Presence Of Structural Heart Disease Research Articles

Left bundle branch pacing versus left ventricular septal pacing as a primary procedural endpoint during left bundle branch area pacing: Evaluation of two different implant strategies.

Implant procedure features and clinical implications of left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP) have not been yet fully described. We sought to compare two different left bundle branch area pacing (LBBAP) implant strategies: the first one accepting LVSP as a procedural endpoint and the second one aiming at achieving LBBP in every patient in spite of evidence of previous LVSP criteria. LVSP was accepted as a procedural endpoint in 162 consecutive patients (LVSP strategy group). In a second phase, LBBP was attempted in every patient in spite of achieving previous LVSP criteria (n = 161, LBBP strategy group). Baseline patient characteristics, implant procedure, and follow-up data were compared. The final capture pattern was LBBP in 71.4% and LVSP in 24.2% in the LBBP strategy group compared to 42.7% and 50%, respectively, in the LVSP strategy group. One hundred and eighty-four patients (57%) had proven LBB capture criteria with a significantly shorter paced QRS duration than the 120 patients (37%) with LVSP criteria (115 ± 9 vs. 121 ± 13 ms, p < .001). Implant parameters were comparable between the two strategies but the LBBP strategy resulted in a higher rate of acute septal perforation (11.8% vs. 4.9%, p = .026) without any clinical sequelae. Patients with CRT indications significantly improved left ventricular ejection fraction (LVEF) during follow-up irrespective of the capture pattern (from 35 ± 11% to 45 ± 14% in proven LBBP, p = .024; and from 39 ± 13% to 47 ± 12% for LVSP, p = .003). The presence of structural heart disease and baseline LBBB independently predicted unsuccessful LBB capture. The LBBP strategy was associated with comparable implant parameters than the LVSP strategy but resulted in higher rates of septal perforation. Proven LBB capture and LVSP showed comparable effects on LVEF during follow-up.

Complications according to intrathoracic versus extrathoracic venous access for cardiac device implantation: results from the PLACE (Planning Lead Access for Cardiac Electrostimulation) study

Abstract Background and Aims The choice of the vascular access for cardiac pacing devices (CIED) implant may impact on patients outcome. Recent studies and consensus documents encourage the use of an extra-thoracic access to prevent adverse events. In this large, multicenter, retrospective study we report the impact of leads access on post-procedural outcome. Methods Consecutive patients receiving a CIED from 2008 to 2019 in 4 high-volume Italian hospitals were enrolled. Short- and long-term complications (i.e. pneumothorax, cardiac tamponade, pocket decubitus, pocket hematoma, lead dislodgement, lead failure) were collected and their relationship with the type of vascular access (extra- vs intra-thoracic, i.e. cephalic vein/extra-thoracic axillary vein vs subclavian vein puncture) was analyzed. Primary endpoint was the occurrence of at least one complication during follow-up. Results A total of 4,443 patients were enrolled; 3,374 (75.9%) received a pacemaker (PM) and 1,069 (24.1%) an implantable cardioverter defibrillator (ICD). Mean follow-up was 1,630±1,010 days. At least one complication occurred in 7.6% of patients. At multivariate Cox regression analysis, adjusted for baseline confounders, the presence of structural heart disease (HR 1.59, 95%CI 1.21-2.10; p=0.001), anticoagulant therapy at implantation [HR 1.31, 95%CI 1.0004-1.71; p=0.05) and female gender (HR 0.78, 95%CI 0.63-0.98; p=0.03) were associated with the primary outcome measure. Extra-thoracic access did not reduce the risk of complications compared to intra-thoracic access (HR 0.97, 95%CI 0.76-1.25 p=0.81). The use of both accesses in the same patient conferred a significant increase in the risk of complications (HR vs single approach:1.95, 95%CI 1.41-2.69; p &amp;lt;0.001). Conclusions The choice of a different vascular access (intra- vs extra-thoracic) does not impact on post-procedural complications in patients receiving CIED. In particular, the intra-thoracic subclavian vein puncture by experienced operators is not related to a poorer outcome. The need for both types of access in the same patient (i.e. increased procedure complexity) increases the risk of post-procedural complications.Graphical abstract

Nonpharmacological Approach to Managing Atrial Fibrillation: A Review

Background: AF's global prevalence underscores its significance as a cardiac rhythm disorder that disrupts atrial activity, impairing normal cardiac function. Over five decades of study have illuminated the pathophysiological mechanisms underlying AF, including insights into re-entrant waves and macro-reentrant circuits. The emergence of non-uniform conduction patterns and bidirectional block regions has further enriched our understanding. Risk factors contributing to AF development encompass cardiovascular conditions, advanced age, and atrial structural changes. With its implications on stroke risk and cardiovascular health, AF has become a growing public health concern. The focus on AF epidemiology has expanded, with attention on the relationship between left atrial size and AF development. Individuals with larger left atria exhibit a heightened risk. Additionally, the elevated stroke risk associated with AF has been consistently documented.&#x0D; To optimize clinical management, distinctions are drawn between chronic and paroxysmal AF, as well as the presence of structural heart disease. Mapping techniques have revealed insights into "atrial remodeling" and AF pathology. In managing AF, controlling heart rate, preventing clot formation, and restoring sinus rhythm are principal objectives. This article categorizes AF into acute, chronic, stable, or unstable forms, tailoring management approaches accordingly. While pharmacological interventions have shown efficacy, their limitations drive the exploration of nonpharmacological strategies. Approaches range from medications to cardioversion, including electrical and pharmacological methods.&#x0D; Objective: This paper aimed to provide a comprehensive exploration of non-pharmacological approaches to AF management.&#x0D; Methodology: This paper employed a structured methodology. This method involved a literature review, data synthesis, and critical analysis. During the literature review phase, we systematically searched electronic databases (PubMed, MEDLINE, Embase, and Google Scholar) for studies published from 1960 to 2023. Specific keywords and phrases such as "atrial fibrillation," "non-pharmacological interventions," "electrical cardioversion," "catheter ablation," "lifestyle modifications," "autonomic modulation," "left atrial appendage closure," and "exercise" were used. Our inclusion criteria encompassed studies addressing various non-pharmacological approaches for AF management, including observational studies and randomized controlled trials.&#x0D; Result: The initial stage of our study involved the identification of a substantial number of relevant studies. We conducted a thorough literature search across multiple databases, using specific search terms and criteria relevant to our research topic. This comprehensive search yielded a total of 1,200 studies. After applying these stringent filtering criteria, we were left with 350 studies. To further refine our final sample and categorize the studies according to type, we conducted a detailed review of the remaining 350 studies. We categorized them into various types based on study design, methodology, and focus. We then also excluded studies with duplicate ideas and finally included 103 studies that addressed the objective of our research plan. (See reference list [1-103]).&#x0D; Conclusion: This reviewed a number of non-pharmacological approaches including electrical cardioversion, catheter ablation, lifestyle modifications, autonomic modulation, left atrial appendage closure, and exercise, the paper delves into each method's advantages, potential risks, techniques, and efficacy. By offering this extensive overview, the article contributes to the expanding repository of knowledge on non-pharmacological approaches for AF management. These approaches offer potential for unique management of atrial fibrillations or in addition to pharmacologic management, may improve patient survivability or reduce complication outcomes.&#x0D; In the management of Atrial fibrillation, choice between rhythm and rate control, lifestyle modifications, and patient adherence to treatment plans are critical factors influencing outcomes are factors to consider. Emerging therapies offer promise, but timely diagnosis, individualized care, and ongoing monitoring remain essential to improving AF patients' overall prognosis.

Focus on malignant ventricular premature contractions

Premature ventricular contractions (PVCs) are common. Although often benign, they can also be associated with increased morbidity and mortality. The aim of this review was to assess the risk evaluation of PVCs in patients with or without structural heart disease and discuss the management of this arrhythmia.Reports published in English were searched in PubMed with the following search terms: premature ventricular contraction, ectopic ventricular beat, ventricular extrasystole, antiarrhythmic drugs, ablation, ventricular arrhythmia, ventricular tachycardia, ventricular fibrillation and torsade de pointe.This analysis suggests that all patients with frequent PVCs should be assessed for PVC burden, symptom status and the presence of structural heart disease. PVCs in patients with structurally normal hearts was once considered a benign phenomenon. Uncommonly, PVCs may provoke life-threatening arrhythmias. Ventricular fibrillation is the initial mode of malignant rapid ventricular arrhythmias (MRVAs). Patients with malignant PVC and PVC burden >10% are at increased risk of MRVA in case of myocardial infarction and heart failure. MRVA is the primary cause of sudden cardiac death in patients with and without structural heart disease. Therapeutic options include medical therapy and catheter ablation, the latter more effective and potentially curable, particularly in patients with left ventricular dysfunction.The timely recognition and effective treatment of malignant PVCs in symptomatic patients with underling cardiomyopathy are mandatory to initiate early therapies before the occurrence of adverse clinical outcomes and to improve the long-term prognosis.

Pharmacological cardioversion of atrial fibrillation: practical considerations.

The choice between rhythm and rate control strategy represents one of the most intriguing dilemmas in the management of atrial fibrillation (AF). Although the advantage of rhythm over rate control in terms of outcome has not been equivocally proven, the initial management of patients with symptomatic episodes of AF frequently involves an attempt of early cardioversion. As electrical cardioversion (EC) is challenging in terms of fasting status and involvement of anesthesiology team, pharmacological cardioversion (PC) is usually selected as the first step towards rhythm conversion. Proper qualification for PC or EC is similar and should comprise assessment of hemodynamic status, estimation of duration of arrhythmic episode, evaluation of anticoagulation regimen, exclusion of other supraventricular arrhythmias and assessment of the chance of rhythm conversion and persistence of sinus rhythm. Finally, the choice of adequate antiarrhythmic drug (AAD) depends on the presence of structural heart disease and local experience. In patients without structural heart disease, complications occur rarely, hence traditional (propafenone, flecainide) or nonclassical Vaughan-Williams class I (antazoline) or class III (vernakalant, ibutilide or dofetilide) drugs are preferred. The presence of structural heart disease consistent with any left ventricular hypertrophy, heart failure, myocardial ischemia or valvular heart disease confines the choice of AAD to amiodarone. Given the risk of ventricular proarrhythmia of AAD, safety should always prevail over the enticing possibility of rhythm conversion. The present review aims to provide a comprehensible summary of proper qualification for PC, selection of suitable AAD and state-of-the-art periprocedural management of patients with recent-onset AF.

Effectiveness of Amiodarone, Propafenone And Synchronized Electrical Cardioversion for Conversion of Atrial Fibrillation Paroxysm to Sinus Rhythm in Rigas Stradins University Hospital Department of Emergency Medicine

Introduction: Atrial fibrillation remains one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity in the world. Its incidence increases with age and the presence of structural heart disease. Materials and methods: The retrospective analysis was performed on 127 patients over a period of three years (73 men, median age 62, range 37-75, and 54 women, median age 60, range 42-78) duration of atrial fibrillation 48 hours or less. Results: Efficiency of amiodarone i/v converting atrial fibrillation to sinus rhythm detected in 56 of 69 patients (81.2%). Efficiency of propafenone i/v converting atrial fibrillation to sinus rhythm detected in 26 of 33 patients (78.8%). Efficiency of electrical cardioversion was pronounced in 24 of 25 patients (96.0%). (p&lt;0.001 compared to both amiodarone and propafenone). In case if atrial fibrillation duration is less than 8h propafenone is more effective and for atrial fibrillation with duration over 24h more effective is amiodarone. Efficacy of amiodarone and propafenone in converting atrial fibrillation paroxysm to sinus rhythm was almost the same. The effect of amiodarone was slightly superior that of propafenon. Conclusion: Amiodarone, propafenone, and electrical cardioversion all three options provide physicians with effective tools to restore sinus rhythm in patients with atrial fibrillation. Atrial fibrillation duration should be taken into account more often to choose an appropriate treatment in emergency department.

PO-05-101 CLINICAL PREDICTORS OF LONG-TERM MORTALITY AFTER FIRST ABLATION OF VENTRICULAR TACHYCARDIA IN PATIENTS WITH STRUCTURAL HEART DISEASE

Catheter ablation is a well-established treatment modality for a wide spectrum of ventricular tachycardias (VT). However, in the presence of structural heart disease (SHD), the long-term prognosis remains poor. The aim of this study was to investigate the predictors of all-cause mortality after SHD-related VT ablation in a high-volume expert centre. We evaluated 1143 patients (age: 63 ± 13 years, males: 87%, ischemic cardiomyopathy [ICM]: 67%, electrical storm [ES]: 25%, NYHA Class: 2.1 ± 1.0, left ventricular ejection fraction [LVEF]: 34 ± 13%, diabetes mellitus [DM]: 32%, chronic obstructive pulmonary disease [COPD]: 12%) who underwent the first ablation for SHD-related VT between August 2006 and December 2020 and were followed up to September 2022. Univariate and multivariate Cox regression analyses were used to assess the predictors of all-cause mortality. During a median follow-up of 4.1 years (IQR: 2.0 – 7.2 years), a total of 322 patients (28%) underwent repeated VT ablation and 548 patients (48%) died. Univariate Cox regression analysis revealed eight parameters associated with all-cause mortality (Figure). After multivariate adjustment, only age >60 years (HR: 1.82, 95% CI: 1.4–2.2, P <0.0001), ICM (HR: 1.48, 95% CI: 1.1–1.8, P <0.001), NYHA class ≥ III (HR: 1.6, 95% CI: 1.3–1.9, P <0.0001), a serum creatinine >1.3 mg/dL (HR: 1.7, 95% CI: 1.4–2.0, P <0.00001), LVEF <25% (HR: 2.2, 95% CI: 1.8–2.6, P <0.00001), ES (HR: 1.26, 95% CI: 1.04–1.5, P <0.05) and DM (HR: 1.4, 95% CI: 1.1–1.6, P <0.001) were strong and independent predictors of mortality. In a large cohort of patients with long-term follow-up after ablation for SHD-related VT, multiple clinical factors were independently associated with all-cause death. Such data could be exploited to propose the composite mortality score.

Coronary Stent Infections — A Systematic Review and Meta-Analysis

BackgroundCoronary stent infection (CSI) represents a rare but potentially fatal complication of percutaneous coronary interventions (PCI). A systematic review and meta-analysis of published reports was performed to profile CSI and its management strategies. MethodsOnline database searches were performed using MeSH and keywords. The primary outcome of the study was in-hospital mortality. A unique Artificial Intelligence-based predictive model was developed for need for delayed surgery and probability of survival on medical therapy alone. ResultsA total of 79 subjects were included in the study. Twenty eight (35.0 %) patients had type 2 diabetes mellitus. Subjects most commonly reported symptoms within the first week of the procedure (43 %). Fever was the most common initial symptom (72 %). Thirty eight percent of patients presented with acute coronary syndrome. The presence of mycotic aneurysms was described in 62 % of patients. Staphylococcus species were the most common (65 %) isolated organism. The primary outcome of in-hospital mortality was seen in a total of 24 patients out of 79 (30.3 %). A comparative univariate analysis comparing those encountering in-hospital mortality versus otherwise revealed the presence of structural heart disease (83 % mortality vs 17 % survival, p = 0.009), and the presence of non ST elevation acute coronary syndrome (11 % mortality vs 88 % survival, p = 0.03), to be a statistically significant factor predicting in-hospital mortality. In an analysis between patients with successful versus failed initial medical therapy, patients from private teaching hospitals (80.0 % vs 20.0 %; p = 0.01, n = 10) had a higher survival with medical therapy alone. ConclusionCSI is a highly under-studied disease entity with largely unknown risk factors and clinical outcomes. Larger studies are needed to further define the characteristics of CSI. (PROSPERO ID CRD42021216031).

Confounding factors leading to misdiagnosing ventricular tachycardia as supraventricular in the emergency room

Studies conducted during the last 50 years have proposed electrocardiographic criteria and algorithms to determine if a wide QRS tachycardia is ventricular or supraventricular in origin. Sustained ventricular tachycardia is an uncommon reason for consultation in the emergency room. The latter and the complexity of available electrocardiographic diagnostic criteria and algorithms result in frequent misdiagnoses. Good hemodynamic tolerance of tachycardia in the supine position does not exclude its ventricular origin. Although rare, ventricular tachycardia in patients with and without structural heart disease may show a QRS duration <120 ms. Interruption of tachycardia by coughing, carotid sinus massage, Valsalva maneuver, or following the infusion of adenosine or verapamil should not discard the ventricular origin of the arrhythmia. In patients with regular, uniform, sustained broad QRS tachycardia, the presence of structural heart disease or A-V dissociation strongly suggest its ventricular origin. Occasionally, ventricular tachycardia can present with AV dissociation without this being evident on the 12-lead ECG. Cardiac auscultation, examination of the jugular venous pulse, and arterial pulse palpation provide additional clues for identifying A-V dissociation during tachycardia. This paper does not review the electrocardiographic criteria for categorizing tachycardia as ventricular but rather why emergency physicians misdiagnose these patients.

Contemporary updates on ventricular arrhythmias: from mechanisms to management.

Ventricular arrhythmias (VAs) are a group of heart rhythm disorders that can be life-threatening and cause significant morbidity. VA in the presence of structural heart disease (SHD) has distinct prognostic implications and requires a comprehensive and multifaceted approach for investigation and management. Early specialist referral should be considered for all patients with VA. Particular urgency is recommended in patients with syncope, nonsustained/sustained VA on Holter monitor and SHD on cardiac imaging because ofthe heightened risk of sudden cardiac death. Comprehensive phenotyping is recommended for most patients with VA, encompassing noninvasive cardiac functional testing, multimodality imaging and genetic testing in select circumstances. Management of idiopathic VA is guided heavily by symptom burden and the presence of ventricular systolic impairment. In SHD, guideline-directed heart failure therapy and device implantation are critical considerations. Whilst commonly used and well-established, antiarrhythmic drugs can be hampered by toxicity and failure of adequate arrhythmia control. Catheter ablation is increasingly being considered a feasible first-line alternative to medical therapy, where outcomes are influenced by disease aetiology and scar burden in SHD. Catheter ablation is associated with reduced arrhythmia recurrence and burden and improved quality of life at follow-up.

Correlation between structural heart disease and cardiac SARS-CoV-2 manifestations

Background:The prognosis of COVID-19 patients with cardiac involvement is unfavorable and it remains unknown which patients are at risk. The virus enters cells via its receptor angiotensin-converting enzyme 2 (ACE2). Myocardial ACE2 expression is increased in structural heart disease (SHD). We, therefore, aimed to analyze correlations between structural heart disease and cardiac SARS-CoV-2 manifestation.Methods:The clinical course of COVID-19 in patients with structural heart disease was assessed in a prospective cohort of 152 patients. The primary endpoints consisted of hospitalization and survival. Cardiac tissue of 23 autopsy cases with lethal COVID-19 course was obtained and analyzed for (a) the presence of SHD, (b) myocardial presence of SARS-CoV-2 via RT,-PCR, and (c) levels of ACE2 expression using immunofluorescence staining.Results:Structural heart disease is found in 67 patients, of whom 56 (83.60%) are hospitalized. The myocardium is positive for SARS-CoV-2 in 15 patients (65%) in 23 autopsy cases of lethal COVID-19. Moreover, most hearts with evidence of myocardial SARS-CoV-2 have structural heart disease [11 (91,67%) vs. 1 (8,33%), p = 0.029]. Myocardial presence of SARS-CoV-2 is correlated with a significant downregulation of ACE2 compared to negative control hearts (6.545 ± 1.1818 A.U. vs. 7.764 ± 2.411 A.U., p = 0.003). The clinical course of patients with cardiac SARS-CoV-2 manifestation is unfavorable, resulting in impaired survival (median, 12 days and 4.5 days, respectively, HR 0.30, 95% CI, 0.13 to 0.73, p = 0.0005)Conclusions:We provide evidence for a correlation between SHD, altered ACE2 receptor expression, and cardiac SARS-CoV-2 manifestation. Consequently, structural heart disease may be considered a distinct risk factor for a severe clinical course after infection with SARS-CoV-2.Registration number local IRB:Ethics Committee of Northwestern and Central Switzerland ID 2020-00629; Ethics Committee of the Medical University Innsbruck EK Nr: 1103/2020.ClinicalTrials.gov number:NCT04416100.

Results of a focused cardiac ultrasound program conducted by neurologists within a stroke care network with cardiac imaging units

Introduction and objectivesRecently, neurologists have begun to perform focused cardiac ultrasound for the detection of a cardiac source of embolism in stroke patients, requiring them to undergo a prior accredited training process. We designed a prospective study to analyze the incidence of heart disease detected by a focused cardiac ultrasound program within a stroke care network with cardiac imaging units and to identify the outcomes of detected structural heart disease at 1 year of follow-up. MethodsWe included patients admitted to a university hospital for ischemic stroke or a transient ischemic attack between 2017 and 2021 who were evaluated by focused cardiac ultrasound. We studied the presence of structural heart disease and cardioembolic sources. We analyzed cardiovascular events (CVE) during the first year of follow-up. ResultsFocused cardiac ultrasound was performed in 706 patients. Structural heart disease was detected in 52.1% and a cardioembolic source in 31.9%. Adverse CVE occurred in 5.49% of the patients in the first year of follow-up. The presence of de novo structural heart disease was independently associated with a higher probability of adverse CVE (HR, 1.72; 95%CI, 1.01- 2.91; P=.046). ConclusionsFocused cardiac ultrasound within a stroke care network with cardiac imaging units is an accessible technique with high diagnostic yield. Its use allows clinical and therapeutic actions in the prevention of stroke recurrences and other CVEs in this group of patients.

Resultados de un programa de ecocardioscopia realizada por neurólogos en el proceso integrado en red de atención al ictus en unidades de imagen cardiaca

Introduction and objectivesRecently, neurologists have begun to perform focused cardiac ultrasound for the detection of a cardiac source of embolism in stroke patients, requiring them to undergo a prior accredited training process. We designed a prospective study to analyze the incidence of heart disease detected by a focused cardiac ultrasound program within a stroke care network with cardiac imaging units and to identify the outcomes of detected structural heart disease at 1 year of follow-up. MethodsWe included patients admitted to a university hospital for ischemic stroke or a transient ischemic attack between 2017 and 2021 who were evaluated by focused cardiac ultrasound. We studied the presence of structural heart disease and cardioembolic sources. We analyzed cardiovascular events (CVE) during the first year of follow-up. ResultsFocused cardiac ultrasound was performed in 706 patients. Structural heart disease was detected in 52.1% and a cardioembolic source in 31.9%. Adverse CVE occurred in 5.49% of the patients in the first year of follow-up. The presence of de novo structural heart disease was independently associated with a higher probability of adverse CVE (HR, 1.72; 95%CI, 1.01- 2.91; P=.046). ConclusionsFocused cardiac ultrasound within a stroke care network with cardiac imaging units is an accessible technique with high diagnostic yield. Its use allows clinical and therapeutic actions in the prevention of stroke recurrences and other CVEs in this group of patients.

Psychological Aspects of Syncopes and Possible Association with Recurrency-The Role of Implantable Loop Recorders.

Syncopes are a very common phenomenon and have a high recurrence rate. The differentiation between the psychogenic and physical, especially of arrhythmic origin, remains difficult. In many cases, an implantable loop recorder is used for the detection of possible arrhythmias, leading to syncopes. Yet, the existing literature suggests that psychological factors may play a significant role in recurrent syncopes. We aimed at analyzing the potential role of several psychological factors on the recurrence of arrhythmic or non-arrhythmic syncopes. Methods and results: A total of 119 patients, who had received an implantable loop recorder for recurrent syncopes at our center between 01/2018 and 12/2021, participated in this retrospective cohort study. Anxiety, depression and quality of life were assessed using extensively validated questionnaires (GAD-7, PHQ-9 and SF-12). The mean follow-up after loop recorder implantation was 710 ± 430 days and 50% of patients were female. The mean patient age was 54.8 ± 18.6 years. Most patients had no evidence of structural heart disease (84%), and normal LV function (92%). A statistical analysis revealed that the presence of structural heart disease was the strongest predictor for arrhythmic syncope during follow-up. In patients with non-arrhythmic syncopes, we found significantly higher levels of anxiety (GAD-7 score: 2.5 ± 2.6 vs. 4.8 ± 4.3) and depression (PHQ-9 score: 3.9 ± 3.6 vs. 6.8 ± 5.1), and a lower quality of life (SF-12 score: 33.7 ± 6.4 vs. 29.6 ± 7.8). Discussion: We identified factors as contributors to a better identification of patients at risk for arrhythmic as well as non-arrhythmic syncopes. Especially anxious or depressive symptoms may hinted at non-arrhythmic causes of syncope. However, the study was limited by its retrospective design and low patient number. Further trials should likewise combine the diagnostic yield of loop recorders with psychometric evaluations before implantation and combine it with additional diagnostic measures, such as video monitoring, to further examine the role of psychological factors in the pathomechanism and treatment of syncope.

Sleep apnea and atrial fibrillation: the spell of Groundhog Day.

Sleep apnea and atrial fibrillation: the spell of Groundhog Day.

Serum visfatin concentrations are positively associated with ventricular arrhythmias: a single-center preliminary study.

Visfatin has been reported to be closely related to cardiovascular diseases associated with inflammation, but the correlation between visfatin and ventricular arrhythmia (VA) has not been discussed yet. The study aims to explore the association between serum visfatin concentrations and VA in patients. Sixty-seven hospitalized patients diagnosed with VA and 131 control subjects were enrolled in this crosssectional study between May 20, 2017 and November 8, 2019. Classification of VA types was based on the presence of structural heart disease (SHD). The patients' blood samples were collected to examine their serum levels of visfatin. Results were analyzed using analysis of variance and t-test. Furthermore, binary logistic regression analysis was used to validate whether elevated visfatin was independently associated with VA. Compared with the controls (mean age, 64.2 ± 13.2 years; 71% of men), the patients with VA (68.2 ± 11.6 years, 58%) had higher serum levels of visfatin (1.80 ± 0.47 ng/mL versus 1.48 ± 0.41 ng/mL; p <0.001). After further grouping patients according to the presence of SHD, the serum levels of VA patients with SHD were the highest. Moreover, binary logistic regression analysis identified age (OR = 1.043; 95% CI, 1.015-1.072, p = 0.003), history of stroke (OR = 2.065; 95% CI, 1.450-5.696, p = 0.005), hsCRP (>10 mg/L) (OR = 4.123; 95% CI, 1.888-9.001, p < 0.001), and elevated visfatin level (>1.40 ng/L) (OR = 3.126; 95% CI, 1.544-6.328, p = 0.002) as independent risk factors with VA. Serum visfatin levels were significantly elevated in the patients with VA, and increased with the risk rating of VA.

A rare case of premature and parallel posterior descending artery and posterior left ventricular branch with conus crossing the right ventricular outflow tract causing provocative coronary ischemia

We report a rarely encountered case of premature and parallel posterior descending artery (PDA) and posterior left ventricular branch (PLVB) in a case of 22-year-old male with effort angina Class II for the last 6 months in whom treadmill test (TMT) was strongly positive for provocative coronary ischemia with structurally normal heart and good biventricular function. Interestingly, all the coronaries were normal without any obstructive coronary lesion. Paradoxically, those two prematurely separating branches were small making the distal right coronary artery (RCA) territory relatively ischemic attributing toward a strongly positive TMT. Small anomalous coronary is a well-known cause of demand ischemia, but our case is unique to describe small prematurely originating PDA and PLVB were the culprit behind coronary ischemia in a young male without conventional risk factors. Furthermore, much premature separation of PDA and PLVB is rarely encountered in routine clinical practice, and recognition of this anomaly is important as it should not be mistaken for duplicate RCA, dual RCA, or split RCA. Our case is also unique to illustrate the association of the premature and parallel PDA and PLVB with a conus crossing the right ventricular outflow tract without the presence of structural heart disease.

Association of age with clinical features and ablation outcomes of paroxysmal supraventricular tachycardias

ObjectiveThe role of age in clinical characteristics and catheter ablation outcomes of atrioventricular nodal re-entrant tachycardia (AVNRT) or orthodromic atrioventricular re-entrant tachycardia (AVRT) has been assessed in retrospective studies categorising...

Transient Acquired QT Interval Prolongation After Administration of Intravenous Ondansetron

A 62-year-old man with a history of stable ischemic heart disease presented to the emergency room with nausea, vomiting, and chest pain at rest. The chest pain was atypical in nature; it did not respond to nitroglycerin and did not worsen with exertion. He took only aspirin, metoprolol, and ramipril at home. The patient was normotensive and normoxemic. Serial high-sensitivity troponin test results were normal, and other bloodwork (including calcium and magnesium levels) was unremarkable, with the exception of a serum potassium level of 2.4 mmol/L. His presenting electrocardiogram (ECG; Fig. 1A ) showed sinus rhythm with a right bundle branch block and a mildly prolonged QTc interval (450 msec using Bazett’s formula1Bazett H. An analysis of the time-relations of electrocardiograms.Heart. 1920; 7: 353-370Google Scholar). However, conduction delays prolong the QRS interval, which affects the length of the QT interval without significant impact on the repolarization duration. Bogossian’s formula can correct the QTc interval in the presence of bundle branch blocks, and this yielded a normal QTc interval of 302 msec.2Bogossian H. Linz D. Heijman J. et al.QTc evaluation in patients with bundle branch block.Int J Cardiol Heart Vasc. 2020; 30: 100636PubMed Google ScholarFigure 1Electrocardiogram showing (A) sinus rhythm with a right bundle branch block (bbb) and mildly prolonged QTc interval; (B) ST changes with profound QTc interval prolongation; and (C) partial resolution of the ST changes.View Large Image Figure ViewerDownload Hi-res image Download (PPT) During his time in the emergency room, he experienced nausea and was given 4 mg of ondansetron intravenously. He was also given 40 mmol of KCl orally for his hypokalemia. Fifteen minutes later, the patient had a mild recurrence of atypical chest discomfort at rest, and another ECG Fig. 1B) was performed. This showed nonspecific ST changes with profound QTc interval prolongation, using both Bogossian’s formula (562 msec) and Bazett’s formula (628 msec). In addition to QTc interval prolongation, there was a dramatic difference in T wave morphology, including prolongation of the Tpeak–Tend interval. Ten minutes later, an ECG (Fig. 1C) and blood work were repeated, which showed a serum potassium level of 3 mmol/L, and partial resolution of the ST changes. The patient was not given any further QT-prolonging medication, and he was subsequently diagnosed with noncardiac chest pain after undergoing normal stress myocardial perfusion imaging. Severe hypokalemia is a known cause of QT interval prolongation.3Yelamanchi V.P. Molnar J. Ranade V. Somberg J.C. Influence of electrolyte abnormalities on interlead variability of ventricular repolarization times in 12-lead electrocardiography.Am J Ther. 2001; 8: 117-122Crossref PubMed Scopus (35) Google Scholar However, this patient’s initial ECG demonstrates a normal (by Bogossian’s formula) or only modestly prolonged (by Bazett’s formula) QTc interval. Subsequent administration of IV ondansetron resulted in profound transient QTc interval prolongation relative to this patient’s baseline, and marked changes in T wave morphology. It has been previously described that intravenous ondansetron administration can lead to QT interval prolongation and T wave changes. Our patient had a history of ischemic heart disease; the presence of structural heart disease increases the risk for acquired QT interval prolongation. Such prolongations of the QTc and Tpeak–Tend intervals are associated with increased risk of Torsades de Pointes and sudden cardiac death, with the risk increasing proportionally to QTc interval duration.4Thomas S. Behr E. Pharmacologic treatment of acquired QT prolongation and torsades de pointe.Br J Clin Pharmacol. 2016; 81: 420-427Crossref PubMed Scopus (67) Google Scholar, 5Hafermann M. Namdar R. Seibold G. et al.Effect of intravenous ondansetron on QT interval prolongation in patients with cardiovascular disease and additional risk factors for torsades: a prospective, observational study.Drug Healthc Patient Saf. 2011; 3: 53-58PubMed Google Scholar, 6Tse G. Gong M. Meng L. et al.Predictive value of Tpeak-Tend indices for adverse outcomes on acquired QT prolongation: a meta-analysis.Front Physiol. 2018; 9: 1226Crossref PubMed Scopus (18) Google Scholar These images demonstrate the importance of cautious administration of QT interval–prolonging medications, particularly in the presence of other risk factors for QT interval prolongation such as hypokalemia and underlying structural heart disease, even if the baseline QTc interval is not markedly prolonged.Novel Teaching Points•Proper assessment of the QT interval is important in the setting of a bundle branch block, as widening of the QRS will cause subsequent QT interval prolongation without significant impact on the duration of repolarization.•Bogossian’s formula is an alternative method for calculating the QT interval in the setting of a bundle branch block. However, no single formula is perfect for QTc interval calculation in every situation.•Caution is needed when prescribing medications that prolong the QT interval, especially for patients with an underlying predilection for QT interval prolongation.

Impact of a predefined pacemapping protocol for ablation of infrequent premature ventricular complexes: a prospective, multicenter study

Abstract Funding Acknowledgements Type of funding sources: None. Background Pacemapping (PM) is a useful maneuver for aiding PVC ablation procedures, but its stand-alone clinical value when activation mapping is precluded is still to be defined. Objectives To analyze the clinical efficacy of a predefined PM protocol to be applied during low-burden premature ventricular complex (PVC) ablation procedures, regardless of their site of origin (SOO) and the presence of prior structural heart disease (SHD). Methods Prospective, non-randomized, multicenter study including 185 consecutive patients referred for a first PVC ablation. A predefined PM protocol was performed to guide ablation whenever a burden &amp;lt; 1 PVC/min was found after a 15-min waiting period, which precluded activation mapping. PM was performed using the PASO module of CARTO3 navigation system, obtaining a correlation grading, color-coded map. A minimum correlation of 94% was required for classifying an area as the PVC-SOO. After identifying the SOO, a high-density PM map with a fill threshold set to 6 was performed and ablation was delivered to the ‘target area’, defined as the area delimited by the 3 best matching points above the minimum correlation of 94%. Three RF applications were systematically applied in the target area with appropriate parameters: 40 W for the RVOT and aortic root, 50 W for the subvalvular LVOT, 20-30 W in the distal coronary sinus, at operator’s discretion in other locations. Clinical success was defined as a PVC-burden reduction of ≥ 80% in the 24-h Holter after 6 months. Results 105/185 patients (57%) could undergo activation mapping, while 60/185 (32%) had to be PM-guided. Only 20 patients (11%) had to be canceled due to complete absence of PVCs. Baseline QRS, PVC burden and an OT origin were independent predictors of the need to undergo a PM-guided ablation. The most frequent SOO locations were RVOT (44%), LV (23%), and LVOT (16%), with a significantly higher proportion of RVOT-SOO in the PM group (52% vs. 40%, p = 0.03). The mean target area was 0.6 ± 0.9 cm2, with a mean smallest PM correlation within that area of 95 ± 4%. The mean 10-ms isochronal area in LAT-guided procedures was significantly higher than the PM target area (1.7 ± 2.3 cm2; p &amp;lt; 0.001). The mean number of PM matching points acquired was 39 ± 21 (range 6 – 98). Mean mapping (29 ± 22 min) and RF (135 ± 124 sec) times were similar both for LAT and PM-guided procedures, with significantly shorter procedure times in the PM group (53 ± 24 vs. 61 ± 26 min; p = 0.04). Clinical success after a 6-month follow-up reached 87% for the PM approach, similar to that of LAT mapping-based ablation procedures (90%; p = 0.58). Conclusions When LAT mapping is precluded by a very low PVC burden in unselected patients referred for PVC ablation procedures, a first-line, stepwise PM and ablation protocol directed to a target area with &amp;gt; 94% matching correlation is a feasible alternative, reaching comparable clinical results regardless of the PVC-SOO and the presence of SHD. Abstract Figure. Example of a predefined PM protocol