A case of acute myocardial infarction in paced rhythm. Utility of the Barcelona algorithm.

We describe the case of a 70-year-old man with a pacemaker implant who presented to us with atypical chest pain. His admission ECG did not satisfy the criteria for myocardial infarction according to standard Sgarbossa criteria, and Smith modified Sgarbossa criteria. However, we applied the recently developed Barcelona algorithm, which is used to diagnose acute myocardial infarction in the presence of intrinsic left bundle branch block.Electrocardiographic criteria for an acute myocardial infarction were met. Lead V6 displayed a low voltage QRS complex (3 mm) with 1 mm ST depression, satisfying the Barcelona criteria for acute myocardial infarction. He underwent primary angioplasty for critical in-stent restenosis of the left anterior descending coronary artery. This is the first case report, to the best of our knowledge, where Barcelona algorithm has been used to diagnose acute coronary syndrome in right-ventricular paced rhythm.

Myocardial infarction in a patient with WPW syndrome. Lifting the veil.

Wolf-Parkinson-White syndrome (WPW) syndrome can mimic myocardial infarction (MI) due to the prominent repolarization changes secondary to abnormal myocardial activation by accessory pathway. Rarely these repolarization changes might mask the classical electrocardiographic (ECG) picture of MI and present with atypical ECG features, delaying the diagnosis in the emergency room. We present a case, where the onset of the MI in WPW syndrome was identified based on delta-T wave concordance, and QRS fragmentation.

His-bundle pacing versus cardiac resynchronisation therapy: Effect on ECG parameters of repolarization.

INTRODUCTION: Cardiac resynchronization therapy (CRT) by biventricular pacing (BiV) may worsen indices of ventricular repolarization. The impact of His bundle pacing (HBP) on repolarization is not well studied in patients with left ventricular systolic dysfunction. The aim of the study is to compare the repolarization parameters in ECG between these two pacing modalities. METHODS: Baseline and post implant parameters of 20 patients who had undergone HBP were compared with 18 patients who underwent CRT (BiV) implantation. Repolarization parameters were monitored before implantation, within 24  hours and after 6 weeks of implantation. Patients were followed up till 6 months with clinical and echocardiographic parameters. RESULT: Baseline clinical, electrocardiographic and echocardiographic parameters were similar in both groups. Significant differences were noted in QTc, Tp-e and Tp-e/QTc between HBP and CRT groups both on immediate post implant and after 6 weeks of implantation. Compared to pre-implantation,significant shortening of Tp-e and Tp-e/QTc was observed immediately (90.54 ± 24.35 vs 69.62 ± 12.92, p < 0.05 and 0.20 ± 0.05 vs 0.15 ± 0.03, p < 0.05) and after 6 weeks (90.54 ± 24.35 vs 66.08 ± 14.95, p < 0.05 and 0.20 ± 0.05 vs 0.15 ± 0.02, p < 0.05) in HBP implant (group A). However, these changes were not present in CRT cohort (group B). During a follow up of 6 months, NYHA class and LV function between two groups remain comparable. CONCLUSION: HBP is associated with significant reduction of Tp-e and Tp-e/QTc compared to CRT. Further evaluation is needed to determine whether this improvement in indices of repolarization is associated with reduction in clinical arrhythmic events or not.

A dynamic Brugada sign due to left anterior descending coronary artery occlusion.

Brugada phenocopies (BrP) include several conditions with a common electrocardiographic (ECG) pattern that are indistinguishable from classical Brugada syndrome (BrS). In this report, we describe two cases of acute myocardial infarction (AMI) presenting as BrP. The majority of cases of BrP in AMI have been reported due to right coronary artery (RCA) occlusion. Rarely, the left anterior descending artery (LAD) is incriminated as the cause. In both our cases of BrP, LAD was the culprit vessel.

A case of cardiac sarcoidosis mimicking Brugada syndrome.

A 17-year-old boy was admitted for management of ventricular fibrillation (VF) with intermittent Brugada pattern on ECG. On evaluation, cardiac MRI revealed myocardial scar and mediastinal lymphadenopathy. 18-Fluorodeoxyglucose positron emission tomography scan showed inflammation in the heart, lungs, and lymph nodes. He was diagnosed as a case of cardiac sarcoidosis (CS) and treated with steroids. However, there was a reactivation of cardiac inflammation and the development of a second VF storm. Following catheter ablation, the patient's arrhythmia improved. This report highlights the inflammation due to CS mimicking channelopathic features.

CT-guided percutaneous epicardial access for ventricular tachycardia ablation: A proof-of-concept study.

INTRODUCTION: The objective of this study was to evaluate the safety and efficacy of preprocedural computed tomography (CT) to guide percutaneous epicardial puncture for catheter ablation of ventricular tachycardia. METHODS AND RESULTS: A preprocedural CT was used to plan the site, angle, and depth of needle insertion during epicardial access in 10 consecutive patients undergoing ventricular tachycardia (VT) ablation. Adjacent structures (right ventricle, diaphragm, liver, colon, internal mammary artery) were visualized and the course of the needle was planned avoiding these structures. During epicardial access, a protractor was used to guide the angle of needle entry into the subxiphoid space. Postprocedural CT was performed to calculate the deviation between the planned and executed access and to assess for any collateral damage. Percutaneous epicardial access was obtained successfully in all the patients using anterior (n = 4) and inferior (n = 6) approaches. The planned site and angle of puncture was more caudal (2.9 ± 0.9 vs. 3.7 ± 0.7 cm, p = .021) and acute (61.7 ± 5.8 vs. 49.0 ± 5.4°, p = .011) for an anterior approach compared to an inferior approach, respectively. Postprocedure CT revealed minimal deviation of the puncture site (5.4 ± 1.0 mm), angle (5.4 ± 1.2°), and length of needle insertion (0.5 ± 0.2 cm). With regard to the site of entry in the pericardial space, there was a deviation of 5.9 ± 1.1, 6.1 ± 1.1, and 5.8 ± 1.4 mm in the x, y, and z dimensions, respectively. In eight patients with minimal deviation between planned and executed access, there was no collateral injury to adjacent viscera or vessels. In two patients with increased deviation of angle and length of needle insertion, there was entry through the diaphragm during inferior access. CONCLUSIONS: Utilizing pre-procedural CT planning may aid in the success and safety of percutaneous epicardial access during VT ablation.

Prevalence, clinical profile, and stroke risk of atrial fibrillation in rural Andhra Pradesh, India (The AP-AF study) - Rationale and design.

INTRODUCTION: The epidemiology of atrial fibrillation (AF) in India has not been studied systematically in large scale population based surveys. Stroke is one of the leading causes of death and disability in India. As AF is a major contributor of stroke, it is important to know the burden of AF and stroke risk in the population. The Andhra Pradesh Atrial Fibrillation (AP-AF) study aims to assess the prevalence, etiology, risk factors and stroke risk among the rural population in Andhra Pradesh, India. METHODS: This is a cross-sectional survey done using a two-stage sampling process. Adults (≥18years) from villages in East and West Godavari districts were sampled. Field investigators used a structured questionnaire to collect information on basic demographics, cardiovascular risk factors and medical history. Anthropometric measurements were performed, blood pressure measured and fasting capillary blood glucose was assessed. Electrocardiogram was done using a hand-held mobile ECG device-KardioMobile. ECGs were interpreted by study cardiologists. Participants diagnosed to have AF were invited to participate in a camp conducted by cardiologists where echocardiogram was done and also a focused history related to AF was collected. Along with age and sex stratified prevalence of AF, descriptive statistics will be used to present demographics, clinical profile, and cardiovascular risk factors. Stroke risk will be calculated using CHA 2 DS 2 -Vasc score. CONCLUSION: The AP-AF study is expected to provide important information on AF epidemiology in rural India. The information may help improve health care policies in preventing stroke and other complications of AF.

Mitral valve tuberculoma: Role of sequential multimodality imaging of an unusual intracardiac mass.

We present an unusual intracardiac mass posing a diagnostic dilemma. A middle-aged male patient was referred for workup of a symptomatic cardiac mass involving the mitral valve. Multimodality imaging consisting of cardiac magnetic resonance (CMR) imaging and 18F-fluorodeoxyglucose positron emission computerized tomography (18FDG-PET) scan was utilized to further characterize the mass after initial echocardiographic identification. CMR imaging identified extent of valvular mass into the interatrial septum and basal portion of the interventricular septum. On 18FDG-PET scan, the intracardiac mass was found to be metabolically active. It also revealed the presence of FDG avid lymph nodes in the abdomen. Histology of the lymph node revealed active granulomatous inflammation suggestive of tuberculosis. Treatment with antitubercular therapy resulted in resolution of the mass and mitral regurgitation, avoiding surgery.

Best Practices for the Catheter Ablation of Ventricular Arrhythmias.

Techniques for catheter ablation have evolved to effectively treat a range of ventricular arrhythmias. Pre-operative electrocardiographic and cardiac imaging data are very useful in understanding the arrhythmogenic substrate and can guide mapping and ablation. In this review, we focus on best practices for catheter ablation, with emphasis on tailoring ablation strategies, based on the presence or absence of structural heart disease, underlying clinical status, and hemodynamic stability of the ventricular arrhythmia. We discuss steps to make ablation safe and prevent complications, and techniques to improve the efficacy of ablation, including optimal use of electroanatomical mapping algorithms, energy delivery, intracardiac echocardiography, and selective use of mechanical circulatory support.

Prevalence, clinical profile, and stroke risk of atrial fibrillation in rural Andhra Pradesh, India (the AP-AF study).

The burden of atrial fibrillation (AF) is increasing worldwide. It is often asymptomatic, with stroke being the first manifestation in some. AF burden in the community and the practice of stroke prophylaxis has not been studied in India. The problem might be higher in rural regions due to poor health awareness and challenges to healthcare access. This study aimed to estimate the prevalence of AF, clinical profile and stroke risk in rural India. METHODS: This is a community-based cross-sectional study done in rural Andhra Pradesh (AP). Adults from 40 villages formed the study population. We did a door-to door survey to collect information on demographics, and medical history. Electrocardiogram was recorded using a smart phone based Alivecor device. Participants diagnosed with AF underwent echocardiogram. Study cardiologists assessed the cardiovascular risk profile and collected detailed medical history. RESULTS: Fourteen of the 4281 individuals screened had AF (0.3%). The mean age of the sampled population was 44 ± 16.5 years with 56% women. The mean age of participants with AF was 71 ±7.8 years; males were 71%. Except for one, all were non-valvular AF. Majority had a CHA2D2S2Vasc score of ≥2. Three had history of stroke. Two were on anticoagulant therapy but without INR monitoring. CONCLUSION: The prevalence of AF is lower in this study compared to studies from the developed countries. Non-rheumatic cardiovascular risk factors were primary causes for AF. Non-adherence to stroke prophylaxis is a major threat that needs to be addressed.

Arrhythmia During Anaphylaxis-An Intrinsic or Extrinsic Cause?

A patient in their 50s presented to the emergency department (ER) within 30 minutes of ingestion of prawns at a restaurant with complaints of an itchy skin rash, and generalized weakness; his pulse rate was 79 bpm, his blood pressure was 50/30 mm Hg, and his respiratory rate was 20 per minute. What is your diagnosis?