Sinus Rhythm Research Articles

Feasibility of Atrial Substrate Mapping During Atrial Pacing and Its Impact on the Omnipolar Voltage and the Peak-Frequency of Electrograms.

Atrial pacing maps are often used as substitutes for sinus rhythm (SR) maps to expedite mapping procedures. However, the impact of this method on electrophysiological parameters has not been systematically examined. This study aimed to elucidate the advantages and limitations of atrial pacing maps. In 21 patients undergoing catheter ablation for atrial fibrillation, left atrial (LA) substrate maps using an HD-grid catheter were performed during SR, and pacing from the sinus-node region with cycle lengths (CLs) of 300 ms (SN-P300) and 600 ms (SN-P600). Mapping time, omnipolar voltage, peak-frequency of electrograms, and global LA activation time were compared among the three maps. The SR-map more frequently required automap-setting changes (p < 0.01), and one SR-map was not completed due to CL-fluctuation. Compared to SR, mapping time significantly decreased (833 [702-1097] seconds for SR vs. 615 [530-700] seconds for SN-P600 and 463 [404-542] seconds for SN-P300, p < 0.01). Mean voltage and peak-frequency of electrograms significantly decreased in SN-P600 and SN-P300 (mean voltage: 2.5 [2.1-3.2] mV for SR vs. 2.3 [2.1-2.8] mV for SN-P600 and 2.2 [2.0-2.7] mV for SN-P300, p < 0.01; mean peak-frequency: 308 [299-325] Hz for SR vs. 303 [288-314] Hz for SN-P600 and 281 [258-295] Hz for SN-P300, p < 0.01). The wavefront collision site shifted in 3/20 (15%) between SR and SN-P600, remaing within 30° along the mitral annulus, but this shift reached 9/20 (45%) between SR and SN-P300, including one patient showing a shift up to 60°. SN-P maps provide faster, higher-resolution substrate maps, but the amplitude and frequency of electrograms may be reduced as the CL shortens. Maps with SN-P600 may be acceptable, maintaining electrophysiological information in SR.

Comparison of Del Nido and histidine-tryptophan-ketoglutarate cardioplegia solutions: an animal study with prolonged ischaemia

ObjectiveMyocardial protection is important for a successful procedure cardiac surgery, and the key element of myocardial protection is cardioplegia. We compared Del Nido cardioplegia (DN) and Bretschneider histidine-tryptophan-ketoglutarate cardioplegia (HTK) regarding cardioprotective effects in a porcine model of prolonged ischaemia.MethodsLandrace pigs weighing 50–60 kg were randomized to receive either DN (n = 9) or HTK (n = 9). All pigs underwent cardiac arrest for 90 min followed by 120 min of reperfusion/convalescence. A detailed set of laboratory, histological and functional parameters was acquired at baseline, during cardiac arrest and following reperfusion/convalescence.ResultsPressure-volume measurements revealed better systolic and diastolic left ventricular performance in DN as compared to HTK (both p &amp;lt; 0.05). Haemoglobin decreased after application of the cardioplegic solution. The decrease was more pronounced in the HTK group than in the DN group (p &amp;lt; 0.01). In contrast to DN, sodium (p &amp;lt; 0.01) and chloride levels (p &amp;lt; 0.05) were significantly decreased in the HTK group after initiation of CPB and remained decreased after reperfusion. The number of animals requiring defibrillations to restore sinus rhythm significantly differed between the groups [HTK: 100% (n = 9/9) vs. DN: 44.4% (n = 4/9), p = 0.03]. Expression of ICAM-1 as a marker of endothelial dysfunction was lower in the DN group compared to the HTK group (p = 0.02). Histological evaluation, oxidative and nitrosative stress, mitochondrial membrane integrity and apoptosis markers were comparable between DN and HTK groups (all p &amp;gt; 0.05).ConclusionsIn this porcine model with prolonged ischaemia, DN was superior to HTK in terms of haemoglobin levels, blood electrolytes, spontaneous return of sinus rhythm, left ventricular function, and endothelial injury. Histomorphological parameters indicative of ischaemia/reperfusion injury, oxidative stress and mitochondrial function as well as apoptosis-inducing factors did not differ.

Approach to the Diagnosis and Management of Complex Fascicular Ventricular Tachycardias.

Complex ventricular tachycardias involving the fascicular system (fascicular ventricular tachycardias [FVTs]) can be challenging. In this review, we describe our approach to the diagnosis and ablation of these arrhythmias with 10 illustrative cases that involve (1) differentiation from supraventricular tachycardia; (2) assessment for atypical bundle branch reentry and other interfascicular FVTs; (3) examination of P1/P2 activation sequences in sinus rhythm, pacing, and tachycardia; and (4) entrainment techniques to establish the tachycardia mechanism and aid circuit localization. To summarize, 5 cases had prior ablation with 2 previously misdiagnosed as supraventricular tachycardia. A short His-ventricular interval supported ventricular tachycardia. Atrial stimulation could initiate and entrain 4 FVTs. P1 potentials were recorded in all cases of left posterior FVT. Entrainment at P1 and P1 to P2 connection sites at the mid-septal region, and the postablation emergence of a late P1 with decremental properties, is consistent with the left septal fascicle being the slowly conducting, retrograde limb of the left posterior FVT circuit. Ablation targeting the mid-septal left septal fascicle and P1 to P2 connection sites successfully eliminated left posterior FVT. Right ventricular apical pacing was useful in differentiating bundle branch reentry and focal FVTs from reentrant FVTs. Two cases exhibited bundle branch reentry and other interfascicular FVTs. Three cases were postinfarct FVTs involving the LPF, where pacing and entrainment at sites of conduction system potentials were able to localize sites critical for ablation, in contrast to previously unsuccessful substrate modification. In conclusion, several ventricular tachycardia mechanisms involving the fascicular system can occur in both structurally normal and abnormal hearts. A high index of suspicion is required given their rarity and potential for misdiagnosis. Once identified, we emphasize a structured approach to the diagnosis and management of FVTs to confirm the mechanism and localize suitable ablation targets involving careful recording of conduction system potentials and pacing/entrainment maneuvers.

Atrial Lesion and Diastolic Dysfunction May Be Associated With Atrial Fibrillation in Patients With Cardiac Amyloidosis.

Atrial fibrillation (AF) is a common arrhythmia associated with cardiac amyloidosis (CA). Diastolic dysfunction and atrial lesions have been reported in patients with AF fibrillation. We aimed to evaluate the diastolic function and atrial lesions in patients with CA and AF. We included 27 patients (mean age 72 years) with biopsy-confirmed CA. We analyzed the average E/e' as diastolic function using echocardiography and atrial late gadolinium enhancement (LGE) as an atrial lesion using cardiac magnetic resonance imaging (CMRI). We compared these parameters among 20 patients with sinus rhythm (SR) and 7 with AF. Echocardiography examination showed that average E/e' were larger in the AF group than in the SR group (average E/e': AF, 21.3 [14.5-30.3]; SR, 14.2 [10.3-16.9]; P=0.0053). CMRI demonstrated that atrial LGE was more severe in the AF group than in the SR group (AF, 7/7 [100%]; SR, 11/21 [52.4%]; P=0.00228). Univariate logistic regression analysis showed that average E/e' demonstrated significant association with AF in all patients (odds ratio 1.24; [95% confidence interval 1.03-1.51]; P=0.0251). AF may be associated with atrial lesions and diastolic dysfunction in patients with CA.

Characterization of Myocardial Recovery in Patients With Tachycardiomyopathy.

The degree and time course of improvement in left ventricular (LV) function with treatment in patients with tachycardiomyopathy (TCMP) is highly variable. This study aims to clinically characterize the recovery of TCMP based on the extent and course of improvement in LV function and identify predictors of complete myocardial recovery. In this prospective, single-center, observational study, patients with suspected TCMP who underwent successful tachyarrhythmia termination/control were included. Clinical and echocardiographic assessment of LV function was done at baseline, within 1 h after tachyarrhythmia termination, 24 h later, and at 12 weeks follow-up. Ninety-nine patients were enrolled in the study. Six patients had immediate normalization of LV ejection fraction (LVEF) with reversion to sinus rhythm and were labeled as "pseudo-TCMP"; the remaining 93 patients were included in the analysis. Based on complete versus partial normalization of LVEF at 12-week follow-up, 50 patients (53.8%) were labeled as completely recovered TCMP and 43 (46.2%) as partially recovered TCMP respectively. Causative arrhythmias included atrial fibrillation (38%), focal atrial tachycardia (28%), atrial flutter (22%), ventricular arrhythmias (11%), and orthodromic re-entrant tachycardia (2%). The LVEF at presentation was 0.25 ± 0.05 which improved to 0.36 ± 0.11 within 1 h after tachycardia termination (p < 0.0001), 0.41 ± 0.14 24 h later (p = 0.009) and to 0.52 ± 0.12 at 12 weeks follow-up (p < 0.0001). Male gender was the only differentiating statistically significant variable between completely recovered and partially recovered TCMP, 24 (48%) versus 30 (69.7%) respectively (p = 0.0339). Nearly half of the TCMP patients have complete recovery of LV function at 12 weeks follow-up, while the other half have a partial recovery only. There was no robust predictor of complete myocardial recovery.

Atypical presentation of Andersen-Tawil syndrome: heart failure with reduced ejection without periodic paralysis or dysmorphic features

Background: Andersen-Tawil syndrome (ATS) is a rare autosomal dominant disorder caused by variants in the KCNJ2 gene. It is associated with periodic paralysis, dysmorphic features and cardiac arrhythmias. The syndrome exhibits incomplete penetrance, leading to a broad spectrum of clinical manifestations, making diagnosis challenging. Case description: A male in his mid-20s with class 3 obesity presented to the emergency department with a week-long history of worsening chest pain, orthopnoea and fatigue. His family history was significant for sudden cardiac death affecting both his mother and brother, with his father having died from complications of Wolff-Parkinson-White syndrome. Cardiovascular examination revealed an S3 heart sound and elevated brain natriuretic peptide levels at 875 pg/ml, with undetectable troponins; potassium level on admission was 3.6 mEq/l. An electrocardiogram showed normal sinus rhythm, first-degree heart block, left atrial enlargement, left bundle branch block and a prolonged QTc of 486 ms. A transthoracic echocardiogram demonstrated a 15-20% reduction in ejection fraction with global left ventricular hypokinesis and left atrial enlargement. Ultimately, he was diagnosed with non-ischaemic dilated cardiomyopathy and referred for genetic testing, which revealed a KCNJ2 variant. Shortly after discharge, he experienced a 55-second run of ventricular tachycardia, necessitating the placement of a single-chamber ICD. Currently, the patient remains on guideline-directed medical therapy and is listed for a heart transplant. Conclusions: Dilated cardiomyopathy, although a rare manifestation in ATS, can profoundly increase the risk of fatal arrythmias, necessitating the need for a low threshold of suspicion, to ensure timely diagnosis and management.

Cardiac rhythm and conduction disturbances in children with bradyarrhythmias during long-term ECG monitoring

The syncope in children with bradyarrhythmias can be life-threatening and their differentiation is important in the evaluation of any child with syncope. In children risk factors for the poor prognosis and progression of bradyarrhythmias leading to the development of arrhythmogenic syncope have not been definitively determined. The aim was to determine the diagnostic significance of the implantable cardiac monitors (ICM) method and identify electrocardiographic and electrophysiological predictors of the development of syncope in children with bradyarrhythmias. Material and methods. The authors analyze the group of 191 children with bradyarrhythmias, recurrent syncope and ICM. The examination of patients included electrocardiography (ECG), echocardiography (ECHO-CG), Holter monitoring (HM) of rhythm, electrophysiological study (EHS), exercise test, and analysis of family anamnesis data. Results. 96 out of 191 children had positive result of long-term cardiac monitoring. 16 out of 96 children had structural heart deseases – congenital heart defects, cardiomyopathies. Episodes of arrhythmias were documented in 30% of children during syncope and asymptomatic arrhythmias were observed in 43% of children. Arrhythmogenic syncope accounts for 7,5% of all registered syncope and 5% of positive monitoring results. Sinus rhythm during syncope was registered in 48% of children, and 2% of patients had a combination of arrhythmogenic and non-arrhythmogenic syncope. The heart rhythm characteristics of standard ECG and HM in patients with symptomatic arrhythmias did not differ significantly from either patients with asymptomatic episodes of arrhythmias or patients with sinus rhythm during syncope. Conclusion. The diagnostic significance of the ICM for identifying the cause of recurrent syncope in children with bradyarrhythmias is 50%. Arrhythmogenic genesis of syncope has been confirmed in 7.5% of children with bradyarrhythmias. The heart rate characteristics and electrophysiological parameters of the previous examination are not predictors of the development of syncope in children with bradyarrhythmias. Long-term cardiac monitoring of ICM can identify children with life-threatening arrhythmogenic syncope from all patients with bradyarrhythmia and make the prevention of sudden cardiac death (SCD).

In Vivo Mapping of Human Ventricular Fibrillation in Brugada Syndrome: The Role of Repolarization Heterogeneity.

Brugada syndrome (BrS) is associated with ventricular fibrillation (VF). Different VF mechanisms have been described, and repolarization gradients were associated with VF in a BrS model. The aim of this study is to map VF in BrS with ECG imaging. Furthermore, spatial correlation between sinus rhythm maps and VF maps was evaluated. Inclusion criteria were (1) BrS diagnosis and (2) VF mapped with ECG imaging during right ventricle outflow tract ablation. VF mechanism was classified into (1) rotational, (2) focal, and (3) irregular. For comparison, 6 controls were enrolled. The following sinus rhythm maps were performed: activation, recovery time, and activation-recovery interval time. Spatial overlap between steep repolarization gradients (cliffs) at recovery time and activation-recovery interval time maps and initiating VF rotational activity was evaluated with photogrammetry. A total of 28 VF maps in 21 patients with BrS were analyzed. In the first ≈7 seconds of VF, rotational, focal, and irregular mechanisms were found. In 19 patients with BrS (90.5%) and none of the controls, a right ventricle outflow tract repolarization cliff only was found. In all these patients, the singularity point of the first initiating rotational VF activity spatially overlapped with the right ventricle outflow tract cliff. Abolition of right ventricle outflow tract repolarization cliffs was confirmed in all but 2 patients (94.3%). In one patient with recurrence, VF was mapped on the anterior right ventricle over a cliff that was not targeted at the first ablation procedure. In patients with BrS, repolarization heterogeneity has a critical role in VF. Repolarization cliffs might be a therapeutic target in VF ablation.

Atrial fibrillation and risk of cognitive impairment and dementia: Relationships, potential mechanisms, and current therapies

Atrial fibrillation (AF), cognitive impairment, and dementia are significant health concerns. The prevalence and incidence of AF have been increasing and are expected to increase continuously in the future. In recent years, emerging evidence has indicated that AF, cognitive dysfunction, and dementia are associated with one another. Given the global increase in individuals who are at risk for AF, a greater focus is needed on the primary and secondary prevention of cognitive impairment and dementia in high-risk groups. Although earlier studies hypothesized that ischemic stroke is the main cause of cognitive impairment and dementia in patients with AF, recent studies have demonstrated that AF may contribute to cognitive impairment in the absence of stroke through other mechanisms. To date, various pathomechanisms have been proposed to explain the association between AF and cognitive decline, including overt ischemic stroke, silent cerebral infarctions, impaired cerebrovascular reactivity, decreased cerebral blood perfusion, neuroinflammation, microbleeds, and shared risk factors. However, a complete understanding of these mechanisms remains elusive. In addition, whether treatments targeting AF, including anticoagulation and rhythm control strategies, can avert cognitive decline and dementia has great clinical implications. To pave the way for targeted effective interventions for cognitive protection, we provide an overview of the association between AF and cognitive impairment and the potential mechanisms underlying this association. In addition, the effectiveness of AF-related treatment strategies, including anticoagulation, sinus rhythm restoration through elective cardioversion and catheter ablation, for cognitive protection in patients with AF is also discussed in this review.

Port-access Totally Thoracoscopic Atrial Fibrillation Procedure: Epicardial Isolations and Left Atrial Appendage Stapler-closure

Minimally invasive heart surgery is developing to treat non-valvular atrial fibrillation, which can achieve rhythm-control and prevention of cardiogenic thromboembolisms. Our procedure is a port-access totally thoracoscopic technique: radio-frequency bipolar endoscopic clamp-isolators and pen-coagulator perform endocardial isolations of the left atrium and superior vena cava and an endoscopic stapler removes the left atrial appendage. This communication briefly explains the procedural indications, clinical settings, surgical technique (and its tips and pitfalls) and medication protocols associated with the operative course. The clinical outcomes, which were published before, are shared and the procedural characteristics, such as extensive clamp-isolations which can exclude important ganglionated plexi on the left atrium, is discussed. Our port-access totally thoracoscopic procedure for treatment of non-valvular atrial fibrillation is a promising minimally invasive choice, which can satisfactorily maintain sinus rhythm and prevent cardiogenic stroke.Central Message: Our port-access thoracoscopic technique for surgical treatment of non-valvular atrial fibrillation consisting of epicardial isolations and left atrial appendage resection is explained.

Evaluation of the efficacy and safety of acupuncture assisted treatment for atrial fibrillation: A systematic review and meta-analysis based on randomized controlled trials.

To systematically evaluate the efficacy and safety of acupuncture in the treatment of atrial fibrillation (AF). Eight databases were searched. The search time limit is from January 2000 to November 2023. All randomized controlled trials on acupuncture treatment of AF were included. After the literature screening, data extraction and quality evaluation were carried out independently according to the inclusion and exclusion criteria, and the included literature was analyzed by Meta using RevMan 5.4 software. A total of 15 research studies on randomized controlled trials were included, involving 1960 patients. The results of the meta-analysis showed that acupuncture therapy could increase the sinus cardioversion rate of patients with AF, and the difference was statistically significant (relative risk = 1.21, 25% confidence interval (CI) [1.11, 1.31], P < .001). The clinically effective rate of the acupuncture plus drug treatment group was higher than that of the drug treatment group (relative risk = 1.32, 95% CI [1.19, 1.46], P < .01). Acupuncture plus other conventional therapies treatment was more helpful in reducing the ventricular rate of patients with AF (mean difference = -7.89, 95% CI [-14.52, -1.26], P = .006). The cardioversion time of patients with AF treated with acupuncture plus conventional therapies was shorter than those treated with traditional therapies alone (standardized mean difference = -1.82, 95% CI [-3.28, -0.35], P = .01). No severe adverse reactions such as hemorrhage, hematoma, or local infection caused by acupuncture were reported in the study. The available evidence shows that acupuncture can effectively improve the total clinical effective rate and sinus rhythm recovery rate, shorten the recovery time of sinus rhythm, and reduce the ventricular rate, and there are no apparent adverse reactions. However, a limited number of studies may affect the generalizability of the findings. Future studies should include more extensive and diverse studies to enhance the power and generalizability of the findings.

A single-center trial ofelectrographic flow mapping and concomitant voltage mapping in sinus rhythm and atrial fibrillation (FLOW EVAL-AF).

Electrographic flow (EGF) mapping reconstructs atrial electrical wavefront propagation, potentially revealing sources of atrial fibrillation (AF). Electrographic flow consistency (EGFC) measures the concurrence of wavefront patterns and may provide insights into atrial substrate health. This study aimed to compare EGF patterns during atrial fibrillation (AF) with sinus rhythm (SR) and explore the correlation between EGFC and regional bipolar voltage. In this single-center, prospective study, AF patients underwent mapping of the atria using bipolar voltage and EGF mapping. Mapping was performed during both AF and SR using a 16-electrode grid catheter (bipolar mapping) and a 64-pole basket catheter (EGF mapping). EGFC was computed as the average modulus of individual EGF vectors, reflecting flow pattern consistency. Ten patients were enrolled. EGF identified 11 sources with a mean source activity of 32 ± 9% during AF. Eight out of eleven sources in AF converted to passive "sinks" when mapped in SR. EGFC was significantly lower during AF compared to SR (0.74 ± 0.14 vs 1.0 ± 0.11 AUs, P < 0.01), consistent with EGFC quantifying the more chaotic wavefront propagation during arrhythmia. No spatial correlation between areas of high EGFC during AF and SR was observed. EGFC correlated with bipolar voltage across rhythms and atria (r = 0.647, P < 0.0001). EGF patterns varied by rhythm with AF showing lower EGFC values. EGFC correlated with bipolar voltage across rhythms and atria, suggesting its potential as an atrial myopathy marker akin to high-density voltage mapping and offering insights into atrial substrate health. Trial registration ClinicalTrials.gov Identifier: NCT06260670.

Characterisation of patients who develop atrial fibrillation-induced cardiomyopathy

IntroductionAtrial fibrillation (AF)-induced cardiomyopathy (AIC) is retrospectively defined after normalisation of left ventricular ejection fraction (LVEF) in sinus rhythm. It is unclear why some patients develop AIC.HypothesisPatients with AIC have...

The value of Hendry’s Score in predicting reduced ejection fraction in chronic heart failure patients with sinus rhythm

Objectives: To evaluate the role of Hendry’s score based on the electrocardiogram in predicting heart failure with reduced ejection fraction. Methods: This is a cross-sectional study, including 91 inpatient heart failure patients at the Vietnam Heart Institute, divided into two groups: heart failure with reduced left ventricular ejection fraction (EF ≤ 40 %) and heart failure with preserved left ventricular ejection fraction (EF ≥ 50%). The collected information included the general characteristics of the disease group (age, gender, etiology, clinical symptoms), blood test NT-proBNP, creatinine, electrolytes, echocardiogram, and electrocardiogram. Results: Forty-seven people were diagnosed with HFpEF, and 44 suffered from HFrEF. Multiple logistic regression analysis revealed certain ECG variables that were independent predictors of HFrEF, i.e., left atrial hypertrophy (LAH), QRS duration &gt; 100 ms, right bundle branch block (RBBB), ST-T segment changes, and prolongation of the QT interval. Based on Hendry’s Score, we obtained a score for HFpEF of -1 to +3. At the same time, HFrEF had a score of +4 to +6 with 81.3% sensitivity, 84% specificity, a 70.5% positive predictive value, an 87.2% negative predictive value, and an accuracy of 86%. Conclusions: The scoring system derived from this study, including the presence or absence of LAH, QRS duration &gt; 100 ms, RBBB, ST-T segment changes, and prolongation of the QT interval can be used to predict the type of HF with satisfactory sensitivity and specificity.

Accelerated atrial pacing reduces left-heart filling pressure: a combined clinical-computational study.

Accelerated atrial pacing offers potential benefits for patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF), compared with standard lower-rate pacing. The study investigates the relationship between atrial pacing rate and left-heart filling pressure. Seventy-five consecutive patients undergoing catheter ablation for AF underwent assessment of mean left atrial pressure (mLAP) and atrioventricular (AV) conduction delay (PR interval) in sinus rhythm and accelerated atrial pacing with 10 bpm increments up to Wenckebach block. Computer simulations (CircAdapt) of a virtual HFpEF cohort complemented clinical observations and hypothesized the modulating effects of AV coupling and atrial (dys)function. In the study cohort, 49(65%) patients had a high HFpEF likelihood (H2FPEF ≥ 5.0), and 28(37%) an elevated mLAP ≥ 15 mmHg at sinus rhythm. Optimal pacing rates of 100 [70-110]bpm (median [IQR]) significantly reduced mLAP from 12.8 [10.0-17.4]mmHg in sinus rhythm (55 [52-61]bpm) to 10.4 [7.8-14.8]mmHg (P < .001). Conversely, higher pacing rates (130 [110-140]bpm) significantly increased mLAP to 14.7 [11.0-17.8]mmHg (P < .05). PR interval and, hence, AV conduction delay prolonged incrementally with increasing pacing rates. Simulations corroborated these clinical findings, showing mLAP reduction at a moderately increased pacing rate and a subsequent increase at higher rates. Moreover, simulations suggested that mLAP reduction is optimized when AV conduction delay shortens with increasing rate. Accelerated pacing acutely reduces left-heart filling pressure in patients undergoing AF catheter ablation and computer simulations with HFpEF features, suggesting it as a potential therapeutic strategy to alleviate congestion symptoms. Virtual HFpEF patient cohorts hypothesize that AV sequential pacing may further optimize this therapy's beneficial effects.

PRECORDIAL THUMP AS A LIFE-SAVING RESUSCITATION MEASURE IN OBESE PATIENTS DURING OUT-OF-HOSPITAL CARDIAC ARREST

Introduction: The precordial thump (PT) was until recently recognized as a life-saving measure for confirmed and monitored shockable rhythm cardiac arrest (CA) cases when a defibrillator is not immediately vailable, but cardiopulmonary resuscitation guidelines no longer mention it. Objectives: We present the PT as a life-saving measure during CA in obese patient. Case report: The emergency medical team intervened on a 69-year-old man, with, complaining of chest pain lasting &gt;1h. He was dyspneic, pale and clammy skin. RR 18/min, SatO2 89%, HR 76 bpm, BP of 80/50 mmHg. ECG: anterior ST elevation myocardial infarction with right bundle branch block. He was allergic to aspirin. He was treated with 180mg of oral ticagrelor, a 500ml saline solution IV and 4 l/min O2 by mask and then went into CA. Before the defibrillator became available, patient was treated with three PTs, an oropharyngeal airway placement, bag valve mask ventilation with 100% oxygen and the initiation of chest compressions. When the biphasic defibrillator arrived, the monitor showed coarse ventricular fibrillation. One DC shock with 200J of energy was delivered. After the shock, the patient regained consciousness, a pulse and spontaneous breathing. The ECG monitor showed a sinus rhythm of 143 bpm, BP 80/50 mmHg, and SatO2 89%. Conclusion: Although CPR guidelines no longer mention the PT, the question remains whether it could be an initial life-saving procedure during CA in obese patients.

Risk Factors for Recurrence of Atrial Fibrillation within 3 Years after Radiofrequency Ablation

Background: Atrial fibrillation is chronic cardiovascular disease, particularly in older patients. Radiofrequency ablation can successfully treat this condition and restore sinus rhythm. However, the postoperative recurrence rate is relatively high. This investigation aimed to address the factors that might increase the risk of recurrence after radiofrequency ablation. Methods: We studied patients who had a successful radiofrequency ablation in our center between 2017 and 2020. We collected information about these patients before the procedure, including their age, sex, obesity, medical history, preoperative laboratory test results, and cardiac ultrasound findings. We divided patients into two groups: those who had atrial fibrillation again within three years and those who did not. We compared the information we collected about these two groups to see if there were any differences to explain why some people had atrial fibrillation again and others did not. We used a statistical method called multivariate logistic regression to analyze these data. Results: After reviewing the patients based on specific criteria, we included 297 patients in our final analysis. Within three years after surgery, 109 patients (36.7%) had a recurrence, whereas 188 (63.3%) did not. When we compared the two groups, we found that older patients, those with obesity, a longer history of atrial fibrillation, a larger left atrium, persistent atrial fibrillation, and higher levels of C-reactive protein before surgery were likely to have atrial fibrillation again within three years (p &lt; 0.05). Our statistical analysis revealed that these factors were independent predictors of atrial fibrillation recurrence. Conclusions: Age, obesity, duration of atrial fibrillation, the size of left atrium, the type of atrial fibrillation, and C-reactive protein (CRP) levels before surgery are closely related to atrial fibrillation recurrence within 3 years after radiofrequency ablation.

The feasibility of a serial 12‑lead ECG wireless patch in the hospital setting

BackgroundChest pain is the second most common reason to present to the emergency department in the United States, and the ECG is a first-line diagnostic tool for myocardial ischemia assessment. For patients with ongoing symptoms or unclear initial ECGs, guidelines recommend performing multiple standard ECGs at 15–30-min intervals during the first 1–2 h, which improves acute coronary syndrome (ACS) detection by 15 % and accelerates triage of high-risk ACS patients. However, obtaining serial ECG is not consistently practiced due to overcrowding and the limited technical abilities of current 12‑lead ECG machines. This study aimed to evaluate an FDA-approved wireless 12‑lead ECG patch for serial cardiac monitoring in the hospital setting. MethodsProspectively, ECG patch was applied in the Mason-Likar electrode configuration after obtaining consent. The patch remained in place for at least one hour. Clinical Utility of the ECGs was categorized from 1 to 3: 1 = uninterpretable, 2 = borderline, and 3 = interpretable. ResultsAmong hospitalized cardiac patients, 28 consented to wear the ECG patch for at least one hour and patients were free to ambulate during the study. Most (70 %) patients were in sinus rhythm, and an episode of asymptomatic TMI was captured. The clinical utility of the ECGs (n = 364) was mostly interpretable, 64 % (n = 231), while 15 % (n = 55) were uninterpretable and 18 % (n = 65) were borderline. Most (69 %) preferred the patch, while 12 % preferred telemetry. The hospitalized cardiac patients reported significantly better ability to ambulate with the ECG patch (Z = −3.607, p < 0.001). ConclusionThus, this experiment demonstrated that the ECG patch provides quality serial ECG monitoring and captures TMI of hospitalized cardiac patients without increasing burden.

Maintenance of Sinus Rhythm Is Associated With Lower Incidence of Stroke in Patients With Drug-Refractory Atrial Fibrillation.

Recent studies have demonstrated that early rhythm control for first-line treatment of atrial fibrillation (AF) improved cardiovascular outcomes. However, there is limited data regarding the long-term outcome of patients who failed antiarrhythmic drugs and who refuse radiofrequency catheter ablation (RFCA). Patients with AF who were refractory to antiarrhythmic drugs and had refused further rhythm control attempts via RFCA were retrospectively identified and propensity-score (PS) matched with thosewho had been treated with RFCA. The primary outcome of interest was all-cause mortality or ischemic stroke. A total of 169 patients who refused rhythm control with RFCA and PS matched 169 patients who had been treated with RFCA were included for analysis. During a mean follow-up of 4.3 (2.3;6.9) years, maintenance of sinus rhythm was more achieved in RFCA group (7 [4.1%] in Refuse group vs. 133 [78.7%] in RFCA group, p < 0.001). The incidence of ischemic stroke was significantly higher in patients who refused RFCA compared with patients who underwent RFCA (2.96 per 100 person-years in the Refused group vs. 0.74 per 100 person-years in the RFCA group, log-rank p < 0.001), but all-cause mortality was not significantly different (log-rank p = 0.8). Refusal of attempted rhythm control via RFCA was an independent risk factor for ischemic stroke on multivariate Cox analysis (hazard ratio [HR] 3.2; 95% confidence interval [CI] 1.2-8.53, p = 0.02). In patients with antiarrhythmic drug-refractory AF, the risk of stroke was significantly higher in patients who refused rhythm control via RFCA compared with that of those treated with RFCA.

Impact of implantable cardioverter defibrillators on mortality in heart failure receiving quadruple guideline-directed medical therapy: a propensity score-matched study

BackgroundIn the contemporary management of heart failure with reduced ejection fraction (HFrEF), the recommended quadruple guideline-directed medical therapy (GDMT) consists of angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter-2 inhibitors (SGLT-2i). This study explored the impact of adding implantable cardioverter-defibrillator (ICD) therapy to this comprehensive regimen in HFrEF patients.MethodsUtilizing deidentified data from the National Electronic Database of the Turkish Ministry of Health, we conducted a nationwide retrospective cohort study on 5450 HFrEF patients receiving quadruple GDMT, including ARNI. Among them, 709 patients underwent additional ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Propensity score matching ensured balanced baseline characteristics between groups. Primary endpoint was determined as all-cause mortality.ResultsIn the matched cohort, all-cause mortality occurred in 108 out of 619 patients (17.4%) in the GDMT group and 101 out of 619 patients (16.3%) in the ICD group, with a hazard ratio (HR) of 0.74 and a 95% confidence interval (CI) ranging from 0.57 to 0.98. The median follow-up time was 1365 days in the matched cohort, 1283 days in the GDMT group. Subgroup analyses consistently demonstrated benefits, particularly among individuals aged 61 years and older (HR: 0.60, 95% CI: 0.42–0.87, p = 0.006), those with sinus rhythm (HR: 0.55, 95% CI: 0.34–0.89, p = 0.013), individuals not using amiodarone (HR: 0.61, 95% CI: 0.42–0.89, p = 0.011), and those with an estimated glomerular filtration rate lower than 61.9 (HR: 0.66, 95% CI: 0.48–0.91, p = 0.011).ConclusionsThis study may offer a glimmer of hope that even after achieving the best current optimal medical therapy, the addition of device therapy could still yield positive outcomes in the management of patients with HFrEF.Graphical