High Risk Of Ventricular Arrhythmias Research Articles

Abstract 14303: Low Global Longitudinal Strain in Ischemic Cardiomyopathy Patients at Baseline is Associated With Ventricular Arrhythmias After Cardiac Resynchronization Therapy

Introduction: Heart failure (HF) patients have an increased risk for ventricular arrhythmias (VA) and in particular patients with ischemic cardiomyopathy (ICM) have a worse prognosis after cardiac resynchronization therapy with defibrillator (CRT-D) compared with non-ischemic patients. Hypothesis: We hypothesize that global longitudinal strain (GLS) at baseline has the ability to identify ICM patients at higher risk for VA after CRT-D. Methods: We prospectively studied 175 consecutive HF patients implanted with CRT-D from a single center. All of them had class II-IV HF symptoms, LV ejection fraction (≤35%), QRS≥120 ms. GLS was measured from the three standard apical views and presented as absolute values. Outcome event was defined as VA (anti-tachycardia pacing or appropriate shock) after CRT in the first 2 years of follow-up. Results: Of 175 patients aged 65±11 years, 135 (77%) were male and 115 (66%) had ICM. They suffered 34 (19%) VA events over 2 years. Mean GLS of the population was 8.1±3.0. GLS (< 6.5%) was associated with VA events after CRT-D with a sensitivity of 70% and specificity of 56%. A cutoff of GLS<6.5% was associated with greater VA events in the ICM patients with HR 2.92 (95% confidence interval 1.48 to 5.77, p=0.002). A similar significant association of GLS was not seen in the non ICM patients (p=0.12). Conclusions: Low GLS (<6.5% in absolute values) in ICM patients is associated with increased risk for VA after CRT-D and might represent more extensive myocardial scarring and has prognostic implications.

Plasma mid-regional pro-adrenomedullin levels are inversely associated with anxiety but unrelated to depression: Results from the observational DIAST-CHF study in patients with cardiovascular risk factors

ObjectivesIt has been postulated that patients with heart failure have a high risk of ventricular arrhythmias and sudden cardiac death resulting from anxiety-induced autonomic arousal. In the prospective and multicenter DIAST-CHF (Diagnostic Trial on Prevalence and Clinical Course of Diastolic Dysfunction and Heart Failure) study, we therefore, tested the hypothesis that adrenomedullin (ADM), a well-established predictor for cardiovascular outcome, is associated with self-rated anxiety symptoms in patients at risk of suffering from or actually with overt heart failure. Participants and measuresStudy participants with risk factors for diastolic dysfunction were requested to complete the Hospital Anxiety and Depression Scale (HADS), and plasma mid-regional pro-adrenomedullin (MR-proADM) concentrations were measured. ResultsIn bivariate analysis, we found significantly lower plasma MR-proADM levels in patients with elevated HADS-anxiety scores above the clinically relevant cut-off level of ≥11 (n=118, 536pmol/l, interquartile range [IQR] 449–626) as compared to non-anxious study participants (n=1,292, 573pmol/l, IQR 486–702, p=0.001). A set of multivariate models adjusted for potential confounders confirmed the negative association between self-rated anxiety symptoms and plasma MR-proADM. In similar models, no significant association was detected between HADS-depression scores and MR-proADM. ConclusionsThe inverse relationship between plasma MR-proADM and anxiety observed in patients with cardiovascular risk factors supports a previous experimental study using a mutant mouse line with a brain-specific loss of ADM expression which displayed hyperactive and over-anxious behavior. Further experimental and clinical studies are warranted to test the hypothesis that also in humans ADM acts as a neuromodulator with anxiolytic properties.

69 Association of TERC Related Genetic Variation and Telomerase Activity with Ventricular Arrhythmias in Ischaemic Cardiomtyopathy

<h3>Introduction</h3> Implantable cardioverter defibrillators (ICD) reduce mortality in ischaemic cardiomyopathy patients at a high risk of ventricular arrhythmias (VA), which are the commonest cause of sudden death. However, ICDs are associated with morbidity and mortality. Importantly 67% of patients never receive an appropriate shock after ICD implantation under current guidelines, suggesting a need for better risk stratification. Telomere and telomerase activity (TA) in leukocytes have recently been shown to correlate with biological ageing and pathogenesis of cardiovascular diseases. Telomerase maintains telomere length and is composed of reverse transcriptase TERT and RNA template TERC. Evidence suggests that genetic variation in key genes has a key impact on TA. Association of SNP12696304 on chromosome 3q26 (at a locus that includes TERC) with telomere length has been shown. We investigated the association between genetic variation in SNP12696304 and leukocyte TA with incidence of VA in ischaemic cardiomyopathy patients. <h3>Methods</h3> 90 ischaemic cardiomyopathy Caucasian patients with primary prevention ICDs were recruited. Genomic DNA was isolated from venous blood samples. TA was measured by the telomere repeat amplification protocol and genotyping done using Taqman SNP assay. Continuous data were compared by unpaired T-test and categorical data by Chi-square test. Logistic regression was used to determine correlation of genotype and TA with VA. <h3>Results</h3> There was no significant difference in baseline demographics between patients with VA(Cases) and no-VA(Controls) as shown in Table 1. The TA was significantly higher in the cases and correlated with incidence of VA (p-value 0.02). No significant correlation between the genotype and VA was identified (C/C OR 1; C/G OR 0.54, CI 0.21 – 1.417, p-value 0.343; G/G OR 0.80, CI 0.198 – 3.236, p-value 0.907). There was a significant correlation between risk of VA and TA increase in C/C genotype (OR7.5, CI1–56.6, p-value 0.04). This correlation was not significant in the G/G or C/G genotype as shown in Figure 1. <h3>Conclusion</h3> There is a significant correlation between TA and VA in ischaemic cardiomyopathy patients. Moreover, homozygosity for C allele of SNP 12696304 (encoding TERC) significantly effects telomerase expression. Thus, increased TA predisposes individuals with C/C genotype to a higher incidence of VA. TA in this genotype can be developed as a biomarker to predict VA and guide ICD prescription in ischaemic cardiomyopathy.

Clinical Case Session I: Sunday 3 May 2015, 10:00-11:00 * Room: Venecia

Clinical Case Session I: Sunday 3 May 2015, 10:00-11:00 * Room: Venecia

Characteristics of ventricular tachycardia ablation in patients with continuous flow left ventricular assist devices.

Left ventricular assist devices (LVADs) are increasingly used as a bridge to cardiac transplantation or as destination therapy. Patients with LVADs are at high risk for ventricular arrhythmias. This study describes ventricular arrhythmia characteristics and ablation in patients implanted with a Heart Mate II device. All patients with a Heart Mate II device who underwent ventricular arrhythmia catheter ablation at 9 tertiary centers were included. Thirty-four patients (30 male, age 58±10 years) underwent 39 ablation procedures. The underlying cardiomyopathy pathogenesis was ischemic in 21 and nonischemic in 13 patients with a mean left ventricular ejection fraction of 17%±5% before LVAD implantation. One hundred and ten ventricular tachycardias (VTs; cycle lengths, 230-740 ms, arrhythmic storm n=28) and 2 ventricular fibrillation triggers were targeted (25 transseptal, 14 retrograde aortic approaches). Nine patients required VT ablation <1 month after LVAD implantation because of intractable VT. Only 10/110 (9%) of the targeted VTs were related to the Heart Mate II cannula. During follow-up, 7 patients were transplanted and 10 died. Of the remaining 17 patients, 13 were arrhythmia-free at 25±15 months. In 1 patient with VT recurrence, change of turbine speed from 9400 to 9000 rpm extinguished VT. Catheter ablation of VT among LVAD recipients is feasible and reasonably safe even soon after LVAD implantation. Intrinsic myocardial scar, rather than the apical cannula, seems to be the dominant substrate.

The ARVD/C Genetic Variants Database: 2014 Update

Arrhythmogenic cardiomyopathy (ACM) is an inherited cardiac disease characterized by myocardial atrophy, fibro-fatty replacement, and a high risk of ventricular arrhythmias that lead to sudden death. In 2009, genetic data from 57 publications were collected in the arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) Genetic Variants Database (freeware available at http://www.arvcdatabase.info), which comprised 481 variants in eight ACM-associated genes. In recent years, deep genetic sequencing has increased our knowledge of the genetics of ACM, revealing a large spectrum of nucleotide variations for which pathogenicity needs to be assessed. As of April 20, 2014, we have updated the ARVD/C database into the ARVD/C database to contain more than 1,400 variants in 12 ACM-related genes (PKP2, DSP, DSC2, DSG2, JUP, TGFB3, TMEM43, LMNA, DES, TTN, PLN, CTNNA3) as reported in more than 160 references. Of these, only 411 nucleotide variants have been reported as pathogenic, whereas the significance of the other approximately 1,000 variants is still unknown. This comprehensive collection of ACM genetic data represents a valuable source of information on the spectrum of ACM-associated genes and aims to facilitate the interpretation of genetic data and genetic counseling.

Genetics of myocarditis in arrhythmogenic right ventricular dysplasia.

Myocarditis occasionally is related to arrhythmogenic right ventricular dysplasia (ARVD) and sometimes overlaps during the early stages, which may lead to misdiagnosis. Acute myocarditis may reflect an active phase of ARVD. The purpose of this study was to evaluate the genetic basis of myocarditis in ARVD and to investigate the association with a poorer prognosis and a higher risk of ventricular arrhythmias. Two groups were analyzed: group A, which consisted of 131 affected patients-84 with ARVD (62% male, age 45 years [range 33-55 years]) and 47 with left-sided forms (arrhythmogenic left ventricular dysplasia [ALVD]) (47% male, age 45 years [range 25-61 years]); and group B, which consisted of 64 nonaffected mutation-carrying relatives (36% male, age 42 years [range 22-56 years]; 23 from classic ARVD families and 41 from ALVD families). Seven patients (3.5%) presented with a clinical diagnosis of acute myocarditis over median follow-up of 34 months. Myocarditis was the first clinical presentation in 6 of 7 cases. In 2 patients, acute myocarditis preceded worsening of left ventricular systolic function. In 1 case, myocarditis was associated with an increased gadolinium pattern in cardiac magnetic resonance. Two patients presented with ECG changes weeks after myocarditis resolution. Myocarditis preceded the development of ventricular tachycardia in 2 other patients. Myocarditis clustered in families bearing DSP Q447* and LDB3 c.1051A>G. Acute myocarditis reflects an active phase of ARVD that leads to changes in phenotype and abrupt progression of the disease. An active phase should be suspected in a patient with myocarditis associated with a family history of ARVD. Certain mutations may increase the susceptibility to superimposed myocarditis in ARVD.

A systematic review of the association between obstructive sleep apnea and ventricular arrhythmias.

Obstructive sleep apnea (OSA) is an independent risk factor for sudden cardiac death. The aim of this review was to study the relationship between OSA and ventricular arrhythmias. PubMed, Medline, and Cochrane databases were searched with MESH headings to find studies linking OSA and ventricular arrhythmias including ventricular ectopy, ventricular tachycardia (VT), and ventricular fibrillation (VF). Studies were graded by a scoring system, and an attempt was made to pool data. There were no matched cohort or case control studies to study the association between OSA and ventricular arrhythmias. Given data heterogeneity, pooling and meta-analysis of data were not possible. An attempt was made to judge the quality of evidence and present a systematic review. Patients with OSA were noted to have higher odds of ventricular ectopy, and were at a higher risk for ventricular arrhythmias. Associations included higher QTc dispersion and HR variability. We did not, however, find any clear evidence for a direct correlation between increased apnea hypopnea index and increased VT or VF. Pooling and meta-analysis of studies linking OSA and ventricular arrhythmias were not possible due to heterogeneity of data. In a systemic review of studies, patients with OSA were noted to have higher odds of ventricular ectopy and arrhythmias. A single study showed that CPAP may help lower arrhythmogenicity; however, it was unclear if CPAP lowered the risk of VT. Further research should focus on studying the association of OSA and causes of sudden cardiac death, including ventricular arrhythmias.

23Association of TERC related genetic variation and telomerase activity with ventricular arrhythmias in ischaemic cardiomyopathy

Introduction: Implantable cardioverter defibrillators (ICD) reduce mortality in ischaemic cardiomyopathy patients at a high risk of ventricular arrhythmias (VA), which are the commonest cause of sudden death. However, ICDs are associated with morbidity and mortality. Importantly, 67% of patients never receive an appropriate shock after ICD implantation under current guidelines, suggesting a need for better risk stratification.Telomere and telomerase activity (TA) in leukocytes have recently been shown to correlate with biological ageing and pathogenesis of cardiovascular diseases. Telomerase maintains telomere length and is composed of a reverse transcriptase, TERT, and an RNA template, TERC. Evidence suggests that genetic variation in key genes has a key impact on TA. Association of SNP12696304 on chromosome 3q26 (at a locus that includes TERC) with telomere length has been shown. We investigated the association between genetic variation in SNP12696304 and leukocyte TA with incidence of VA in ischaemic cardiomyopathy patients. Methods: 90 ischaemic cardiomyopathy Caucasian patients with primary prevention ICDs were recruited. Genomic DNA was isolated from venous blood samples. TA was measured by the telomere repeat amplification (TRAP) protocol and genotyping done using Taqman SNP assay. Continuous data were compared by unpaired T-test and categorical data by Chi-square test. Logistic regression was used to determine correlation of genotype and TA with VA. Results: There was no significant difference in baseline demographics including age, WCC, gender, LVEF, GFR and follow up since ICD implant between patients with VA (Cases) and no-VA (Controls). The TA was significantly higher in the cases and correlated with incidence of VA (p-value 0.02). No significant correlation between the genotype and VA was identified (C/C OR 1; C/G OR 0.54, CI 0.21–1.417, p-value 0.343; G/G OR 0.80, CI 0.198–3.236, p-value 0.907). There was a significant correlation between risk of VA and TA increase in C/C genotype (OR7.5, CI1-56.6, p-value 0.04). This correlation was not significant in the G/G or C/G genotype as shown in Conclusion: There is a significant correlation between TA and VA in ischaemic cardiomyopathy patients. Moreover, homozygosity for C-allele of SNP12696304 (encoding TERC) signifcantly effects telomerase expression. Thus, increased TA predisposes individuals with C/C genotype to a higher incidence of VA. This needs to be validated in prospective studies for clinical use. ![Graphic][1] Figure 1 TA and genotype - cases vs controls [1]: /embed/inline-graphic-1.gif

Information provision, satisfaction and emotional distress in patients with an implantable cardioverter-defibrillator

The implantable cardioverter-defibrillator (ICD) is the treatment of choice for primary and secondary prevention of sudden cardiac death due to ventricular arrhythmias [ 1 Moss A. Hall W. Cannom D. et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. N Engl J Med. 1996; 335: 1933-1940 Crossref PubMed Scopus (3569) Google Scholar , 2 Bardy G.H. Lee K.L. Mark D.B. et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005; 352: 225-237 Crossref PubMed Scopus (5302) Google Scholar , 3 The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med. 1997; 337: 1576-1584 Crossref PubMed Scopus (3004) Google Scholar ]. Although the majority of patients adapts well to living with an ICD, 1 in 4 patients report anxiety and depression [ [4] Sears S.F. Conti J.B. Quality of life and psychological functioning of ICD patients. Heart. 2002; 87: 488-493 Crossref PubMed Google Scholar ]. Sufficient understanding of the reasons for ICD implantation, its benefits, side effects, and impact on daily life plays a major role in adaptation. Adequate information provision and psycho-education may facilitate adaptation and reduce emotional distress [ 5 Vazquez L.D. Conti J.B. Sears S.F. Female-specific education, management, and lifestyle enhancement for implantable cardioverter defibrillator patients: the FEMALE-ICD study. Pacing Clin Electrophysiol. 2010; 33: 1131-1140 Crossref PubMed Scopus (38) Google Scholar , 6 Dunbar S.B. Dougherty C.M. Sears S.F. et al. Educational and psychological interventions to improve outcomes for recipients of implantable cardioverter defibrillators and their families: a scientific statement from the American Heart Association. Circulation. 2012; 126: 2146-2172 Crossref PubMed Scopus (158) Google Scholar , 7 Dunbar S.B. Langberg J.J. Reilly C.M. et al. Effect of a psychoeducational intervention on depression, anxiety, and health resource use in implantable cardioverter defibrillator patients. Pacing Clin Electrophysiol. 2009; 32: 1259-1271 Crossref PubMed Scopus (81) Google Scholar , 8 Eads A.S. Sears S.F.J. Sotile W.M. Conti J.B. Supportive communication with implantable cardioverter defibrillator patients: seven principles to facilitate psychosocial adjustment. J Cardiopulm Rehabil Prev. 2000; 20: 109-114 Crossref Scopus (22) Google Scholar ]. Paradoxically, recent surveys indicate that many patients have insufficient knowledge about their ICD and associated challenges [ 9 Cinar F.I. Tosun N. Kose S. Evaluation of an education and follow-up programme for implantable cardioverter defibrillator-implanted patients. J Clin Nurs. 2013; 22: 2474-2486 Crossref PubMed Scopus (15) Google Scholar , 10 Groarke J. Beirne A. Buckley U.N.A. et al. Deficiencies in patients' comprehension of implantable cardioverter defibrillator therapy. Pacing Clin Electrophysiol. 2012; 35: 1097-1102 Crossref PubMed Scopus (23) Google Scholar ].

Heart rate variability parameters and ventricular arrhythmia correlate with pulmonary arterial pressure in adult patients with idiopathic pulmonary arterial hypertension

ObjectiveThis aim of this study was to correlate heart rate variability (HRV) parameters to pulmonary arterial pressure (PAP) in patients with purely idiopathic pulmonary arterial hypertension (IPAH). BackgroundHRV is decreased in patients with PAH. Whether HRV indices can be used to assess PAP in IPAH patients remains unclear. MethodsHRV parameters obtained by 24-h ECG were evaluated in 26 IPAH patients and 51 controls. ResultsTime-domain HRV parameters (SDNN, p < 0.0001; SDANN, p < 0.0001; RMSSD, p = 0.006) were lower in IPAH patients. Frequency-domain indices (high-frequency power, HFP, p = 0.001; low-frequency power, LFP, p = 0.003; total power, TP, p = 0.001) were also decreased in IPAH patients. In IPAH patients, RMSSD (p = 0.001), HFP (p = 0.015), and LFP (p = 0.027) were significantly correlated with PAP. IPAH patients had longer QTc intervals (p < 0.0001) and more premature ventricular contractions (p < 0.0001) than controls. ConclusionsIPAH is associated with autonomic dysfunction. RMSSD, HFP, and LFP may be used as a supplemental tool to assess PAP in IPAH patients. IPAH patients with autonomic dysfunction are at high risk for ventricular arrhythmia.

AB0862 Qt Dispersion and P Wave Dispersion in Fibromyalgia

BackgroundFibromyalgia syndrome is a chronic disease with unknown etiology, characterized by widespread pain. QT dispersion represents a general repolarization abnormality and autonomic dysfunction. Longer QT dispersion is associated with higher...

QT dispersion in HIV-infected patients receiving combined antiretroviral therapy.

A higher prevalence of QT prolongation has been reported among human immunodeficiency virus (HIV)-infected patients. Previous studies have demonstrated that QT dispersion is a better predictor of serious ventricular tachyarrhythmia and cardiac mortality than corrected QT (QTc) interval. However, data of QT dispersion in HIV-infected patients receiving a combined antiretroviral therapy (cART) is limited. We sought to assess QTc interval and QT dispersion in HIV-infected patients receiving cART. The association between QT parameters and heart rate variability (HRV) was also examined. Ninety-one HIV-infected patients receiving cART (male = 33, mean age = 44 ± 10 years) and 70 HIV-seronegative subjects (male = 25, mean age = 44 ± 8 years) were enrolled in the study. In a resting 12-lead electrocardiogram, QT interval was measured by the tangent method in all leads with well-defined T waves. The QT dispersion was defined as the difference between maximum and minimum QTc intervals in any of 12 leads. The baseline characteristics were not different between the two groups. We demonstrated the significantly longer mean QTc interval (420 ± 21 vs. 409 ± 21 ms, P < 0.001), and greater QT dispersion in HIV-infected group compared to the control group (85 ± 29 vs. 55 ± 23 ms, P < 0.001). Among the HIV-infected patients, those who had lower CD4 lymphocyte count (<350 cells/mm(3)) tended to have greater QT dispersion (92 ± 28 vs. 81 ± 29 ms, P = 0.098). There were no associations between QT parameters and either HRV or cART regimens. HIV-infected patients receiving cART were associated with prolonged QTc interval and increased QT dispersion, independent of autonomic dysfunction and antiretroviral drugs, which may have led to the potentially higher risk of ventricular arrhythmia and cardiac mortality.

Therapeutic management in Sicilian patients with definite arrhythmogenic right ventricular dysplasia/cardiomyopathy and focus on the role of implantable cardioverter-defibrillator therapy

Arrhythmogenic Right Ventrticular Dysplasia/Cardiomyopathy (ARVD/C) is an inherited cardiomyopathy characterized by right ventricular myocyte loss with fibrofatty replacement, a high risk of ventricular arrhythmias (VA) and sudden cardiac death (SCD) [1]. Prevention of SCD represents the most important management strategy and the achievement of this target can be reached by different therapeutic strategies including implantable cardioverter-defibrillator (ICD) implantation, pharmacologic therapy, catheter ablation of ventricular tachycardia (VT) and cardiac transplantation [2,3].

Novel approaches to the post-myocardial infarction/heart failure neural remodeling

The review aims to discuss the role of nerve growth factor (NGF) as a potential novel biomarker in post-myocardial infarction (MI) and in heart failure (HF), with a specific focus on neural remodeling and sprouting processes occurring after tissue damage. Many experimental data show that MI induces nerve sprouting, leading to increased sympathetic outflow and higher risk of ventricular arrhythmias and sudden cardiac death. In this framework, cardiac and circulating NGF might be an indicator of the innervation process and neural remodeling: it dramatically increases after MI, while it declines along with advanced HF and ventricular dysfunction. The bimodal behavior of NGF in acute and chronic settings leads to the speculation that NGF modulation may be a pharmacological target for intervention in different stages of the ischemic heart disease. Specifically, a fascinating possibility is to support or to inhibit NGF receptors, in order to prevent negative cardiac remodeling after MI and consequent ventricular dysfunction.

Abstract 18662: Frequency and Temporal Patterns of Implantable Cardiac Defibrillator Therapies in Patients With Left Ventricular Assist Devices

Background: Left ventricular assist device (LVAD) use is becoming increasingly common in patients with end-stage heart failure. These patients are at high risk for ventricular arrhythmias. The pattern of ICD therapies in these patients is not well characterized. Methods: Our single-center retrospective cohort included 86 patients with ICDs and LVADs followed at Emory University Hospital. Data collected included frequency of ICD therapies, type of therapy (appropriate vs. inappropriate; shocks vs. anti-tachycardia pacing (ATP)), and time-course of therapies. Results: 36 patients (42%) received ICD therapy during a mean follow-up period of 13.6 months. There were 105 episodes (2.9 episodes/patient) during which ICD therapies were delivered, with a total of 379 individual arrhythmias treated (3.6 arrhythmias per episode of therapy). 61.4% of therapies were appropriate, 8.4% were inappropriate, and 31.6% were unknown. Of the 79 episodes treated with appropriate therapy, 36 episodes (46%) required ICD shocks, whereas 43 episodes (54%) were treated with ATP alone. Overall, 33% of the total cohort and 81% of patients who received therapy received at least one ICD shock. Twenty-two patients (61%) received therapy between 1-3 times, while the remainder (14 patients, 39%) received therapy 3-10 times. Eighteen (17%) episodes occurred within the first month after LVAD implantation, with 10 (10%) occurring between 1-3 months, 53 (50%) occurring between 3-12 months, and 24 (23%) occurring more than one year after LVAD implantation. Conclusion: Analysis of our LVAD cohort revealed three important findings: 1. ICD therapy is very common (42%) in the first year after LVAD implantation; 2. Ventricular arrhythmias are highly clustered in this cohort; 3. ATP is frequently effective. These findings have important implications on device follow-up and programming for this expanding patient population.

Fragmented QRS complexes in adult patients with repaired tetralogy of fallot: a correlation study with cardiovascular magnetic resonance

Introduction: Tetralogy of Fallot (ToF) is the most frequent cyanotic congenital heart disease in adulthood and is associated with a higher risk of ventricular arrhythmias. Fragmented QRS (fQRS) reflects conduction delay caused by myocardial fibrosis and dysfunction and its analysis in ToF has recently been drawn to attention. Purpose: The aim of this study was to evaluate the association of fQRS to morphofunctional data obtained by cardiovascular magnetic resonance (CMR) in ToF patients (pts). Methods: Adult pts with surgically corrected ToF were included. All pts had contemporary ECG and CMR. fQRS was defined as the presence of >2 notches on the R/S wave, or the presence of > 1 R' (fragmentation) if QRS duration ≤120 mseg, in ≥ 2 contiguous leads. Results: 48 pts (30 women) were included, 31±9.5 years, follow-up time of 23±7 years since ToF repair; 24 pts had moderate to severe pulmonary regurgitation (PR). Late gadolinium enhancement (LGE) was present in the right ventricular (RV) wall in 44 pts. fQRS was present in 83% of pts. fQRS in the inferior leads was correlated to higher RV volumes (RV end-diastolic volume (RVEDV) (p 0.017), RV end-systolic volume (RVESV) (p 0.037], higher RVEDV/LVEDV ratio (p 0.022), and higher PR volume (p 0.022). Lateral fQRS complexes were associated to RVEDV > 150mL/m2 (X2 4.97, p 0.027) and to the presence of RVOT aneurysm (X2 6.4, p 0.012). Prolonged QRS duration correlated to higher ventricular volumes and lower ejection fraction: LVEDV (rho 0.307, p 0.036), LVESV (rho 0.442, p 0.002), LV mass (rho 0.457, p 0.001), LVEF (rho -0.457, p 0.001); RVEDV (rho 0.307, p<0.036), RVESV (rho 0.359, p<0.013), RVEF (rho -0.353, p 0.015). Pts with PR had longer QRS complexes (p 0.030) as well as did those with ascending aorta dilatation (AAD) (p 0.003). Length of cQT was positively correlated to LVESV (rho 0.378, p 0.01), LV mass (rho 0.316, p 0.031), to RVEDV (rho 0.512, p<0.001), RVESV (rho 0.559, p<0.001), ratio RVEDV/LVEDV (rho 0.513, p<0.001), PR volume (rho 0.494, p 0.002), and was negatively correlated to both LVEF (rho -0.496, p<0.001) and RVEF (rho -0.471, p<0.001). cQT was longer in pts with PR (p<0.001) and in those with AAD (p 0.045). Conclusion: In our population, fQRS complexes were present in the vast majority of patients and were associated to higher RV volumes, an established marker of prognosis, but not with fibrosis or ventricular function. QRS duration and cQT should not be forgotten in the ECG analysis, since they have strong correlations not only to ventricular morphofunctional data, but also with the presence of moderate to severe pulmonary regurgitation and ascending aorta dilatation.

Role of Implantable Cardioverter-Defibrillators in Patients With Continuous Flow Ventricular Assist Devices

The management of advanced heart failure has been transformed in the past 2 decades by the advent of cardiac implantable electronic devices, such as implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy, and more recently the left ventricular assist device (LVAD). All 3 of these devices have been found to improve survival in patients with advanced heart failure.1–6 Cardiac resynchronization augments cardiac output by coordinating the timing of intrinsic muscular contraction to enhance its efficiency in patients with preexisting dyssynchrony. After LVAD placement, the contribution of native LV activity may be negligible, so that continued LV pacing likely does not significantly enhance cardiac function. However, LVAD recipients remain at high risk for ventricular arrhythmias (VAs) that may adversely affect right ventricular function, preload, and cardiac output. VAs (including ventricular fibrillation) are often tolerated for prolonged time periods in LVAD recipients, permitting patients to seek medical care when symptoms are present. In this setting, the incremental survival benefit of ICDs and LVADs in combination is not clear and, indeed, controversial. Enriquez et al7 report important data in this edition of Circulation Arrhythmia and Electrophysiology . This article is the largest study so far to examine this question in patients receiving the most commonly implanted LVAD at this time, and the only device Food and Drug Administration approved for bridge to transplant and destination therapy, the Heartmate II continuous flow device. Article see p 668 The investigators report the clinical outcomes and survival of a cohort of 106 patients, the majority of whom received an LVAD as bridge to cardiac transplantation. Patients surviving <30 days after implant were excluded, but are referenced separately in the article. After LVAD implantation, 36.7% of patients did not have …

N-3 Fatty acids and cardiovascular disease: the story is not over yet

A large body of evidences suggest a beneficial role of n-3 poly-unsaturated fatty acids (n-3 PUFAs) on cardiovascular disease, but recent observations and meta-analyses have raised doubts on their real efficacy. Many of these analyses, however, should be interpreted with caution, because of methodological shortcomings, heterogeneity of population, variability of drug dose and composition and other interpretation issues, and are not able to convincingly confute the results of the major clinical trials. Indeed, they demonstrated the efficacy of n-3 PUFAs at least in particular subset of individuals, such as post-acute myocardial infarction patients, at high risk of ventricular arrhythmias. The utilization of n-3 poly-unsaturated fatty acids in the current clinical practice should not be withheld, yet.

Controversy surrounding the best time for ICD implantation after myocardial infarction

Controversy surrounding the best time for ICD implantation after myocardial infarction