Anatomical considerations and clinical interpretation of the 12-lead ECG in the prone position: a prospective multicentre study.

AIMS: The aim of this study is to provide guidance for the clinical interpretation of electrocardiograms (ECGs) in prone position and to establish the electroanatomic explanations for the possible differences to supine position ECGs that may be observed. Additionally, to determine if prone back ECG can be used as an alternative to standard ECG in patients who may benefit from prone position. METHODS AND RESULTS: The ECG in supine (standard ECG), prone back (precordial leads placed on the patient's back), and prone anterior position (precordial leads placed in the standard position with the subjects in prone position) were prospectively examined on 85 subjects. Comparisons of ECG parameters between these positions were performed. Computed tomography (CT) scans were performed in both positions to determine possible electroanatomic aetiologies for prone-associated ECG changes. There were significant differences in QRS amplitude in Leads V1-V5 between supine and prone positions. Q waves were more frequently observed in prone back position vs. supine position (V1: 74.1 vs. 10.6%, P < 0.0001; V2: 23.5 vs. 0%, P < 0.0001, respectively). Flat and inverted T waves were more common in prone back leads (V1: 98 vs. 66%, P < 0.0001; V2: 96 vs. 8%, P < 0.0001; V3: 45 vs. 7%, P < 0.0001). The 3D-CT reconstructions measurements corroborated the significant inverse correlation between QRS amplitude and the distance from the centre of the heart to the estimated lead positions. CONCLUSION: In prone back position ECG, low QRS amplitude should not be misinterpreted as low voltage conditions, neither should Q waves and abnormal T waves are considered anteroseptal myocardial infarction. These changes can be explained by an increased impedance (due to interposing lung tissue) and by the increased distance between the electrodes to the centre of the heart.

The Entero-Mammary Pathway and Perinatal Transmission of Gut Microbiota and SARS-CoV-2.

COVID-19 is a severe respiratory disease threatening pregnant women, which increases the possibility of adverse pregnancy outcomes. Several recent studies have demonstrated the ability of SARS-CoV-2 to infect the mother enterocytes, disturbing the gut microbiota diversity. The aim of this study was to characterize the entero-mammary microbiota of women in the presence of the virus during delivery. Fifty mother−neonate pairs were included in a transversal descriptive work. The presence of SARS-CoV-2 RNA was detected in nasopharyngeal, mother rectal swabs (MRS) and neonate rectal swabs (NRS) collected from the pairs, and human colostrum (HC) samples collected from mothers. The microbiota diversity was characterized by high-throughput DNA sequencing of V3-16S rRNA gene libraries prepared from HC, MRS, and NRS. Data were analyzed with QIIME2 and R. Our results indicate that several bacterial taxa are highly abundant in MRS positive for SARS-CoV-2 RNA. These bacteria mostly belong to the Firmicutes phylum; for instance, the families Bifidobacteriaceae, Oscillospiraceae, and Microbacteriaceae have been previously associated with anti-inflammatory effects, which could explain the capability of women to overcome the infection. All samples, both positive and negative for SARS-CoV-2, featured a high abundance of the Firmicutes phylum. Further data analysis showed that nearly 20% of the bacterial diversity found in HC was also identified in MRS. Spearman correlation analysis highlighted that some genera of the Proteobacteria and Actinobacteria phyla were negatively correlated with MRS and NRS (p < 0.005). This study provides new insights into the gut microbiota of pregnant women and their potential association with a better outcome during SARS-CoV-2 infection.

Epicardial access complications during electrophysiology procedures.

INTRODUCTION: Percutaneous epicardial access (EA) was first described more than two decades ago. Since its initial introduction, indications for its utilization in the field of electrophysiology have expanded dramatically. DISCUSSION: Epicardial mapping and ablation in patients with ventricular tachycardia is routinely performed in tertiary electrophysiology centers around the world. Although limited by lack of randomized controlled trials, epicardial ablation for atrial fibrillation has been suggested as a conjunctive strategy in patients who have failed an initial endocardial catheter ablation attempt, and it is necessary for placement of some left atrial appendage occlusion devices as well. An accurate understanding of the cardiac anatomy is crucial to avoid complications such as inadvertent right ventricular puncture, injury to the coronary arteries, abdominal viscera, phrenic nerves, and esophagus during both EA and catheter ablation. CONCLUSION: The aim of this review is to provide a comprehensive overview of the cardiac anatomy, technical aspects to optimize the safety of epicardial puncture, recognize and avoid potential complications.

Current practice in transvenous lead extraction in Latin America: Latin American Heart Rhythm Association survey.

BACKGROUND: Transvenous lead extraction (TLE) is standard of care for the management of patients with cardiac implantable electronic device infection or lead-related complications. Currently, objective data on TLE in Latin America is lacking. OBJECTIVE: To describe the current practice standards in Latin American centers performing TLE. METHODS: An online survey was sent through the mailing list of the Latin American Heart Rhythm Society. Online reminders were sent through the mailing list; duplicate answers were discarded. The survey was available for 1 month, after which no more answers were accepted. RESULTS: A total of 48 answers were received, from 44 different institutions (39.6% from Colombia, 27.1% from Brazil), with most respondents (82%) being electrophysiologists. Twenty-nine institutions (66%) performed <10 lead extractions/year, with 7 (16%) institutions not performing lead extraction. Although most institutions in which lead extraction is performed reported using several tools, mechanical rotating sheaths were cited as the main tool (66%) and only 13% reported the use of laser sheaths. Management of infected leads was performed according to current guidelines. CONCLUSION: This survey is the first attempt to provide information on TLE procedures in Latin America and could provide useful information for future prospective registries. According to our results, the number of centers performing high volume lead extraction in Latin America is smaller than that reported in other continents, with most interventions performed using mechanical tools. Future prospective registries assessing acute and long-term success are needed.

Chagas heart disease: A contemporary review.

Chagas disease is caused by a parasite infection endemic of the Americas. Traditionally observed in rural areas of Latin America, current migration trends have turned Chagas disease into a global epidemic. Acute infection is rarely severe and once it resolves, some patients can develop cardiomyopathy as part of the chronic form many years later. Multiple factors related with both the host and the parasite determine the susceptibility and progression to cardiomyopathy. Current imaging techniques are able to identify cardiac autonomic denervation, perfusion abnormalities, and myocardial fibrosis at an early of stage before the development of symptoms. The prognosis of patients with Chagasic cardiomyopathy remains poor and life-threatening ventricular arrhythmias can occur at an early stage. Treatment of chronic Chagas cardiomyopathy is challenging with a great need for more studies in the field.

Guidelines in review: Comparison of ESC and ACC/AHA guidelines for the diagnosis and management of patients with stable coronary artery disease.

In 2012, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) Task Force on Practice Guidelines jointly with the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons produced a set of recommendations intended to assist physicians in the diagnosis and management of patients with stable ischemic heart disease. Two years later, a focused update on the 2012 guidelines was published. A year before this update, The Task Force on the management of stable coronary artery disease (CAD) of the European Society of Cardiology (ESC) issued a guideline on the management of stable CAD. This document brings together European and American recommendations that include the use of stress testing and non-invasive imaging for the diagnosis and management of patients with known or suspected stable CAD.

Comparison of ESC and ACC/AHA guidelines for myocardial revascularization.

In 2014, the Task Force on Myocardial Revascularization of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery with the special contribution of the European Association of Percutaneous Cardiovascular Interventions published a comprehensive set of recommendations on myocardial revascularization in patients presenting with acute or chronic coronary artery disease. In the United States, pertinent guidance on this topic has been published by the American College of Cardiology, American Heart Association and other relevant societies in multiple guideline documents that have been published in recent years. This document brings together European and American recommendations on myocardial revascularization with a focus on the role of cardiac imaging.

Differential effects of nebivolol vs. metoprolol on microvascular function in hypertensive humans.

Use of ß-adrenergic receptor (AR) blocker is associated with increased risk of fatigue and exercise intolerance. Nebivolol is a newer generation ß-blocker, which is thought to avoid this side effect via its vasodilating property. However, the effects of nebivolol on skeletal muscle perfusion during exercise have not been determined in hypertensive patients. Accordingly, we performed contrast-enhanced ultrasound perfusion imaging of the forearm muscles in 25 untreated stage I hypertensive patients at rest and during handgrip exercise at baseline or after 12 wk of treatment with nebivolol (5-20 mg/day) or metoprolol succinate (100-300 mg/day), with a subsequent double crossover for 12 wk. Metoprolol and nebivolol each induced a reduction in the resting blood pressure and heart rate (130.9 ± 2.6/81.7 ± 1.8 vs. 131.6 ± 2.7/80.8 ± 1.5 mmHg and 63 ± 2 vs. 64 ± 2 beats/min) compared with baseline (142.1 ± 2.0/88.7 ± 1.4 mmHg and 75 ± 2 beats/min, respectively, both P < 0.01). Metoprolol significantly attenuated the increase in microvascular blood volume (MBV) during handgrip at 12 and 20 repetitions/min by 50% compared with baseline (mixed-model P < 0.05), which was not observed with nebivolol. Neither metoprolol nor nebivolol affected microvascular flow velocity (MFV). Similarly, metoprolol and nebivolol had no effect on the increase in the conduit brachial artery flow as determined by duplex Doppler ultrasound. Thus our study demonstrated a first direct evidence for metoprolol-induced impairment in the recruitment of microvascular units during exercise in hypertensive humans, which was avoided by nebivolol. This selective reduction in MBV without alteration in MFV by metoprolol suggested impaired vasodilation at the precapillary arteriolar level.

Mechanisms of sudden cardiac death.

Sudden cardiac death (SCD) continues to be a major public health problem and is thought to account for almost half of all cardiac deaths. Cardiac arrest and SCD are most commonly due to ventricular arrhythmias. Most patients who suffer cardiac arrest have underlying structural heart disease, with coronary artery disease (CAD) being the most common. In the setting of CAD, ventricular arrhythmias can result due to acute ischemia in the absence of preexisting myocardial scarring or in the presence of established scar from prior infarction without clinically significant ischemia. LV systolic dysfunction is an important predictor of risk for SCD in ischemic heart disease and in most nonischemic disorders, although other factors such as ventricular hypertrophy also play a role. Cardiac arrest and SCD can also occur due to primary electrical disorders in the absence of major structural abnormalities.

A Mobile and Low-Cost System for Environmental Monitoring: A Case Study.

Northern Italy has one of the highest air pollution levels in the European Union. This paper describes a mobile wireless sensor network system intended to complement the already existing official air quality monitoring systems of the metropolitan town of Torino. The system is characterized by a high portability and low cost, in both acquisition and maintenance. The high portability of the system aims to improve the spatial distribution and resolution of the measurements from the official static monitoring stations. Commercial PM 10 and O 3 sensors were incorporated into the system and were subsequently tested in a controlled environment and in the field. The test in the field, performed in collaboration with the local environmental agency, revealed that the sensors can provide accurate data if properly calibrated and maintained. Further tests were carried out by mounting the system on bicycles in order to increase their mobility.

The evaluation and treatment of endocrine forms of hypertension.

Endocrine hypertension is an important secondary form of hypertension, identified in between 5% and 10% of general hypertensive population. Primary aldosteronism is the most common cause of endocrine hypertension, accounting for 1%-10% in uncomplicated hypertension and 7%-20% in resistant hypertension. Other less common causes of endocrine hypertension include Cushing syndrome, pheochromocytoma, thyroid disorders, and hyperparathyroidism. Diagnosis requires a high index of suspicion and the use of appropriate screening tests based on clinical presentation. Failure to make proper diagnosis may lead to catastrophic complications or irreversible hypertensive target organ damage. Accordingly, patients who are suspected to have endocrine hypertension should be referred to endocrinologists or hypertension specialists who are familiar with management of the specific endocrine disorders.

Hybrid convergent procedure with proactive oesophageal cooling for the treatment of long-standing persistent atrial fibrillation: a case series.

Background: The hybrid convergent procedure is approved to treat symptomatic patients with long-standing persistent atrial fibrillation (AF). Despite direct visualization during surgical ablation as well as the use of luminal oesophageal temperature (LET) monitoring, oesophageal injury is still possible. A dedicated device for proactive oesophageal cooling has recently been cleared by the Food and Drug Administration to reduce the likelihood of ablation-related oesophageal injury resulting from radiofrequency cardiac ablation procedures. This report describes the first uses of proactive oesophageal cooling for oesophageal protection during the epicardial ablation portion of hybrid convergent procedures. Case summary: Five patients with long-standing persistent AF underwent hybrid convergent ablations with the use of proactive oesophageal cooling as means of oesophageal protection. All cases were completed successfully with no adverse effects. Most notably, cases were shorter when compared to cases using LET monitoring, likely due to lack of pauses for overheating of the oesophagus that would otherwise be required to prevent damage to the oesophagus. Discussion: This report describes the first uses of proactive oesophageal cooling for oesophageal protection during the epicardial ablation portion of five hybrid convergent procedures. Use of cooling enabled uninhibited deployment of lesions without the need to pause energy delivery due to elevated temperatures in the oesophagus, providing a feasible alternative to LET monitoring.

Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review.

Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.

Left Bundle Branch Pacing vs Left Ventricular Septal Pacing vs Biventricular Pacing for Cardiac Resynchronization Therapy.

BACKGROUND: Left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP) are considered to be acceptable as LBBAP strategies. Differences in clinical outcomes between LBBP and LVSP are yet to be determined. OBJECTIVES: The purpose of this study was to compare the outcomes of LBBP vs LVSP vs BIVP for CRT. METHODS: In this prospective multicenter observational study, LBBP was compared with LVSP and BIVP in patients undergoing CRT. The primary composite outcome was freedom from heart failure (HF)-related hospitalization and all-cause mortality. Secondary outcomes included individual components of the primary outcome, postprocedural NYHA functional class, and electrocardiographic and echocardiographic parameters. RESULTS: A total of 415 patients were included (LBBP: n = 141; LVSP: n = 31; BIVP: n = 243), with a median follow-up of 399 days (Q1-Q3: 249.5-554.8 days). Freedom from the primary composite outcomes was 76.6% in the LBBP group and 48.4% in the LVSP group (HR: 1.37; 95% CI: 1.143-1.649; P = 0.001), driven by a 31.4% absolute increase in freedom from HF-related hospitalizations (83% vs 51.6%; HR: 3.55; 95% CI: 1.856-6.791; P < 0.001) without differences in all-cause mortality. LBBP was also associated with a higher freedom from the primary composite outcome compared with BIVP (HR: 1.43; 95% CI: 1.175-1.730; P < 0.001), with no difference between LVSP and BIVP. CONCLUSIONS: In patients undergoing CRT, LBBP was associated with improved outcomes compared with LVSP and BIVP, while outcomes between BIVP and LVSP are similar.

Real-world data of radiofrequency catheter ablation in paroxysmal atrial fibrillation: Short- and long-term clinical outcomes from the prospective multicenter REAL-AF Registry.

BACKGROUND: The safety and long-term efficacy of radiofrequency (RF) catheter ablation (CA) of paroxysmal atrial fibrillation (PAF) has been well established. Contemporary techniques to optimize ablation delivery, reduce fluoroscopy use, and improve clinical outcomes have been developed. OBJECTIVE: The purpose of this study was to assess the contemporary real-world practice approach and short and long-term outcomes of RF CA for PAF through a prospective multicenter registry. METHODS: Using the REAL-AF (Real-world Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation; ClincalTrials.gov Identifier: NCT04088071) Registry, patients undergoing RF CA to treat PAF across 42 high-volume institutions and 79 experienced operators were evaluated. The procedures were performed using zero or reduced fluoroscopy, contact force sensing catheters, wide area circumferential ablation, and ablation index as a guide with a target of 380-420 for posterior and 500-550 for anterior lesions. The primary efficacy outcome was freedom from all-atrial arrhythmia recurrence at 12 months. RESULTS: A total of 2470 patients undergoing CA from January 2018 to December 2022 were included. Mean age was 65.2 ±11.14 years, and 44% were female. Most procedures were performed without fluoroscopy (71.5%), with average procedural and total RF times of 95.4 ± 41.7 minutes and 22.1±11.8 minutes, respectively. At 1-year follow-up, freedom from all-atrial arrhythmias was 81.6% with 89.7% of these patients off antiarrhythmic drugs. No significant difference was identified comparing pulmonary vein isolation vs pulmonary vein isolation plus ablation approaches. The complication rate was 1.9%. CONCLUSION: Refinement of RF CA to treat PAF using contemporary tools, standardized protocols, and electrophysiology laboratory workflows resulted in excellent short- and long-term clinical outcomes.

Utility of the NavX® Electroanatomic Mapping System for Permanent Pacemaker Implantation in a Pregnant Patient with Chagas Disease.

Chagas disease is a highly prevalent zoonosis in Mexico, Central, and South America. Early cardiac involvement is one of the most serious complications of this disease, and conduction disturbances may occur at an early age. We describe a young pregnant woman with Chagas disease and a high degree atrioventricular block, who required implantation of a permanent dual chamber pacemaker. Using an electroanatomic navigation EnSite NavX® system the pacemaker was successfully implanted with minimal fluoroscopic exposure. This case demonstrates the safety and feasibility of using an electroanatomic navigation system to guide permanent pacemaker implantation minimizing x-ray exposure in pregnant patients.

Fluoroless catheter ablation of atrial fibrillation: a step-by-step workflow.

Catheter ablation is an important therapeutic strategy for patients with atrial fibrillation (AF). While some critical steps of the procedure have traditionally relied on fluoroscopy, advances in electroanatomic mapping and the growing use of intracardiac echocardiography have made non-fluoroscopic AF ablation a reality. This hands-on review provides an overview on how to perform radiofrequency ablation of AF without the use of fluoroscopy, focusing on technical aspects, new technologies, and troubleshooting.

Cystic Tumor of the Atrioventricular Node Causing Rapid-Onset and Reversible Complete Heart Block.

Cystic tumors of the atrioventricular node are rare primary cardiac neoplasms, frequently reported as a postmortem diagnosis during autopsy. Despite their small size, they can present with complete heart block or sudden cardiac death. Herein, we present a case of rapidly progressing high-grade atrioventricular block that improved after surgery. (Level of Difficulty: Intermediate.).

Catheter Ablation of Left Ventricular Summit Arrhythmias from Adjacent Anatomic Vantage Points.

Idiopathic ventricular arrhythmias (VA), particularly left ventricular outflow tract (LVOT) VA accounts for up to 10% of all VAs referred for ablative therapy. In addition to being infrequent, its intricate anatomy and its pathophysiology make catheter ablation (CA) of these arrhythmias a challenge even for experts. In this scenario, detailed right ventricular outflow tract as well as LVOT electroanatomic mapping including epicardial mapping are essential. In this article, we will emphasize our approach toward the CA technique used for LVOT VA, particularly IVS and/or LVS VA originating from intramural foci, along with its acute and long-term efficacy and safety.