Ventricular Ectopy Research Articles

Resuming Training in High-Level Athletes After Mild COVID-19 Infection: A Multicenter Prospective Study (ASCCOVID-19)

BackgroundThere is a paucity of data on cardiovascular sequelae of asymptomatic/mildly symptomatic SARS-Cov-2 infections (COVID).ObjectivesThe aim of this prospective study was to characterize the cardiovascular sequelae of asymptomatic/mildly symptomatic COVID-19 among high/elite-level athletes.Methods950 athletes (779 professional French National Rugby League (F-NRL) players; 171 student athletes) were included. SARS-Cov-2 testing was performed at inclusion, and F-NRL athletes were intensely followed-up for incident COVID-19. Athletes underwent ECG and biomarker profiling (D-Dimer, troponin, C-reactive protein). COVID(+) athletes underwent additional exercise testing, echocardiography and cardiac magnetic resonance imaging (CMR).Results285/950 athletes (30.0%) had mild/asymptomatic COVID-19 [79 (8.3%) at inclusion (COVID(+)prevalent); 206 (28.3%) during follow-up (COVID(+)incident)]. 2.6% COVID(+) athletes had abnormal ECGs, while 0.4% had an abnormal echocardiogram. During stress testing (following 7-day rest), COVID(+) athletes had a functional capacity of 12.8 ± 2.7 METS with only stress-induced premature ventricular ectopy in 10 (4.3%). Prevalence of CMR scar was comparable between COVID(+) athletes and controls [COVID(+) vs. COVID(−); 1/102 (1.0%) vs 1/28 (3.6%)]. During 289 ± 56 days follow-up, one athlete had ventricular tachycardia, with no obvious link with a SARS-CoV-2 infection. The proportion with troponin I and CRP values above the upper-limit threshold was comparable between pre- and post-infection (5.9% vs 5.9%, and 5.6% vs 8.7%, respectively). The proportion with D-Dimer values above the upper-limit threshold increased when comparing pre- and post-infection (7.9% vs 17.3%, P = 0.01).ConclusionThe absence of cardiac sequelae in pauci/asymptomatic COVID(+) athletes is reassuring and argues against the need for systematic cardiac assessment prior to resumption of training (clinicaltrials.gov; NCT04936503).

Study of Dilated Cardiomyopathy in Correlation with Electrocardiography and Echocardiography in Patients less than 40 Years Age

Background: DCM is a disease of the heart muscle, primarily affecting the left ventricle and characterized by ventricular dilatation, impaired systolic function, and reduced myocardial contractility. The present study was conducted to study the electrocardiographic and echocardiographic findings in patients with dilated cardiomyopathy in patients less than 40 years in Varun Arjun Medical College, Banthra, Shahjahanpur over 2 years. Material and methods: The present study was performed in 100 patients (50 males and 50 females) of dilated cardiomyopathy over 2 years. Diagnosis of dilated cardiomyopathy was done by echocardiography. After selection of patients, detail history and complete clinical examination was carried out. ECG and Echocardiography was done among all these patients using standard techniques. Results: The axis was normal in majority (85%). Left axis deviation was seen in 9% and right axis deviation in 6%. The most common abnormality was ventricular ectopics seen in 43% of patients. Sinus tachycardia and left bundle branch blocks were seen in 40% of subjects. Non specific ST-T changes were seen in 27% whereas atrial fibrillation was present in 12%. LVH was seen in 20% and left atrial enlargement in 14% of subjects.

Ventricular Arrhythmias in Patients with Implanted Cardiac Devices at High Risk of Obstructive Sleep Apnea.

Background and Objectives: Patients with pre-existing cardiac disease have a higher prevalence of Obstructive Sleep Apnea (OSA). OSA has been associated with an increased risk of supraventricular and ventricular arrhythmia. We screened subjects with implanted pacemakers and automated implantable cardioverter defibrillators (AICD) for OSA with the Berlin Questionnaire and compared the incidence of ventricular arrhythmias and automated implantable cardioverter defibrillator (AICD) firing between high and low OSA risk groups. Materials and Methods: We contacted 648 consecutive patients from our arrhythmia clinic to participate in the study and performed final analyses on 171 subjects who consented and had follow-up data. Data were abstracted from the electronic health record for the incidence of non-sustained ventricular tachycardia (NSVT), ventricular tachycardia (VT), ventricular fibrillation (VF) and AICD firing and then compared between those at high versus low risk of OSA using the Berlin Questionnaire and multivariate negative binomial regression. Results: The average follow-up period was 24.2 ± 4.4 months. After adjusting for age, gender and history of heart failure, those subjects at high risk of OSA had a higher burden of NSVT vs. those with a low risk of OSA (33.4 ± 96.2 vs. 5.82 ± 17.1 episodes, p = 0.003). A predetermined subgroup analysis of AICD recipients also demonstrated a significantly higher burden of NSVT in the high vs. low OSA risk groups (66.2 ± 128.6 vs. 18.9 ± 36.7 episodes, p = 0.033). There were significant differences in the rates of VT, VF or AICD shock burden between the high and low OSA risk groups and in the AICD subgroup analysis. Conclusions: There was increased ventricular ectopy among pacemaker and AICD recipients at high risk of OSA, but the prevalence of VT, VF or AICD shocks was similar to those with low risk of OSA.

Cardioprotective effects of exercise preconditioning on ischemia-reperfusion injury and ventricular ectopy in young and senescent rats.

Aging decreases ischemic tolerance, while exercise prevents myocardial ischemia reperfusion (IR) injury. The cardioprotective role of high intensity interval training (HIIT), however, is unknown. Accordingly, we investigated 8weeks (5days/week, 40min/day) of HIIT treadmill exercise (60%/90% of VO2 peak) on IR injury in young (2-month) and senescent (20-month) Wistar rat myocardia (N=10/group). Surgical IR (30min/120min) was performed via reversible left anterior descending artery ligation and ECG was analyzed to determine ventricular ectopy during IR period. Infarction size and oxidative stress were measured in hearts post-mortem. Glutathione peroxidase activity and Myeloperoxidase levels were mitigated with age, but elevated post IR. HIIT potentiated antioxidant defenses in young and old hearts, and infarction size was lower in young HIIT trained. Metrics of reactive oxygen species were not lower after IR, and were not affected by HIIT in young or old rats. Ventricular ectopy score in senescent rats was insignificantly more than young rats and HIIT significantly decreased ventricular ectopy score in young and senescent rats. Findings indicate that IR tolerance is mitigated in senescent hearts, while HIIT ameliorated infarction by increasing antioxidant enzymes activity in young and senescent hearts.

Cardiac screening in police and armed forces: a pilot project

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Most international bodies now recommend cardiac screening for all individuals undertaking high intensity physical activity. The sensitivity and specificity of the ECG in cardiac screening is undisputed. Study Objective Two major national institutions (Police Force and the Armed Forces) have now recognized the importance of having a cardiac screening program. As of 2020, the department of Cardiology has been offering remote ECG interpretation for all new recruits. The aim of the study was to retrospectively review this service, specifically looking at the diagnostic yield. Methodology All reported ECGs were retrospectively evaluated. ECG changes were labelled as training related, borderline or pathological ECG patterns as depicted in the 2017 International Recommendations for ECG interpretation in athletes. Demographic, symptom and ECG data were tabulated. The clinical outcomes of those referred were also recorded. Categorical data was presented as percentages. Statistical analysis was performed using SPSS v23. Results 318 recruits were screened, mean age 31.42 ± 13.2 years. The majority (n=196, 61.6%) were younger than 35 years. It was a predominant male population (n=262, 82.4%), all being Caucasian. Armed forces and police force recruits were equally represented (n=154, 48.4% vs n=164, 51.6%). No one reported symptoms (0.0%). The commonest training related changes included early repolarisation (22.3%), left ventricular hypertrophy (15.4%), sinus bradycardia (14.2%) and partial right bundle branch block (7.5%). Some had pathological ECG patterns (Anterior T Wave Inversion n=6 [1.9%], ST segment depression n=6 [1.9%], pathological Q waves n=5 [1.6%], ventricular ectopics n=3 [0.9%], pre-excitation n=2 [0.6%], inferior T Wave inversion n=1 [0.3%], Short QT n=1 [0.3%]). Most were cleared at the initial assessment (n=292, 91.5%). 26 (8.2%) were referred for further evaluation. 14 (4.4%) needed a repeat ECG. Most (n=6, 23.1%) were cleared after secondary evaluation. Another 4 (15.4%) needed surveillance. 6 (23.1%) had a clinical diagnosis, equating to 1 in 53 individuals screened (1.9% of initial cohort). Two patients were already under the care of a cardiologist (n=1 sinus venosus defect with PAPVD, n=1 ischaemic cardiomyopathy). 4 were newly diagnosed cardiac patients (n=1 HCM, n=2 WPW, n=1 Aortopathy). Age did not have any significant impact on the diagnostic yield (<35 [50%] vs ≥35 [50%] years, p=0.244). Conclusion 8.2% were referred for further evaluation (1 in 12). 1.9% (1 in 53) had a clinical diagnosis. This highlights the importance of an ECG based screening algorithm in close liaison with experts in cardiac screening. A clinical diagnosis in law enforcement and army personnel may have important lifelong career implications.

PO-614-06 SMART WATCH SYNDROME IN PEDIATRICS - HOW WELL DOES IT PREDICT ARRHYTHMIA?

Smart watches have the capability of assessing heart rate (HR) and rhythm; some can produce a single lead ECG tracing. These features may enhance detection of atrial fibrillation in adults based on a recent study. Tachyarrhythmias in children such as supraventricular tachycardia (SVT) may also be detectable with a smart watch. Alternatively, misunderstood or inaccurate smart watch data may lead patients to seek unnecessary evaluation. Assess the likelihood of a true arrhythmia in pediatric patients presenting with concerns about smart watch cardiac data. Single center retrospective review of children aged 10-18 years who had ever presented to the pediatric cardiology clinic with concerns related to smart watch cardiac data. The primary study outcome was diagnosis of arrhythmia based on clinical evaluation or documentation of arrhythmia by clinical testing. There were 126 patients (mean age 15.6 ± 2.4 yrs) that presented with a smart watch based rhythm concern - tachycardia in 89%. Symptoms were present in 95 (75%); with palpitations accounting for 78% of those. Smart watch measured HRs were available in 121/126 (96%) with 45 (37%) reporting HR ≥ 190 bpm. Presenting smart watch data was sufficient to diagnose SVT in 3. Additional testing was used to confirm or rule out arrhythmia in 72 (57%). The majority, 83 (66%), were discharged after a single visit +/- testing. In all, 19 / 126 (15%) patients were diagnosed with true arrhythmia: 13 SVT, 3 Wolff Parkinson White, 2 atrial tachycardia, 1 ventricular ectopy. The odds of a true arrhythmia diagnosis with symptoms vs no symptoms was 3.2 (95%CI 0.7 - 14.5); and with HR ≥ 190 bpm vs HR < 190 was 14.3 (95%CI 3.8 - 52.8). The positive predictive value of HR ≥ 190 AND symptoms together to predict arrhythmia was only 39% (95%CI 28 - 52). The negative predictive value for arrhythmia having neither symptoms nor HR > 190 was 95% (95%CI 75 - 99). The likelihood of a true arrhythmia in pediatric patients presenting with a smart watch based HR concern was low. Symptoms and HR > 190 improved but did not optimize the predictability of an arrhythmia. The absence of symptoms or HR > 190bpm predicted no arrhythmia in 95% of patients. Rarely, smart watch EGMs or trend data was sufficient for arrhythmia diagnosis.

PO-684-06 ARRHYTHMIC MITRAL VALVE PROLAPSE WITH ONLY MILD OR MODERATE MITRAL REGURGITATION: CHARACTERIZATION BY PET/MRI

Mitral valve prolapse (MVP) has been associated with ventricular arrhythmias and sudden cardiac death (SCD). A majority of MVP-related SCD occurs in patients with only mild or moderate MR. Replacement fibrosis, which is known to occur in the absence of severe MR, may be preceded and accompanied by an inflammatory response. We previously reported on a series of patients with severe MR planned for elective mitral valve surgery who underwent Hybrid PET-MRI imaging, and demonstrated that >90% of those patients with complex ventricular ectopy had evidence of FDG uptake, suggestive of ongoing subclinical inflammation. To evaluate the presence of myocardial inflammation/fibrosis and VA burden in a cohort of patients with MVP (Barlow’s) and less than severe MR. 10 patients with degenerative MVP and mild or moderate MR by transthoracic echocardiography underwent 18F-FDG PET/MRI (“Hybrid” PET/MRI). Focal 18F-FDG uptake was evaluated as a surrogate of inflammation, and LGE imaging was evaluated for myocardial fibrosis. Ambulatory extended ECG monitoring was performed to assess VA burden and severity. Mean age was 56.3 ±11.4 years, and 70% were female. Mean LVEF and LV end-diastolic diameter were 61.8 ±5.6% and 48.3±6.2 mm. Focal 18F-FDG uptake and LGE (PET+/MRI+) were present in 70% (n=7) of patients (Figure); 1 patient had focal 18F-FDG uptake and LGE was not performed. Only 2 patients had neither inflammation or fibrosis (PET-/MRI-). Complex ventricular ectopy was detected in 80% (n=8). In a cohort of patients with only mild or moderate MR, of which a majority had complex ventricular ectopy, 70% had evidence of myocardial inflammation and fibrosis. These findings may provide insight into the observation that a majority of sudden deaths in patients with MVP occur in patients with less than severe MR, as inflammation and fibrosis are both known to be pro-arrhythmic. Future studies are needed to determine whether the presence of myocardial inflammation impacts the natural history of degenerative MVP.

A comparison between the efficacy of methylphenidate and cocaine for nasal vasoconstriction before nasal surgery—A randomized prospective study

&lt;p&gt;&lt;strong&gt;Objectives: &lt;/strong&gt;Cocaine is regularly utilized topically to give the vasoconstriction to nasal medical procedure; However, it is said to create intraoperative cardiovascular unfriendly impacts. Methylphenidate was considered in the place of cocaine as a substitute to look at the vasoconstriction in nasal medical procedure. &lt;strong&gt;Methods: &lt;/strong&gt;Outcome of the study will be examining the vasoconstriction based on a 5-point scale (1 = unacceptable, 5 = excellent), followed by the administration of either 20–30 mg per day methylphenidate or 4% cocaine randomly to the adult patients subjected to nasal septoplasty. &lt;strong&gt;Results: &lt;/strong&gt;Methylphenidate and cocaine were administered with 38 and 28 patients respectively. The quality of vasoconstriction was noticed to be good in both the groups with the median rating of 4.0 and a P value of 0.85. With both the gatherings, the median blood loss was 46 and 58 ml with a p estimation of 0.48. A non-mediocrity delta of 1 point with a p estimation of 0.009 and non-inadequacy delta of 24 ml with a p esteem 0.026 concerning vasoconstriction and blood loss individually is seen which demonstrates methylphenidate is comparable to cocaine. Non importance is noted with the recurrence of ventricular ectopy, ST section changes after nasal packing with the gatherings. &lt;strong&gt;Conclusions: &lt;/strong&gt;With the results obtained, methylphenidate can be very well replaced for cocaine for vasoconstriction in septoplasty. As there are lot many underlying chances for cocaine abuse and administrative issues related to its handling, methylphenidate may serve as a substitute.&lt;/p&gt;

Short-coupled ventricular ectopics leading to cardiac arrest in a young woman

BackgroundThis case report highlights the importance of recognizing that ventricular ectopy may be a cause for syncope and sudden cardiac death, through triggered disorganized arrhythmia. In the context of syncope, ventricular ectopy should be carefully assessed for coupling interval and morphology.Case presentationA 39-year-old woman, who had presented with recurrent syncope, had a cardiac arrest shortly after admission that required emergency defibrillation. Review of her cardiac monitoring revealed an episode of polymorphic ventricular tachycardia which had degenerated into ventricular fibrillation. The dysrhythmia had been initiated by a short-coupled (R-on-T) ventricular ectopic (VE) beat. Anti-arrhythmic therapy was initiated in the form of hydroquinidine, but the patient continued to have frequent VEs of right bundle branch block (RBBB) morphology with a relatively narrow QRS complex and a variation in frontal axis. A cardiac MRI revealed late gadolinium enhancement of the posterior papillary muscle (indicative of focal scarring). The patient underwent electrophysiological mapping and catheter ablation of her ectopy. The patient made a good recovery and was discharged from hospital with a secondary prevention implantable cardioverter-defibrillator (ICD) in situ.ConclusionsShort-couped VEs that are superimposed onto the preceding T wave (R-on-T) are indicative of electrical instability of the heart and should prompt urgent investigation. By studying the morphologies and axes of the QRS complexes produced by VEs, we can identify their likely origins and ascertain their clinical significance.

Reduced features set neural network approach based on high-resolution time-frequency images for cardiac abnormality detection

A suitable temporal and spectral processing of the electrocardiogram (ECG) signals can facilitate the visual interpretation and discrimination between known patterns for classification. This paper proposes a non-invasive hybrid neural network and time-frequency (TF) based method to detect and classify commonly found cardiac abnormalities in ECG signals including congestive heart failure, ventricular tachyarrhythmia, intracardiac atrial fibrillation, arrhythmia, malignant ventricular ectopy, normal sinus rhythm, and postictal heart rate oscillations in partial epilepsy. Non-stationary raw ECG signals are collected from an online healthcare dataset source ‘PhysioBank’ that contains physiologic signals. These temporal signals are processed through Wigner-Ville distribution to produce high-resolution and concentrated TF images depicting specific visual patterns of cardiac abnormalities. The TF images are used to extract the abnormality parameters with the help of medical experts with good diagnostic accuracy. Principal component analysis (PCA) is employed for feature reduction and important features selection from the ECG signals. The selected features are used for training the multilayer feed-forward artificial neural network (ANN) for detection and classification while training parameters like the number of epochs, activation functions, and the learning rate is suitably selected with appropriate stopping criteria. Experimental results demonstrate the effectiveness of the hybrid neural-TF approach using PCA for abnormality detection and classification.

Gentle Giant: An Unusual Cause of Heart Block

<h3>Introduction</h3> Inflammatory cardiomyopathies can be a diagnostic dilemma. Early management can lead to reduced morbidity and mortality for patients. We describe a rare presentation of an unusual cardiomyopathy. <h3>Case Report</h3> A 58-year-old female presented with a 10-day prodrome of cough, NYHA class III dyspnea, and fatigue with minimal symptoms of orthopnea, paroxysmal nocturnal dyspnea or peripheral edema. She was previously healthy with no cardiac medications. Family history was significant for granulomatosis with polyangiitis. COVID-19 swab was negative. She was symptomatic with transient complete heart block and junctional escape of 20bpm. A temporary transvenous pacemaker was placed. Echocardiogram showed biventricular dysfunction with left ventricular ejection fraction < 30%. Troponin and brain-natriuretic peptide were elevated. Coronary angiogram showed no significant occlusions. CT excluded pulmonary embolism, pneumonia, or adenopathy. She was initiated on heart failure medications but beta blocker was not started given heart block. Six days into admission, her heart failure improved but she developed transient complete heart block without junctional escape. There was no ventricular ectopy. Evaluation for rheumatologic, infectious, and inflammatory causes showed elevated C-reactive protein and antineutrophil cytoplasmic antibodies. The remainder of the workup was negative. Leading diagnoses were idiopathic giant cell myocarditis or cardiac sarcoidosis. An endomyocardial biopsy revealed multinucleated giant cells and myocyte necrosis. She was diagnosed with giant cell myocarditis. Prior to discharge, she had defibrillator insertion and was initiated on prednisone and tacrolimus. Shortly after this time, she returned with critical cardiogenic shock despite intensification of immunosuppressive therapies and was listed for cardiac transplant. <h3>Summary</h3> Giant cell myocarditis (GCM) is a rare and often fatal autoimmune cause of heart failure. Patients frequently present with congestive heart failure, ventricular arrhythmia and a rapid progression of symptoms. In GCM, it is rare to present with atrioventricular conduction delays. Given the crossover in symptoms with sarcoidosis and GCM, diagnosis may be challenging. In this case of an acute presentation of heart failure and complete heart block, endomyocardial biopsy was central to the diagnosis and management of GCM.

IDF21-0234 The Virtual COVID In-patient (VCIP) Care and Post Covid Symptoms: a Comparison with Conventional Care

Background: VCIP is a home based interventional economic model wherein a consenting patient will remain in their home and consult the VCIP team via audio-video consultations to treat COVID-19 in a manner similar to inpatient care. While the widely prevalent home-based care that is currently available is often limited to monitoring of vital signs, the VCIP program described here involves active therapeutic intervention. Aim: We assessed the impact of VCIP in the management of COVID and post COVID symptoms. Method: Since September 2020, our center has been practicing VCIP for our patients with diabetes, already enrolled in our hospital, to treat COVID and Post COVID symptoms. This is a retrospective analysis of the data of 243 COVID-19 positive patients who enrolled in VCIP. A 24/7 dedicated WhatsApp group of patients, their relatives, doctors, nurses, dietitian and a psychologist was created for remote monitoring of temperature, blood pressure, blood glucose, respiratory and pulse rate along with the symptoms and then to follow up them for 4-6 months post-COVID. The vital parameters and general wellbeing of patients are monitored once every 4 hrs. Contrary to conventional domiciliary care, in VCIP, lab investigations, corticosteroids and other interventions were carried out as and when necessary, at home for the successful management of COVID-19. For patients with diabetes on insulin, the dosages were titrated based on SMBG values or real time CGM. We also assessed the post-COVID symptoms in these patients. Results: Out of 243 patients who availed of the VCIP facility, all 243 of them recovered. However, 2 hospitalizations were there, one, due to the impending fear of death and the other one, due to intolerance to oral corticosteroids, yielding a 99.5% success rate in preventing hospitalization. There was a wide range of post-COVID-19 symptoms and illnesses experienced by <10% of the patients, which was very low compared to patients in conventional care, including headache(5%), generalized itching(7%), fatigue(20%), vertigo(<1%), urticaria(<1%), exacerbation of sinusitis(<1%), insomnia(15%), and bacterial infection(30%). The patients recovered from these symptoms within 2-3 months. Some patients who experienced more severe complications such as atrial fibrillation and ventricular ectopics (<1%) picked up in Apple watch ECG was referred to a cardiologist for evaluation. The arrhythmias disappeared spontaneously with clinical improvement in the majority of the patients. Discussion: VCIP when compared to hospitalizations have proven to be cost effective, with significantly better immediate outcomes. With regular and structured teleconsultations and lab assessments, patients likely to deteriorate are identified quite early and treatment initiated without wasting any time. The comorbidities were also aggressively managed. The significantly less occurrence of post Covid symptoms in the VCIP group compared to hospitalized patients could have resulted from these early interventions.

Idiopathic Central Diabetes Insipidus as an Etiology of Left Ventricular Suction and Ventricular Arrhythmias

<h3>Introduction</h3> Left ventricular assist device (LVAD) implantation has increased in patients with end-stage heart failure. Left ventricular suction is a known complication of LVAD therapy, with etiologies including hypovolemia, sepsis and ventricular arrhythmias. Prompt recognition of the underlying cause is crucial in the management and prevention of suction events. <h3>Case Report</h3> A 59-year-old male with non-ischemic cardiomyopathy status post LVAD and ventricular tachycardia (VT) presented with shocks from his implantable defibrillator. He noted 2-3 weeks of low flow alarms and daily suction events with associated lightheadedness and dizziness. On admission, device interrogation revealed two episodes of successfully terminated VT. His antiarrhythmic therapy and device settings were adjusted by the electrophysiology team. On day two of hospitalization, he had ventricular fibrillation associated with a suction event. He was noted to have increased urine output despite holding diuresis. LVAD speed was decreased and he was given intravenous fluids, however right heart catheterization revealed very low filling pressures despite these interventions. He continued to have polyuria despite liberalization of fluid intake and suction alarms with associated ventricular ectopy. Urine studies revealed low urine osmolality of 266 mOsm/Kg and urine sodium of 41 mmol/L. Hypertonic saline challenge resulted in hypernatremia and improved but suboptimal urine concentration. Workup for causes of nephrogenic diabetes insipidus (DI) was unrevealing. Computed tomography of the sella did not reveal any pituitary abnormalities. He was started on desmopressin and urine output appropriately decreased. He had no further ventricular arrhythmias, though he continued to have intermittent suction alarms associated with positional changes. <h3>Summary</h3> Treatment of left ventricular suction events includes correction of underlying etiology, maintaining preload, reducing LVAD speed and management of complications including ventricular arrhythmias. Our patient's suction events and ventricular arrhythmias were presumed secondary to hypovolemia in the setting of central DI and polyuria, which improved with treatment with desmopressin. In review of literature, this is the first documented case of diabetes insipidus resulting in suction events and ventricular arrhythmias.

Sarcoidosis: Hiding in Plain Sight

<h3>Introduction</h3> Sarcoidosis is a systemic disease that can masquerade as many conditions. Due to its often patchy distribution, myocardial biopsy is only ∼30% sensitive. Herein we present a case of sarcoidosis diagnosed from an extra-cardiac biopsy years after the onset of cardiomyopathy. <h3>Case Report</h3> A 54 year old man initially presented with dyspnea and fatigue due to new onset HFrEF of 20%. He had a significant family history of SCD. His workup revealed non-obstructive CAD, a myxomatous mitral valve with bileaflet prolapse and moderate regurgitation, and a cystic structure attached to the tricuspid valve. Given his frequent ventricular ectopy, he was discharged on guideline therapy for HFrEF and a wearable cardioverter defibrillator. Genetic testing for dilated cardiomyopathies revealed EYA4 and TTN variants of unknown significance. A cardiac MRI a few months later demonstrated no abnormal late gadolinium enhancement and persistent systolic dysfunction, so he underwent AICD implant. His course was further complicated by recurrent admissions for supraventricular and ventricular tachyarrhythmias. A cardiopulmonary exercise stress test demonstrated low-risk results. Further evaluation noted prolonged AV conduction. A RHC revealed mild post-capillary pulmonary hypertension and a mildly decreased cardiac index at 2.01 L/min/m². Months later, he underwent CRT-D upgrade. He started improving functionally until he developed left eyelid swelling, initially thought to be lymphoma. An orbital biopsy revealed non-caseating granulomas. A PET/CT demonstrated FDG uptake within subcarinal lymph nodes but no cardiac uptake. Initially he declined immunomodulatory therapy, but as his symptoms worsened, he started corticosteroids and transitioned to mycophenolate mofetil due to intolerance of methotrexate. Due to disease progression on repeat FDG-PET, he was switched to infliximab. <h3>Summary</h3> The diagnosis of sarcoidosis can be difficult due to its variable presentation, including heart block, heart failure, ventricular arrhythmias and sudden cardiac death. Cardiac involvement occurs in 25% of cases. Our case was complicated by a cMRI that was negative for cardiac involvement, which emphasizes the importance of complimentary inflammatory imaging with FDG-PET. A multidisciplinary approach is needed that engages sarcoid specialists for earlier diagnosis to ensure rapid initiation of therapy to reduce end-organ dysfunction.

Malignant Mitral Valve Prolapse: Risk and Prevention of Sudden Cardiac Death.

The purpose of this review is to explore the prevalence and risk factors for a malignant phenotype in mitral valve prolapse (MVP) characterized by life-threatening ventricular arrhythmias and sudden cardiac arrest and death (SCD), including mechanistic and pathophysiologic findings and mechanism-based potential therapies. A malignant phenotype in MVP characterized by life-threatening arrhythmias has long been recognized, although MVP is often benign. Efforts to identify this malignant phenotype have revealed potential risk factors for SCD that include elongated, myxomatous leaflets, ECG changes and complex ventricular ectopy. More recently, malignant MVP has been associated with myocardial fibrosis in the papillary muscles and inferobasal left ventricular wall. This localization suggests a central role of prolapse-induced mechanical forces on the myocardium in creating an arrhythmogenic substrate and triggering life-threatening arrhythmias. This mechanism for fibrosis is also consistent with imaging evidence of prolapse-induced mechanical changes in the papillary muscles and inferobasal left ventricular wall. Currently, no therapy to prevent SCD in malignant MVP has been established and limited clinical data are available. Mechanistic information and prospective study have the potential to identify patients at risk of SCD and preventive strategies. Malignant MVP relates to unique properties and mechanical abnormalities in the mitral valve apparatus and adjacent myocardium. Increased understanding of disease mechanisms and determinants of arrhythmias is needed to establish effective therapies.

Predictors of Mortality Following Aortic Valve Replacement in Aortic Stenosis Patients.

Background: Understanding of the risk factors for the development of adverse outcomes after aortic valve replacement is necessary to develop timely preventive measures and to improve the results of surgical treatment. Methods: We analyzed patients with aortic stenosis (n = 742) who underwent surgical treatment in the period 2014–2020. The average age was 63 (57;69) years—men 58%, women 42%. Results: The hospital mortality rate was 3% (22 patients). The following statistically significant threshold values (cut-off points) were obtained in the ROC analysis: aortic cross-clamp time > 93 min AUC (CI) 0.676 (0.640–0.710), p = 0.010; cardiopulmonary bypass time > 144 min AUC (CI) 0.809 (0.778–0.837), p < 0.0001, hemoglobin before op <120 g/L. AUC (CI) 0.762 (0.728–0.793), p < 0.0001, hematocrit before op <39% AUC (CI) 0.755 (0.721–0.786), p < 0.001, end-diastolic dimension index >2.39 AUC (CI) 0.647 (0.607–0.686), p = 0.014, end-systolic dimension index > 1.68 AUC (CI) 0.657 (0.617–0.695), p = 0.009. Statistically significant independent predictors of hospital mortality were identified: BMI > 30 kg/m2 (OR 2.84; CI 1.15–7.01), ischemic heart disease (OR 3.65; CI 1.01–13.2), diabetes (OR 3.88; CI 1.38–10.9), frequent ventricular ectopy before operation (OR 9.78; CI 1.91–50.2), mitral valve repair (OR 4.47; CI 1.76–11.3), tricuspid valve repair (OR 3.06; CI 1.09–8.58), 3 and more procedures (OR 4.44; CI 1.67–11.8). Conclusions: The hospital mortality rate was 3%. The main indicators associated with the risk of death were: diabetes, overweight (body mass index more than 30 kg/m2), frequent ventricular ectopy before surgery, hemoglobin level below 120 g/L, hematocrit level below 39%, longer cardiopulmonary bypass time and aortic cross-clamp time, additional mitral and tricuspid valve interventions.

Developing a Mechanistic Approach to Sudden Death Prevention in Mitral Valve Prolapse.

Sudden cardiac death (SCD) from ventricular fibrillation (VF) can occur in mitral valve prolapse (MVP) in the absence of other comorbidities including mitral regurgitation, heart failure or coronary disease. Although only a small proportion with MVP are at risk, it can affect young, otherwise healthy adults, most commonly premenopausal women, often as the first presentation of MVP. In this review, we discuss arrhythmic mechanisms in MVP and mechanistic approaches for sudden death risk assessment and prevention. We define arrhythmogenic or arrhythmic MVP (AMVP) as MVP associated with complex and frequent ventricular ectopy, and malignant MVP (MMVP) as MVP with high risk of SCD. Factors predisposing to AMVP are myxomatous, bileaflet MVP and mitral annular disjunction (MAD). Data from autopsy, cardiac imaging and electrophysiological studies suggest that ectopy in AMVP is due to inflammation, fibrosis and scarring within the left ventricular (LV) base, LV papillary muscles and Purkinje tissue. Postulated mechanisms include repetitive injury to these regions from systolic papillary muscle stretch and abrupt mitral annular dysmotility (excursion and curling) and diastolic endocardial interaction of redundant mitral leaflets and chordae. Whereas AMVP is seen relatively commonly (up to 30%) in those with MVP, MVP-related SCD is rare (2–4%). However, the proportion at risk (i.e., with MMVP) is unknown. The clustering of cardiac morphological and electrophysiological characteristics similar to AMVP in otherwise idiopathic SCD suggests that MMVP arises when specific arrhythmia modulators allow for VF initiation and perpetuation through action potential prolongation, repolarization heterogeneity and Purkinje triggering. Adequately powered prospective studies are needed to assess strategies for identifying MMVP and the primary prevention of SCD, including ICD implantation, sympathetic modulation and early surgical mitral valve repair. Given the low event rate, a collaborative multicenter approach is essential.

LDIAED: A lightweight deep learning algorithm implementable on automated external defibrillators.

Differentiating between shockable and non-shockable Electrocardiogram (ECG) signals would increase the success of resuscitation by the Automated External Defibrillators (AED). In this study, a Deep Neural Network (DNN) algorithm is used to distinguish 1.4-second segment shockable signals from non-shockable signals promptly. The proposed technique is frequency-independent and is trained with signals from diverse patients extracted from MIT-BIH, MIT-BIH Malignant Ventricular Ectopy Database (VFDB), and a database for ventricular tachyarrhythmia signals from Creighton University (CUDB) resulting, in an accuracy of 99.1%. Finally, the raspberry pi minicomputer is used to load the optimized version of the model on it. Testing the implemented model on the processor by unseen ECG signals resulted in an average latency of 0.845 seconds meeting the IEC 60601-2-4 requirements. According to the evaluated results, the proposed technique could be used by AED’s.

An Exploratory Study on Vectorcardiographic Identification of the Site of Origin of Focally Induced Premature Depolarizations in Horses, Part II: The Ventricles.

Simple SummaryVentricular arrhythmias occur commonly in horses. Knowledge on the origin of ventricular arrhythmias is essential for proper treatment. Former studies in horses showed contradictory results regarding the diagnostic value of 12-lead electrocardiography and vectorcardiography due to the anatomical differences in horses compared to humans and small animals. As a consequence, no standardized approach is available for electrocardiography electrode configurations in horses. The current study investigated whether the anatomical origin of experimentally induced ventricular premature depolarizations in horses could be differentiated based upon spherical statistics of the vectorcardiography characteristics. Vectorcardiography shows the magnitude and direction of the cardiac electrical forces in three dimensions. The vectorcardiogram was recorded in seven horses under general anesthesia while right and left ventricular pacing was performed from inside the heart. Using spherical statistics, it could be shown that pacing induces significantly different initial and maximum electrical axes between different locations and between pacing and normal sinus rhythm. The current approach could be used in clinical patients to identify the origin of ventricular arrhythmias without the need for invasive studies. The technique could also be used in other species for which a standardized electrocardiogram electrode configuration is not available.In human cardiology, the anatomical origin of ventricular premature depolarizations (VPDs) is determined by the characteristics of a 12-lead electrocardiogram (ECG). Former studies in horses had contradictory results regarding the diagnostic value of the 12-lead ECG and vectorcardiography (VCG), which results were attributed to the different cardiac conduction system in this species. The objective of this study was to determine if the anatomical origin of pacing-induced VPDs could be differentiated in horses based upon VCG characteristics. A 12-lead ECG was recorded in seven horses under general anesthesia while right and left ventricular endomyocardial pacing was performed (800–1000 ms cycle length) at the apex, mid and high septum and mid and high free wall, and at the right ventricular outflow tract. Catheter positioning was guided by 3D electro-anatomical mapping and echocardiography. A median complex, obtained from four consecutive complexes, was calculated for each pacing location and sinus rhythm. The VCG was calculated from the 12-lead ECG-derived median complexes using custom-made algorithms and was used to determine the initial and maximum electrical axes of the QRS complex. An ANOVA for spherical data was used to test if VCGs between each paced location and between pacing and sinus rhythm were significantly (p < 0.05) different. The model included the radius, azimuth and elevation of each electrical axis. Pacing induced significantly different initial and maximum electrical axes between different locations and between pacing and sinus rhythm. The current results suggest that VCG is a useful technique to identify the anatomical origin of ventricular ectopy in horses.

ECG Recurrence Plot-Based Arrhythmia Classification Using Two-Dimensional Deep Residual CNN Features.

In this paper, an effective electrocardiogram (ECG) recurrence plot (RP)-based arrhythmia classification algorithm that can be implemented in portable devices is presented. Public databases from PhysioNet were used to conduct this study including the MIT-BIH Atrial Fibrillation Database, the MIT-BIH Arrhythmia Database, the MIT-BIH Malignant Ventricular Ectopy Database, and the Creighton University Ventricular Tachyarrhythmia Database. ECG time series were segmented and converted using an RP, and two-dimensional images were used as inputs to the CNN classifiers. In this study, two-stage classification is proposed to improve the accuracy. The ResNet-18 architecture was applied to detect ventricular fibrillation (VF) and noise during the first stage, whereas normal, atrial fibrillation, premature atrial contraction, and premature ventricular contractions were detected using ResNet-50 in the second stage. The method was evaluated using 5-fold cross-validation which improved the results when compared to previous studies, achieving first and second stage average accuracies of 97.21% and 98.36%, sensitivities of 96.49% and 97.92%, positive predictive values of 95.54% and 98.20%, and F1-scores of 95.96% and 98.05%, respectively. Furthermore, a 5-fold improvement in the memory requirement was achieved when compared with a previous study, making this classifier feasible for use in resource-constricted environments such as portable devices. Even though the method is successful, first stage training requires combining four different arrhythmia types into one label (other), which generates more data for the other category than for VF and noise, thus creating a data imbalance that affects the first stage performance.