACs and its impact on patient prognosis, this mini-review proposes to 1) detail the physiological and clinical elements linking PACs and AF, 2) present the evidence in favor of supraventricular ectopic activity as a marker of cardiomyopathy, and 3) outline the current limitations of this concept and the potential future clinical implications.

РОЛЬ ВЕГЕТАТИВНОЙ НЕРВНОЙ СИСТЕМЫ В ГЕНЕЗЕ ПЕРВИЧНОЙ ХРОНИЧЕСКОЙ БОЛИ У ПОДРОСТКОВ ПО РЕЗУЛЬТАТАМ ВЫБОРОЧНОГО КРОСС-СЕКЦИОННОГО ИССЛЕДОВАНИЯ

The “Chronic Pain” in children and adolescents is an expression that is currently not used widely in Russian pediatric practice. At the same time the clinical variants of Chronic Pain are widely used in practice and are often considered within the classification framework of autonomic dysfunction. The purpose of the study was to determine the possible influence of the autonomic nervous system (ANS) on the occurrence and course of Chronic Pain in male adolescents with recurrent headaches and abdominal pains as the example diagnoses; to value the various diagnostic criteria of ANS activity indicators for Chronic Pain; to demonstrate the doubtfulness of attributing these manifestations of Chronic Pain to ANS diseases. Materials and methods: the research work was carried out in February to May, 2013. A selective cross-sectional study was conducted among 14 to 18 years old male pupils of the cadet corps. The main group of patients consisted of adolescents with headaches and/or abdominal pains (n=90, average age 15.5 y/o, CI 15.2-15.8), whose clinical characteristics fully consistent with generally accepted international criteria for primary headaches and functional disorders occurring with abdominal pains. The comparison group (n=93, average age 15.6 y/o, CI 15.3-15.9) consisted of apparently healthy male adolescents. The VNS indicators were assessed using the A.M. Wayne questionnaire (the N.A. Belokon version) coupled with the cardiointervalography (CIG) data: the background ANS activity indicators as the baseline and the characteristics of the ANS reactivity. The CIG was performed in 111 (60.7%) patients who had sinus rhythm according to the ECG data. In the remaining 72 (39.3%) patients the ectopic atrial rhythm was detected which had prevented the evaluation of the CIG results. To assess the ANS activity characteristics with a masked method the ECG was registered and deciphered in 100% of patients; and the CIG in patients with the absence of cardiac arrhythmias. In addition, all of the participants (183) have undergone a clinical assessment of the initial autonomic tone using a questionnaire. Results: there were no statistically significant differences in the ANS activity between the two groups of patients: those with primary Chronic Pain and healthy individuals. There was therefore no significant diagnostic value found of the abovementioned characteristics according to the odds ratio criterion. The evidence of the VNS role in the genesis of the primary Chronic Pain was not registered. Conclusion: the conventional belief that headaches and abdominal pains are a manifestation of autonomic dysfunction had not been confirmed. The existing concept of ANS dysfunction with polymorphic clinical manifestations, including pain, has no proper justification and raises doubts about its appropriateness.

At-home ECG monitoring with a real-time outpatient cardiac telemetry system during the COVID-19 pandemic.

During the COVID-19 pandemic, essential in-person electrocardiogram (ECG) recordings became unfeasible, while patients continued to suffer from cardiac conditions. To circumvent these challenges, the cardiology clinic (Long Island Heart Rhythm Center [LIHRC]) at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM) transitioned to a remote real-time outpatient cardiac telemetry (ROCT) service. The goal of this study is to test the hypothesis that at-home ROCT, provided by the LIHRC, is an effective method of providing ECG monitoring to symptomatic patients during the COVID-19 pandemic. Seventeen patients at the LIHRC that required ECGs between March 11 and August 1, 2020, were included in this study. The patients' medical records were de-identified and reviewed for age, gender, ROCT indications, findings, patient comfort, and ease of use. A retrospective analysis of observational de-identified data obtained from the LIHRC was approved and permitted by the NYITCOM Institutional Review Board (BHS-1465). These FDA-cleared medical devices (DMS-300, DM Software, Stateline, NV) were shipped to the patients' homes and were self-applied through adhesive chest patches. The devices communicated with a cloud-based system that produced reports including a continuous 6-lead ECG and many other cardiovascular parameters. Additionally, a patient-activated symptom recorder was available to correlate symptoms to ECG findings. Seventeen patients (15 women) from the LIHRC were included in the analysis with an average monitoring duration of 27h (range, 24-72h). The patients' ages ranged from 21 to 85years old with a mean of 37years old and a standard deviation of 19. ROCT indications included palpitations (n=9), presyncope (n=8), chest pain (n=5), syncope (n=3), and shortness of breath (n=2). One also received ROCT due to short PR intervals observed on a prepandemic ECG. Two patients experienced palpitations while wearing the ROCT device: one had supraventricular tachycardia at 150 beats per minute; the other had unifocal premature ventricular contractions (PVCs) and eventually underwent a successful cardiac ablation. Most patients experienced no symptomatic episodes during ROCT (n=15). The 6-lead ROCT ECG for five of those patients showed arrhythmias including wandering atrial pacemaker (n=2), PVCs (n=2), sinus tachycardia (n=1), premature atrial contractions (PACs) (n=1), ectopic atrial rhythms (n=1), and sinus arrhythmia (n=1). One patient who experienced issues with our device was able to obtain a device from a separate clinic and was found to have bradycardia, PVCs, and nonsustained ventricular tachycardia. Overall, 16/17 (94.1%) patients were monitored effectively with the LIHRC ROCT system, and all (17/17, 100%) patients were monitored effectively with a ROCT system either from the LIHRC or a separate clinic. With the unique challenges of the COVID-19 pandemic, physicians can use this innovative ROCT method to prevent infection and diagnose cardiac diseases. Most patients and staff were able to utilize the system without issues. Therefore, this system may also be utilized to deliver patient-centered care to those with limited mobility when coupled with a telemedicine visit.

Up is down, down is up: ectopic atrial bradycardia or junctional Rhythm?

Up is down, down is up: ectopic atrial bradycardia or junctional Rhythm?

Revisiting where to apply preimplant mapping to improve P-wave sensing of insertable cardiac monitors.

BackgroundInsertable cardiac monitors (ICMs) are used for long‐term cardiac rhythm monitoring. They have proven useful in diagnosing arrhythmias. They are conventionally inserted at the 4th intercostal space without preimplant mapping.MethodWe develop a new method, VisP, that finds an optimal insertion position by applying the lightweight preimplant mapping to nine candidate positions beyond the conventional ones. We retrospectively analyze consecutive 60 patients who underwent ICM insertion (Reveal LINQ™) between April 2019 and March 2021 and compare the two groups with and without VisP.ResultsAfter 9 patients were excluded because of ectopic atrial rhythms or atrial fibrillation, 51 patients were analyzed. Thirty‐one patients underwent the conventional insertion (non‐mapping), whereas 20 patients underwent VisP. VisP achieved large P‐wave amplitudes while retaining the R‐wave amplitude for all patients; in contrast, P waves were not detected for 11 patients out of the 31 patients in the non‐mapping group (35%). On average, the P‐wave amplitude was 0.065 mV for VisP, compared to 0.029 mV for the non‐mapping group (p‐value< .001). The average R‐wave amplitude was 0.69 mV for VisP and 0.71 mV for non‐mapping (p‐value = .88), indicating the R‐wave difference is insignificant between the two groups. VisP selected the 4th, 3rd, and 2nd intercostal spaces for 7, 11, and 2 patients, respectively, meaning that 13 out of the 20 cases (65%) fell out of the conventional insertion location of the 4th intercostal space.ConclusionsVisP improves the diagnostic ability of ICMs by finding an optimal position that yields reliable sensing of P waves while keeping high R‐wave sensing.

Atrial arrhythmias in patients beyond 40 Years of age post atrial septal defect device closure

BackgroundPatients >40 years with an atrial septal defect (ASD) may have atrial arrhythmia which warrants treatment. It is unclear whether preventive left atrial appendage (LAA) occlusion should be performed simultaneously during ASD closure in these patients. ObjectiveThis study aimed to examine the incidence of de novo atrial arrhythmia in patients >40 years old post transcatheter closure of ASD. MethodsThis was a single-center, retrospective study involving all consecutive patients who have undergone device closure of ASDs at age >40 years. Standard 12-lead ECGs were performed pre-procedure and during every clinic follow-up. Ambulatory monitors were applied when indicated. ResultsEighty-eight patients (mean age: 51.81 ± 8.01 years; male: 22.7%) were recruited and followed up over a median duration of 3.6 years (range: 1–6.5). Seven patients (8%) had documented atrial arrhythmia (AA) pre and post ASD closure. Two patients (2.5%) developed de novo atrial fibrillation and one patient (1.2%), ectopic atrial rhythm during follow-up. In univariate analyses, age >61.3 years (p < 0.001), a history of palpitation (p = 0.006), right atrial area >25.15cm2 pre-closure (p = 0.004); dilated right and left atrium immediately post ASD closure (p = 0.016 & 0.001) and pulmonary vascular resistance >1.31Woods unit (p = 0.036) were associated with increased risk of AA. However, on multivariate analyses, none were significantly associated with AA. ConclusionsDe novo atrial arrhythmia after ASD device closure is uncommon.

Prevalence of Physiological Electrocardiographic Findings in a Brazilian Cohort of Young Football Players: B-Pro Foot ECG Pilot Study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Hospital de Clínicas de Porto Alegre Research and Event Incentive Fund (FIPE-HCPA) Introduction The 12-lead electrocardiogram (ECG-12) is a useful tool in the assessment of athletes, and it may present findings compatible with physiological adaptations to regular exercise. ECG-12 findings in Brazilian soccer players are unknown. Purpose To describe the prevalence of physiological ECG-12 findings in young Brazilian soccer players based on the "2017 International Criteria for Electrocardiographic Interpretation in Athletes". Methods Continuous variables were displayed as mean and standard deviation or median and interquartile range, while prevalence’s with 95% confidence intervals, and stratified by race. Intra-group differences were estimated by linear models or binomial and multinomial logistic regressions. Type I error was set to set a at 0.05. An additional margin of 0.025 was considered at the discretion of the statistician conditioned to the quality of the model. All analysis were running in Stata version 16.0.0. Results 2,581 athletes from 27 clubs (mainly first division), aged 15-35 years (median: 18 years) were evaluated. 1,268 (49.1%) were Caucasians, 796 (30.8%) Mixed-race (MR) and 517 (20.1%) Afro-Brazilians (AB). In this sample from across the country, we identified the following findings and its respective prevalence: sinus bradycardia (50%), ectopic atrial rhythm (1.4%), junctional rhythm (0.3%), incomplete right bundle branch block (23.7%), first-degree atrioventricular (AV) block (3.0%), Mobitz type I AV block (0.1%), and increase QRS voltage for left or right ventricular hypertrophy (35.2% and 17.3%, respectively). The mean PR interval was 153.9±28.7 ms, corrected QT interval 399.2±28.0 ms, and QRS duration 96.0±14.0 ms. ST elevation followed by T-wave inversion in leads V1–V4 was identified in 11/517 (2.1%) of AB athletes. Early repolarization was present in 828 athletes (32.1%), being more prevalent in AB when compared to MR and Caucasians (P = 0.003). Likewise, AB had a greater PR interval in comparison to MR and Caucasians (P &amp;lt;0.001 and P = 0.007, respectively). On the other hand, Caucasians had a significant longer QRS duration compared to AB. For all remaining variables there was no difference among races. Conclusions To the best of our knowledge, this is the first large study to describe the prevalence of physiological electrocardiographic finding in young Brazilian soccer players, according to "2017 International Criteria for Electrocardiographic Interpretation in Athletes". Future studies comparing the frequency of these findings with the prevalence observed in other cohorts are welcome.

Prenatal diagnosis of hepatic interruption of the inferior vena cava with azygos/hemiazygos continuation without structural heart defects: A case series.

To describe fetal spectrum and echocardiographic characteristics of interrupted inferior vena cava (IIVC) with azygos/hemiazygous continuation without other structural heart defects and to evaluate its association with visceral heterotaxy and isomerism, extracardiac and genetic anomalies, and to review neonatal outcome. This was a retrospective study of 14 fetuses with a confirmed diagnosis of IIVC with normal intracardiac anatomy. The following variables were collected; indication for referral, gestational age at diagnosis; associated isomerism and visceral heterotaxy, heart rhythm, genetic and extracardiac abnormalities, and fetal/neonatal outcome. Among 36 fetuses with IIVC, 14 cases (38.8%) had normal intracardiac anatomy. These IIVC cases correspond to 0.19% (14/7250) of all fetal cardiac examinations, and to 1.5% (14/922) of all cardiac abnormalities. Six patients had visceral abnormalities. Atrial appendage morphology was clearly depicted in three fetuses, both appendages were left. One fetus had bradyarrhythmia revealing atrial ectopic rhythm. Six fetuses did not have any concomitant cardiac or visceral abnormalities, therefore regarded as isolated. All babies were delivered at term with a good prognosis. Our study has shown that almost half of the IIVC cases without intracardiac structural anomalies displayed other findings of isomerism while the other half was isolated benign vascular variant. Therefore, prenatal diagnosis of IIVC should prompt a comprehensive evaluation for cardiac, situs, and visceral anomalies. The outcome is favorable.

Unilateral Atrial Ectopic Rhythm in a Golden Retriever

Background: Atrial ectopic rhythm is a type of supraventricular arrhythmia, originating in two distinct points in the atrial region. In the electrocardiographic (ECG) tracing, it is represented by independent depolarizations of sinus P waves and ectopic P waves. The occurrence of this disorder is rare, and the diagnosis criteria are the presence of the described waves within the basal rhythm. In humans, there have been reports related to severe heart failure with an unfavorable prognosis. The present report aimed to describe the clinical case of a dog with unilateral atrial ectopic rhythm without any underlying cardiac disorder.Case: A 8-year-old male golden retriever was brought to a veterinary clinic for a preoperative evaluation for lipoma removal in the right forelimb. On clinical examination, the owner stated that the patient was active, with no signs of easy fatigue or cough. The canine displayed normophagy, normodipsia, normoquezia, and normouria. On physical examination, he demonstrated a lymphatic temperament with tachypnea. The temperature and capillary filling time were within the normal range, with a normokinetic pulse. Cardiac auscultation revealed a mild grade I/VI murmur in mitral focus and an 80-bpm heart rate. Respiratory auscultation revealed the presence of harshy lung sounds. The cough reflex was positive; the Piparote test, negative. The blood test showed no noticeable changes in blood count and serum biochemistry. Systemic systolic blood pressure was 120 mmHg. On radiographic examination, no evidence of heart or lung abnormalities were identified. After the clinical evaluation, an ECG examination was performed; a unilateral atrial ectopic rhythm was observed with different frequencies between atrial and ventricular rhythm and with P (164°) and P waves (80°). On echocardiographic examination, no morphological abnormalities were seen, though trivial mitral insufficiency was identified in a color Doppler study. Blood was collected to measure electrolytes to check for possible electrolytic abnormalities; the results were within the normal range. The patient was released for and remained stable throughout the procedure, maintaining the rhythm detected during the transoperatory time. Upon reassessment in a new ECG examination, the arrhythmia persisted, suggesting that a primary lesion in the atrial tissue was present.Discussion: An atrial ectopic rhythm diagnosis requires a detailed study with the aim of ruling out heart diseases that may affect the propagation of the cardiac stimulus. However, no morphological or functional abnormalities of note that justified triggering stimuli for the ectopic rhythm were observed. In addition, based on the echocardiographic evaluation, myocardial function was preserved, supporting the canine’s release for the procedure. The suspicion of hydroelectrolytic alteration and hypoxia was present after discarding structural causes, though it was discarded due to normal laboratory results. The presence of ectopic P waves was due to the non-interference in the sinus P’ waves; consequently, they were found in the sinus heart rhythm. Upon assessing the ectopic P wave frequency, the atrial rhythm frequency was higher than the heart rate, juxtaposing the different irregular intervals within the atrial cycle. The rhythm alone may explain that its severity can be linked to the physical findings. This indicated that they did not influence the presentation of ectopia since the cardiac output, controlled by the sinus rhythm part, was responsible for maintaining the rhythm and the demand of the organism; the electrical conduction system, responsible for atrial systole, represents 15-25% of the blood ejection for the ventricular filling. Patients with rhythm disorders as described need guidance and follow-up for the early detection of clinical signs resulting from the destabilization of the condition.Keywords: atrial dissociation, supraventricular arrhythmia, electrocardiogram, dogs.

Abstract 14587: Electrocardiogram Findings Amongst Latin American Immigrants at Risk for Chagas Disease in Florida

Introduction: Chagas disease (CD) is caused by the parasite Trypanosoma cruzi and can lead to chronic Chagas cardiomyopathy (CCC). Cardiac arrhythmias are common in CCC and include AV node pathology, intraventricular conduction disease, ventricular arrhythmias, and other abnormalities. In the U.S. there are at least 300,000 immigrants from Latin America living with CD, but it is estimated that only 1% have been diagnosed. Florida is suspected to carry the third highest burden with approximately 18,000 people living with CD. Hypothesis: The purpose of this study is to investigate the prevalence of electrocardiogram (ECG) findings amongst a Hispanic immigrant population at risk for CCC in Florida. Methods: Latin American immigrants who were either born or lived in endemic regions and now reside in Florida were enrolled in the study after informed consent. All participants completed an epidemiological survey, underwent 12-lead ECG testing, and provided a fingerstick and venous blood sample for further CD testing. ECGs were interpreted by a board-certified electrophysiologist. Results: A total of 151 individuals were enrolled with a mean age of 44 years and 58.9% being female. The most common countries of origin were Venezuela (34.4%), Mexico (18.5%), Honduras (12.6%), and Colombia (11.9%). Overall, 7.3% had an intraventricular conduction delay (LBBB 0.7% , RBBB 2.0%, LAFB 2.0%, and other IVCD 2.6%). A 1st degree AV block was found in 0.7% and no participants had a higher degree AV block. Ischemic changes were noted in 15.9% of participants, with infarct pattern in 3.3% and non-specific ST-T wave changes in 13.2%. Rhythm findings included normal sinus rhythm 77.5%, sinus bradycardia 21.2%, atrial fibrillation 0.7%, and ectopic atrial rhythm 0.7%. Other findings included borderline prolonged QTc 1.3%, prolonged QTc 2.0%, PACs 1.3% and no patients with PVCs. Conclusions: Review of this preliminary data shows a significant number of ECG abnormalities among this cohort of Latin American immigrants in Florida which can be associated with CD and CCC. Of particular interest is the high prevalence of sinus bradycardia as compared to prior population studies. A full comparative analysis of ECG findings amongst those who test positive for CD in this cohort is ongoing.

The unusual case of a Topsy-Turvy ECG with a pseudo-infarct pattern

Unique electrocardiogram (ECG) patterns can be generated by inadvertent lead misplacements. The commonest of these is left arm-right arm (LA-RA) reversal leading to inverted lead I, right axis deviation and an upright aVR. Changes in placement of the neutral (right leg: RL) electrode with one of the LA or RA cables may produce more atypical patterns, which often mimic myocardial ischemia. We describe an unusual case wherein the ECG suggested an ectopic atrial rhythm and ischemic changes in the inferior leads. Closer scrutiny revealed a bilateral LA-LL and RA-RL (left arm- left leg and right arm- right leg) reversal. Familiarity and quick recognition of such ECG patterns shall help clinicians in avoiding diagnostic and therapeutic errors.

B-PO05-167 ATRIAL TACHYARRHYTHMIAS IN CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA: A REPORT FROM THE INTERNATIONAL PEDIATRIC CPVT REGISTRY

While Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) is typically characterized by adrenergic-induced bidirectional or polymorphic ventricular tachycardia, atrial arrhythmias also occur. However, little is known about this manifestation. To compare demographics and outcomes of pediatric CPVT patients with and without atrial tachyarrhythmias (AT). In this prospectively followed pediatric CPVT population, we compared baseline demographics, therapy, genetics and outcomes in patients <19 years old with and without AT. Eighty patients without AT were compared to 27 patients with AT, identified during treadmill (n=11), Holter (n=7), epinephrine/isoproterenol (n=6) testing and device interrogation (n=3). Fifteen patients (56%) had atrial tachycardia, 11 (41%) had atrial fibrillation, and 1 (4%) had an ectopic atrial rhythm. Of these patients, 1 had sinus node dysfunction necessitating a pacemaker. Median age at presenting symptom in the AT group was 6.5 (IQR: 4-9.3) years vs 11 (IQR: 7-14) years in the non-AT group (p<0.001). Sex, proband status and baseline therapy did not differ significantly between groups. Combination therapy (flecainide and β-blocker) was used in 15 AT patients and was ineffective in controlling AT in 56% (5 of 9) with follow-up data. Catheter ablation for AT was unsuccessful in 3 of 5 (60%) patients. In the AT group, 10 of 24 (42%) patients with genetic testing had a likely pathogenic/pathogenic RYR2 variant vs 46 of 76 (61%) in the non-AT group (p=0.16). The rate of life-threatening cardiac events (death, cardiac arrest, syncope, appropriate ICD discharge) during follow-up for AT patients was 48% (13 of 27) vs 34% (27 of 80) in the non-AT group (p=0.25). One quarter of pediatric CPVT patients had AT, which were associated with younger age of CPVT onset. However, the numerically higher rate of life-threatening events during follow-up in those with AT was not statistically significant. Current available treatments appear ineffective for CPVT-related AT, which should be recognized as an important feature of the disease.

Radiofrequency catheter ablation of focal atrial tachycardia: characteristics and results of a series in a tertiary hospital

Abstract Funding Acknowledgements Type of funding sources: None. Background Focal atrial tachycardia (AT) is a relatively uncommon arrhythmia with poor response to medical treatment. Radiofrequency (RF) ablation appears to be a good option for treatment of symptomatic patients (P). Purpose To describe the clinical characteristics, electrophysiological (EP) findings, safety and short-term efficacy of catheter ablation in P with AT. Methods Retrospective analysis of consecutive P submitted to AT ablation using electroanatomical mapping between 2015 and 2020. If the AT was not present spontaneously, pacing maneuvers (atrial drive or burst pacing with up to 3 extra-stimuli) and isoprenaline was employed until reproducible induction of an ectopic atrial rhythm. Radiofrequency (RF) ablation was delivered at the site of earliest activation after validation of local electrograms until non-inducibility. Results A total of 46P (61% female) were included, with a mean age of 48 ± 23 years (minimum 8 months, maximum 86 years). Idiopathic AT was observed in 47,8%, while 52.2% had other relevant comorbidities (chronic pulmonary disease 17.4%; previous cardiac surgery 8,7%; congenital heart disease 10.9%; coronary artery disease 6.5%). Despite anti-arrhythmic therapy, daily palpitations were present in 87% of the cases and dizziness or syncope occurred in 22%). Nearly half (47.8%) had previously sought urgent medical care and 30.4% had a hospital admission due to arrhythmia. The clinical arrhythmia was documented in 34P (47.8% by 12-lead electrocardiography and 26.1% in 24h Holter monitoring). During the EP study a focal AT was documented in all P (spontaneously in 54.3% and induced with pacing maneuvers in 45.7%). AT origin after electroanatomical activation mapping is depicted in figure 1. After focal RF ablation, a second AT was induced in 16P (34.8%) and a new ablation was performed in 15 cases (93.8%). Total RF time was 508 ± 386 sec. One P developed right phrenic nerve palsy after ablation on the lateral wall of the right atrium. No other complications were noted. On follow-up (mean 320 ± 92 days), symptoms improved in 88.1% of the P, with a 3-fold decrease in urgent medical care visits and hospital admission for arrhythmia. Three P (8.7%) were submitted to a new EP study, in which an AT was documented and ablated in 2P. Conclusion AT is a very symptomatic arrhythmia, associated with increased usage of hospital resources and poor response to antiarrhythmic therapy. Ablation is an efficient treatment option, with a high success rate, low rate of complications and short-term clinical benefits. Abstract Figure. Distribution of focal atrial tachycardia

The different surgical impact of the superior cavoatrial incision in children and adults.

The single- and double-patch repairs are undoubtedly the most commonly used techniques for the surgical management of partial anomalous pulmonary venous connection associated with sinus venosus atrial septal defect. The aim of this study was to retrospectively compare early and long-term surgical outcomes in paediatric and adult patients, focusing in particular on the occurrence of ectopic atrial rhythm. Seventy patients (male: 38, 54.2%) underwent surgical repair for partial anomalous pulmonary venous connection with sinus venosus atrial septal defect. Forty-nine patients (70%) underwent surgical repair in paediatric age (<16 years old), while 21 of (30%) patients were operated in adulthood. Thirty patients (42.8%) underwent single-patch repair and 39 patients (55.7%) underwent double-patch repair. In only one patient, the Warden procedure was performed (1.4%). Median follow-up time was 52 months (IQ 15.1-113). The type of surgical technique didn't affect the incidence of ectopic atrial rhythm (26.6% in single-patch group and 25.6% in double-patch groups, p = 0.9). At long-term follow-up, ectopic atrial rhythm, as an expression of sinoatrial node disturbance, was however significantly more frequent in the paediatric population (28.8% paediatric group and 4.7% adult group, p = 0.02). The higher incidence of ectopic atrial rhythm in children is probably related to the closer position of the sinus node to the superior cavoatrial incision, which makes irreversible iatrogenic traumatism more likely to occur. Surgical techniques that avoid any manipulation on the superior cavoatrial junction should, therefore, be preferred for children undergoing partial anomalous pulmonary venous connection repair.

Isolated right ventricular myocardial infarction: a case report.

BackgroundIsolated right ventricular myocardial infarction (RVMI) due to a recessive right coronary artery (RCA) occlusion is a rare presentation. It is typically caused by right ventricle (RV) branch occlusion complicating percutaneous coronary intervention. We report a case of an isolated RVMI due to flush RCA occlusion presenting via our primary percutaneous coronary intervention ST-elevation myocardial infarction pathway.Case summaryA 61-year-old female smoker with a history of hypercholesterolaemia presented via the primary percutaneous coronary intervention pathway with sudden onset of shortness of breath, dizziness, and chest pain while walking. Transradial coronary angiography revealed a normal left main coronary artery, large left anterior descending artery that wrapped around the apex and dominant left circumflex artery with the non-obstructive disease. The RCA was not selectively entered despite multiple attempts. The left ventriculogram showed normal left ventricle (LV) systolic function. She was in cardiogenic shock with a persistent ectopic atrial rhythm with retrograde p-waves and stabilized with intravenous dobutamine thus avoiding the need for a transcutaneous venous pacing system. A computed tomography pulmonary angiogram demonstrated no evidence of pulmonary embolism while an urgent cardiac gated computed tomography revealed a recessive RCA with ostial occlusive lesion. A cardiac magnetic resonance imaging confirmed RV free wall infarction. She was managed conservatively and discharged to her local district general hospital after 5th day of hospitalization at the tertiary centre.DiscussionThis case describes a relatively rare myocardial infarction presentation that can present with many disease mimics which can require as in this case, a multi-modality imaging approach to establish the diagnosis.

Abnormal ECG in a Structurally Normal Heart

A 63-year-old woman presented with an abnormal electrocardiogram (ECG) triggered by a murmur on physical examination. The ECG showed low atrial ectopic rhythm at rate 46 bpm with diffuse abnormal T wave and prolonged QTc at 546 milliseconds (Fig. 1). She was completely asymptomatic. She had a history of hypertension with no other cardiovascular risk factors along with normal laboratory values. Coronary angiography revealed normal coronary arteries and normal left ventricle (LV) contractility. An ECG demonstrated normal LV size and systolic function, and cardiac magnetic resonance imaging (MRI) revealed normal LV size and function with no evidence of myocardial edema, necrosis, fibrosis, or acute myocardial tissue injury of the LV. Right ventricular size and systolic function were also normal. The main differential diagnosis of inverted T waves includes ischemia, hypertrophy, and intracranial abnormalities. As such, we did proceed with computed tomography head that showed evidence of 3.7 cm mass most consistent with planum sphenoidale meningioma. A subsequent MRI confirmed a broad-based dural mass measuring 34 × 35 × 27 mm centred in the anterior cranial fossa with a significant superolateral mass effect on the overlying bilateral frontal lobes with vasogenic edema (Fig. 2, A and B ). Dynamic ECG changes have been observed in patients with subarachnoid haemorrhage or stroke. Cerebrovascular masses may also increase sympathetic activity and a-adrenergic stimulation with subsequent ECG changes such as ST-segment depression, profound T-wave inversion, and QTc interval prolongation.1Hersch C. Electrocardiographic changes in head injuries.Circulation. 1961; 23: 853-860Crossref PubMed Scopus (86) Google Scholar, 2Kopikkar S. Baranchuk A. Guzman J.C. Morillo C.A. Stroke and ventricular arrhythmias.Int J Cardiol. 2013; 168: 653-659Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 3Kukla P. Jastrzębski M. Kurdzielewicz W. et al.Dynamic ECG changes in a patient with subarachnoid haemorrhage.Kardiol Pol. 2014; 72: 473-475Crossref PubMed Scopus (1) Google Scholar Our patient presented with ECG changes secondary to the meningioma mass effect. The patient was referred to neurosurgery and is planned for surgical excision of the mass.

The presence of ectopic atrial rhythm predicts adverse cardiovascular outcomes in a large hospital-based population

Whether ectopic atrial rhythm (EAR) is a high-risk cardiovascular phenotype (eg, the manifestation of a diseased sinoatrial node) or just a benign accelerated ectopic pacemaker remains unclear. We aimed to analyze the cardiovascular outcomes and underlying mechanisms in patients with EAR. From a 12-lead electrocardiogram hospital-based electrocardiogram database, a total of 2896 adults with EAR were propensity score matched at 1:5 with 14,480 patients with sinus rhythm (SR). Patients were retrospectively followed up for cardiovascular mortality (the primary outcome) and permanent pacemaker implantation (the secondary outcome). Heart rate variability was analyzed to compare autonomic function between patients with EAR and those with SR. The prevalence of EAR was 1.13%, which increased with age. Compared with the matched patients, those with EAR had a higher risk of cardiovascular mortality (adjusted hazard ratio 1.93; 95% confidence interval 1.52-2.44; P < .0001) and permanent pacemaker implantation (adjusted hazard ratio 5.94; 95% confidence interval 3.89-9.09; P < .0001) according to the Cox proportional hazards regression model. The risk of cardiovascular mortality was similar across the subgroups on the basis of age, sex, hypertension, type 2 diabetes mellitus, congestive heart failure, myocardial infarction, stroke, and chronic kidney diseases. In patients with EAR, the low frequency/high frequency and standard deviation of the mean normal-to-normal intervals/root mean square of successive RR interval differences ratios for heart rate variability were both lower than those in patients with SR. This implied autonomic imbalance in patients with EAR. Patients with EAR have a higher risk of cardiovascular mortality and permanent pacemaker implantation, which was associated with autonomic imbalance.