Outcome of tailored therapy in rheumatic heart disease with persistent atrial fibrillation (RHD-AF).

INTRODUCTION: Rheumatic heart disease with persistent atrial fibrillation (RHD-AF) is associated with increased morbidity. However, there is no standardized approach for the maintenance of sinus rhythm (SR) in them. We aimed to determine the utility of a stepwise approach to achieve SR in RHD-AF. METHODS: Consecutive patients with RHD-AF from July 2021 to August 2023 formed the study cohort. The stepwise approach included pharmacological rhythm control and/or electrical cardioversion (Central illustration). In patients with recurrence, additional options included AF ablation or pace and ablate strategy with conduction system pacing or biventricular pacing. Clinical improvement, NT-proBNP, 6-Minute Walk Test (6MWT), heart failure (HF) hospitalizations, and thromboembolic complications were documented during follow-up. RESULTS: Eighty-three patients with RHD-AF (mean age 56.13 ± 9.51 years, women 72.28%) were included. Utilizing this approach, 43 (51.81%) achieved and maintained SR during the study period of 11.04 ± 7.14 months. These patients had improved functional class, lower NT-proBNP, better distance covered for 6MWT, and reduced HF hospitalizations. The duration of AF was shorter in patients who achieved SR, compared to those who remained in AF (3.15 ± 1.29 vs 6.93 ± 5.23, p = 0.041). Thirty-five percent (29) maintained SR after a single cardioversion over the study period. Only one underwent AF ablation. Of the 24 who underwent pace and ablate strategy, atrial lead was implanted in 22 (hybrid approach), and 50% of these achieved and maintained SR. Among these 24, none had HF hospitalizations, but patients who maintained SR had further improvement in clinical and functional parameters. CONCLUSIONS: RHD-AF patients who could achieve SR with a stepwise approach, had better clinical outcomes and lower HF hospitalizations.

Radiofrequency catheter ablation of ventricular arrhythmias in patients with hypertrophic cardiomyopathy.

BACKGROUND: Compared to other non-ischemic substrates, there is limited data on the role and outcome of catheter ablation in HCM. The objective of this study is to assess the safety and efficacy of catheter ablation for the treatment of VT in patients with HCM. METHODS: Fourteen patients with HCM and drug refractory VT who underwent catheter ablation at a single center were included in this study. The data was evaluated retrospectively. Acute success, procedure-related complications, and long-term outcomes were documented during follow up. RESULTS: Among the 14 patients (mean age 48.2 ± 8.2 years, 85.7% males, mean LVEF 42.6 ± 6.5%), 4 had an apical aneurysm. Eleven patients had evidence of scar-related VT and three patients had a bundle-branch re-entry VT. The most common sites for scar-related VT were the border-zones of the apical aneurysms, basal septum, and LV lateral wall. Patient either underwent an endocardial ablation or a combined endocardial and epicardial ablation. Acute success was achieved in all patients. In 6 patients VT was terminated during ablation. In two patients, non-clinical VTs were inducible at the end of the procedure. No major or minor complications were observed during and after the procedure in all patients. During long-term follow up, elimination of VTs reached 78%. CONCLUSION: Catheter ablation of VT in patients with HCM is safe and successful in eliminating VT. Combining endocardial and epicardial ablation techniques can potentially lead to better outcomes in these patients. Bundle branch re-entry should be considered as a potential mechanism of VT in patients with HCM.

High rate episodes in a dual chamber pacemaker: What is the mechanism?

Detection of high rate episodes can potentially result from oversensing of physiological or nonphysiological signals. Assessment of lead integrity, lead connection and analysis of noise characteristics on electrograms are decisive steps in the evaluation of oversensing. We report a case of high atrial and ventricular rate episodes due to minute ventilation oversensing in the presence of lead connector issues.

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 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.

Refractory heart failure with LBBB - Pause before CRT.

In this report, we describe complete disappearance of LBBB with normalization of LV function in two patients with cardiac sarcoidosis (CS) after immunosuppressive therapy. Both of these patients were ideal Class IA candidates for CRT (Complete LBBB, QRS ≥ 150 ms, EF < 30%). If CS is identified early, immunosuppressive treatment can lead to not only improvement of left ventricular function but also disappearance of the left bundle branch block. Timely diagnosis and management of CS obviated the need of CRT in these patients. It may be reasonable to evaluate all non-ischemic cardiomyopathies for underlying reversible causes prior to CRT implantation.

PVCs with multiple exits and single site of origin in the outflow tract: What is the mechanism?

A 40 year old man with frequent PVCs with two different morphologies was referred for catheter ablation. Although initial mapping in the RVOT revealed fragmented potentials 20ms earlier than PVC2 onset with a good pace map score, ablation at this site was unsuccessful. Subsequent mapping in the LCC/NCC junction revealed that local ventricular activation preceded QRS onset by 30 and 28 ms for PVC1 and PVC2, respectively. Altering the pacing output at this site produced QRS morphologies similar to PVC1(low output,6mA) and PVC2(high output,15mA) with better pace map scores compared to RVOT. During high-output pacing, there was an increase in stim-QRS latency with decremental conduction. Ablation at this site was successful and suppressed both PVCs.

Inappropriate defibrillator shock due to oversensing. What is the mechanism?

Implantable cardioverter defibrillator (ICD) is often advised for secondary prevention of sudden cardiac death. Inappropriate shocks from ICD is uncommon but can seriously affect the quality of life. One of the reasons for inappropriate ICD shock is loose set screw, which may remain undetected by device interrogation and/or fluoroscopy. A 55-year lady presented with multiple inappropriate shocks few hours after an ICD implantation. The discrepancy between near field (NF, tip to ring) and far field (FF, Can to RV coil) signals helped us to suspect noise related to loose set screw, as the underlying problem. Re-exploration of the pocket had to be performed as the last resort to confirm the diagnosis and rectify the problem.

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.

Impact of the inflammation on the outcomes of catheter ablation of drug-refractory ventricular tachycardia in cardiac sarcoidosis.

INTRODUCTION: Catheter ablation (CA) of ventricular tachycardia (VT) in cardiac sarcoidosis (CS) has been reported with varying success. However, there is a scarcity of data on the outcomes of CA based on ongoing inflammation. OBJECTIVE: We hypothesized that the response to VT ablation depends upon the stage of the disease. METHODS: Between July 2004 and December 2018, 24 patients of CS presented with drug-refractory VT at CARE Hospital (Hyderabad) and the University of Minnesota (Minneapolis, MN). Patients were classified into two groups based on cardiac magnetic resonance imaging and positron emission tomography: (a) inflammatory phase, (b) scar phase. All patients underwent 3D electro-anatomic mapping guided CA. RESULTS: The clinical VT was ablated in all but one patient. In 16 patients (66.6%), both the clinical and nonclinical VTs were ablated (complete success), while in seven patients (29.1%) nonclinical VTs was still inducible. In patients with inflammation (group A), complete success for VT ablation was achieved in 10 out of 17 (58.8%). In patients without inflammation (group B), complete success was achieved in six out of seven patients (85.7%). Eleven patients (45.8%) had a recurrence of VT. Among patients in the inflammatory phase (group A): 10 out of 17 patients had a recurrence of VT, while only one out of seven patients in the scar phase (group B) had VT recurrence over a mean follow-up of 5.7 ± 3.9 years. Epicardial ablation was performed in 10 (41.6%) patients. CONCLUSION: CA of drug-refractory VT in CS is effective, often requiring the epicardial approach. Incomplete success and recurrence of VT were higher in the inflammatory phase of the disease.

Underdiagnosis of VT due to cycle length variation among cardiac sarcoidosis patients having ICD: Problem with stability discriminator.

BACKGROUND: Implantable cardioverter defibrillator (ICD) is recommended for patients with ventricular tachycardia (VT) due to cardiac sarcoidosis (CS). Programming supraventricular tachycardia (SVT) discriminators (onset, stability, and morphology/template match) is generally recommended to minimize inappropriate therapies. However, VT in patients with CS is known to show cycle length variability (CLV) and pleomorphism. OBJECTIVE: To determine whether the stability criterion, designed to prevent inappropriate therapy during atrial fibrillation with rapid ventricular rates, could potentially lead to incorrect classification of VT as SVT and inappropriately delay or inhibit ICD therapy. METHODS: Cases of biopsy-proven CS with VT were analyzed. For patients with implanted devices, all recorded electrograms of tachycardia episodes and ICD therapies were analyzed at last follow up. RESULTS: A total of 142 patients were included (mean age 38 years, 87 males). One hundred and three of 142 patients had implanted devices (ICD or CRT-D). Thirty eight of 103 (36.9%) patients received appropriate ICD therapies over 3 ± 2.2 years follow up. Four of 38 (10.5%) of patients experienced delayed-detection or underdetection of VT related to CLV, resulting in VT counters being repeatedly "reset" (classified as "unstable" rhythms). Retrospective analysis of other VT episodes in 70 of 103 (68%) patients revealed that 25 of 80 (31.3%) episodes had > 50 ms cycle length oscillations. CONCLUSION: Among CS patients with VT, CLV is a common occurrence seen in two-thirds of VT episodes. Routine programming of the stability criterion may result in underdetection of VT in a subset of such patients. We recommend that the stability criterion should be programmed "OFF" for patients with CS, unless the patient has documented atrial fibrillation.

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.

Impact of interventricular delay on repolarization parameters in patients with biventricular pacing.

A 48-year-old man who was previously a responder to cardiac resynchronization therapy (CRT) presented with worsening of heart failure and reduction in the percentage biventricular (BiV) pacing. Device interrogation revealed T-wave oversensing that was eliminated by optimizing the interventricular (VV) delay. Compared to simultaneous BiV pacing, both sequential left ventricle-right ventricle (LV-RV) and univentricular LV pacing shortened the QTc, T peak-end intervals and reduced the T wave amplitude. Modification of VV delays can result in changes in wavefront of activation and thereby affect ventricular repolarization patterns.

Outflow-tract ventricular tachycardia: Can 12 lead ECG during sinus rhythm identify underlying cardiac sarcoidosis?

BACKGROUND: Patients with outflow tract ventricular tachycardia (OTVT) with normal echocardiogram are labeled as idiopathic VT (IVT). However, a subset of these patients is subsequently diagnosed with underlying cardiac sarcoidosis (CS). OBJECTIVE: Whether electrocardiogram (ECG) abnormalities in sinus rhythm (SR) can differentiate underlying CS from IVT. METHODS: We retrospectively analyzed the SR-ECGs of 42 patients with OTVT/premature ventricular complexes (PVC) and normal echocardiography. All underwent advanced imaging with cardiac magnetic resonance (CMR)/18FDG PET-CT for screening of CS. Twenty-two patients had significant abnormalities in cardiac imaging and subsequently had biopsy-proven CS (Cases). Twenty patients had normal imaging and were categorized as IVT (Controls). SR-ECGs of all patients were analyzed by 2 independent, blinded observers. RESULTS: Baseline characteristics were comparable. Among the ECG features analyzed - fascicular (FB) or bundle branch block (BBB) was seen in 9/22 Cases vs. 1/20 controls (p = 0.01). Among patients without FB or BBB, fragmented QRS (fQRS) was present in 9/13 cases but in none of the controls (p < 0.001). Low voltage QRS was more often seen among cases as compared to controls (10/22 vs. 3/20 p = 0.03). A stepwise algorithm based on these 3 sets of ECG findings helped to diagnose CS among patients presenting with OTVT/PVC with sensitivity of 91%, specificity of 75%, a PPV of 80%, and a NPV of 88%. CONCLUSIONS: In patients presenting with OTVT/PVC: FB/BBB, fQRS, and low QRS voltage on the baseline ECG were more often observed among patients with underlying CS as compared to true IVT. These findings may help to distinguish underlying CS among Cases presenting with OTVT/PVC.

Serum angiotensin converting enzyme, Erythrocyte sedimentation rate and high sensitive-C reactive protein levels in diagnosis of cardiac sarcoidosis- where do we stand?

BACKGROUND: Cardiac sarcoidosis (CS) is increasingly being recognized in the last two decades. The diagnosis of CS depends on clustering of multiple symptoms, investigations and demonstration of a non-caseating granuloma on histopathology. Serum Angiotensin Converting Enzyme (SACE) level, one of the serological markers, is often elevated in systemic sarcoidosis. However, the yield of SACE level among patients with isolated or predominant CS is unclear. We conducted a retrospective study to assess the prevalence of elevated SACE level among patients with proven CS. MATERIALS AND METHODS: From our Granulomatous myocarditis (GM) registry, 45 biopsy proven CS patients were enrolled. INCLUSION CRITERIA: Clinical diagnosis of CS [HRS definition + Lymph Node biopsy/Endomyocardial biopsy (non-caseating granuloma)]. Exclusion criteria - Other causes of GM like cardiac tuberculosis (TB culture/AFB smear -positive) and patients taking medications affecting SACE level. RESULTS: Among 143 GM cases, 45 CS were analyzed. Mean age:42 ± 11 years (Range 22-63 years, 19 females). With our laboratory reference of SACE (Normal range: 20-70 U/L), 3 out of 45 (6.7%) patients of CS had elevated SACE. In a comparative analysis we found, Erythrocyte Sedimentation Rate (ESR) and High sensitive-C Reactive Protein (Hs-CRP) are much more sensitive, although not specific for CS. Patients with pulmonary involvement more often had elevated SACE level. CONCLUSION: Serum ACE is elevated only in approximately 6.7% of patients with biopsy proven CS. Hence, it is insensitive serological tool for diagnosis of CS even in the active phase of the disease. In contrast, ESR and Hs-CRP emerges to be more sensitive markers of active CS.

Severe left ventricular systolic dysfunction after permanent pacemaker implantation: Should we pause before upgrading to biventricular pacing?

Left ventricular (LV) systolic dysfunction leading to heart failure (HF) is known to occur after permanent pacemaker implantation (PPI) in a subset of patients. They are often treated by upgradation of the pacemaker to cardiac resynchronisation therapy (CRT). We report a case of progressive LV dysfunction and HF after PPI. Cardiac 18FDG-PET-CT scan revealed abnormal myocardial FDG uptake suggestive of cardiac sarcoidosis (CS). Biopsy from FDG avid lymph node demonstrated non-caseating granuloma. Therapy with steroids resulted in resolution of HF symptoms accompanied by a significant improvement in LV function.

Rosuvastatin: Role in Secondary Prevention of Cardiovascular Disease.

Cardiovascular (CV) diseases are a major cause of premature death and disability. Non-communicable diseases (NCD) are responsible for 52% of mortality amongst Indians, of these CV diseases are responsible for 66% of NCD mortality in India. We not only need widespread primary preventive strategy but also need effective secondary prevention protocols to reduce this. Secondary prevention in patients who already had myocardial infarction (MI) or revascularization is of utmost importance to reduce mortality, cardiac events and improve quality of life. Lifestyle changes and medical therapy have a very important role in secondary prevention of CVD. Optimal control of hypertension, diabetes mellitus and dyslipidemia plays a critical role in secondary prevention. Statins are one of the most commonly used drugs in secondary prevention as a part of medical therapy. Effective LDL reduction, more patients achieving LDL goals, reduction in intima thickness, improvement in endothelial dysfunction, reduction in inflammatory markers are considered to be surrogate markers of reduced risk with statins. Rosuvastatin is one of the two most commonly used statins. It is a potent, effective and safe HMG-COA reductase inhibitor. Data related to secondary prevention is limited with rosuvastatin. Most of the clinical evidences with rosuvastatin have shown more effective LDL reduction than other statins. More number of patients achieve LDL goals and reduction in intima thickness. This article attempts to explore data on role of rosuvastatin for secondary prevention.

Tailored approach for management of ventricular tachycardia in cardiac sarcoidosis.

INTRODUCTION: Treating ventricular tachycardia (VT) in patients with cardiac sarcoidosis (CS) is challenging as patients present in different phase of the disease (inflammatory, scar, or sometimes both). A  customized approach to treatment is required for better outcomes. We describe our experience in the management of VT in CS based on the phase of the disease. METHODS AND RESULTS: Patients were considered to have myocardial inflammation if there was an increased myocardial 18 fluorodeoxy glucose (FDG) uptake in PET-CT scan of the chest (n = 14). These patients were treated with antiarrhythmic drugs (AADs) and immunosuppression. Patients with scar related VT (without active inflammation) were managed with AADs and underwent radiofrequency ablation (RFA) if unresponsive to drug therapy (n = 4). Patients previously treated for CS who presented with VT and evidence of reactivation (abnormal FDG uptake) after a quiescent period of 6 months were treated with intensified immunosuppression alongside AADs (n = 3/14). Patients with myocardial inflammation responded well to immunosuppression. Patients with drug resistant VT in the scar phase responded well to RFA. Four patients in the inflammatory group had recurrence of VT during follow-up of whom 3 were found to have disease reactivation. Intensified immunosuppression suppressed VT in all 3 patients. In 1 patient, VT recurrence was found to be scar related and required RFA for control. CONCLUSION: Tailoring therapy for VT in CS according to the phase of disease results in good clinical outcome and avoids unnecessary immunosuppression.

Catheter ablation of recurrent polymorphic tachycardia: Use of sodium channel blockade to organize the tachycardia: A case report.

A 55 year old male presented with recurrent implantable cardioverter defibrillator (ICD) shocks due to polymorphic ventricular tachycardia (PMVT). He had undergone prior catheter ablation for VT three years ago. During the prior attempt he underwent voltage guided substrate ablation. With programmed ventricular extrastimulation (PVES), PMVT was repeatedly induced requiring DC shock. Intravenous procainamide was administered and PVES was repeated which induced sustained monomorphic ventricular tachycardia (MMVT). This VT had pseudo delta waves with maximum deflection index of 0.68, suggestive of epicardial origin. Activation mapping was performed epicardially. Presystolic potentials were recorded in mid anterolateral wall of left ventricular epicardial region. Radiofrequency (RF) ablation at this site terminated the VT. Post ablation there was no inducible tachycardia and patient is free of arrhythmias during 2 years of follow-up.