The Average Age of Atrioventricular Block Onset in Middle Eastern Patients with Cardiac Rhythm Devices Adjusted for the Overall Young Population: Insights from a Multicenter International Registry.

Background: Previous registries have shown a younger average age at presentation with cardiovascular diseases in the Middle East (ME), but no study has examined atrioventricular block (AVB). Moreover, these comparisons are confounded by younger populations in the ME. We sought to describe the average age at presentation with AVB in ME and quantify the effect of being from ME, adjusted for the overall younger population. Methodology: This was a retrospective analysis of PANORAMA registries, which collected data on patients who underwent cardiac rhythm device placement worldwide. Countries with a median population age of ≤30 were considered 'young countries'. Multivariate linear regression was performed to assess the effect of being from ME, adjusted for being from a 'young country', on age at presentation with AVB. Results: The study included 5,259 AVB patients, with 640 (8.2%) from the ME. Mean age at presentation was seven years younger in ME than in other regions (62.9 ± 17.8 vs. 70 ± 14.1, P < 0.001). Being from a 'young country' was associated with 5.6 years younger age at presentation (95%CI -6.5--4.6), whereas being from ME was associated with 3.1 years younger age at presentation (95%CI -4.5--1.8), (P < 0.001 for both). Conclusion: The average age at presentation with AVB in the ME is seven years younger than in other regions. While this is mostly driven by the overall younger population, being from the ME appears to be independently associated with younger age. Determinants of the earlier presentation in ME need to be assessed, and care should be taken when applying international recommendations.

Burden of bradycardia and barriers to accessing bradycardia therapy in underserved countries.

Bradycardia, a condition characterized by an abnormally slow heart rate, poses significant challenges in terms of diagnosis and treatment. While it is a concern world-wide, low- and middle-income countries (LMICs) face substantial barriers in accessing appropriate bradycardia therapy. This article aims to explore the global aetiology and incidence of bradycardia, compare the prevalence and management of the condition in high-income countries versus LMICs, identify the key reasons behind the disparities in access to bradycardia therapy in LMICs, and emphasize the urgent need to address these disparities to ensure equitable healthcare on a global scale.

The Reliability of the Apple Watch's Electrocardiogram.

Background An electrocardiogram (ECG) is a standard tool used to detect various cardiovascular abnormalities. Detection sensitivity for atrial fibrillation (AF) was recently shown to be greatly increased by using short, intermittent ECG recordings. Modern mobile ECG recording devices that can monitor patients' heart activities around the clock have made this a reality. The Apple Watch is one of these portable ECG devices that can detect heart rhythms and is approved by the American FDA for screening and detecting AF. Objectives We compared the results of the Apple Watch I lead ECG with conventional ECG results to assess the sensitivity and specificity of the Apple Watch I lead ECG. We then determined the abnormalities that can be detected by the Apple Watch I lead ECG. Methods This study was conducted on outpatient cardiac clinics at King Abdullah bin Abdulaziz University Hospital (KAAUH), and Prince Sultan Cardiac Center (PSCC), from May to October 2021. A standard 12-lead ECG was recorded and compared with the Apple Watch I lead ECG. A total of 469 ECG comparisons were included in this study and evaluated by two investigators. The data on patient demographics, medical and medication history, and ECG data were reviewed and analyzed using IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States). Results No significant differences were seen between the Apple Watch and the 12-lead ECG in terms of the studied ECG characteristics. A significant and strong positive correlation between the heart rate measurements in the 12-lead ECG and Apple Watch ECG was documented. The most commonly found abnormalities in the Apple Watch ECG were AF in 37 (7.9%), followed by first-degree atrioventricular (AV) block in 32 (6.8%). The sensitivity of Apple Watch's automated interpretation to detect an AF was 99.54%, while the manual interpretation yielded a sensitivity of 100%. Conclusion The results of this study demonstrated a robust relationship between the 12-lead ECG and Apple Watch ECG in the diagnosis of arrhythmias. Consequently, cardiac patients may consider the Apple Watch ECG a trustworthy remote monitoring technique.

Long-term reverse remodeling and clinical improvement by MultiPoint Pacing in a randomized, international, Middle Eastern heart failure study.

PURPOSE: Cardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing (MultiPoint™ Pacing, MPP) has been shown to improve CRT response, although MPP response using automated pacing vector programming has not been demonstrated in the Middle East. The purpose of this study was to compare the impact of MPP to conventional biventricular pacing (BiV) using echocardiographic and clinical changes at 6-month post-implant. METHODS: This prospective, randomized study was conducted at 13 Middle Eastern centers. After de novo CRT-D implant (Abbott Unify Quadra MP™ or Quadra Assura MP™) with quadripolar LV lead (Abbott Quartet™), patients were randomized to either BiV or MPP therapy. In BiV patients, the LV pacing vector was selected per standard practice; in MPP patients, the two LV pacing vectors were selected automatically using VectSelect. CRT response was defined at 6-month post-implant by a reduction in LV end-systolic volume (ESV) ≥ 15%. RESULTS: One hundred and forty-two patients (61 years old, 68% male, NYHA class II/III/IV 19%/75%/6%, 33% ischemic, 57% hypertension, 52% diabetes, 158 ms QRS, 25.8% ejection fraction [EF]) were randomized to either BiV (N = 69) or MPP (N = 73). After 6 months, MPP vs. BiV patients experienced greater ESV reduction (25.0% vs. 15.3%, P = 0.08), greater EF improvement (11.9% vs. 8.6%, P = 0.36), significantly greater ESV response rate (68.5% vs. 50.7%, P = 0.04), and significantly greater NYHA class improvement rate (80.8% vs. 60.3%, P = 0.01). CONCLUSIONS: With MPP and automatic LV vector selection, more CRT patients in the Middle East experienced reverse remodeling and clinical improvement relative to conventional BiV pacing.

Brucella cardiac implantable electronic device infection: A single-center case series.

BACKGROUND: Cardiac implantable electronic devices (CIEDs), including implantable cardiac defibrillators, pacemakers, and cardiac resynchronization therapy devices, are lifesaving. However, device infections can lead to morbidity and mortality. The aim of this study was to describe the outcome of Brucella CIED infections treated at our center, and to identify risk factors for Brucella infection in patients with CIEDs. Study Settings: Single-center study, Prince Sultan Military Medical City, Riyadh, KSA. METHODS: This case series included all Brucella-related CIED infections treated at a tertiary care center between 2009 and 2020. Data on patient demographics, clinical manifestations, predisposing factors, microbiology, treatment regimens, and outcomes were reviewed. RESULTS: Fifteen patients met the Brucella CIED infection criteria. The mean age was 62.2 years, and 80% were males. Common comorbidities included hypertension (73%), diabetes mellitus (67%), ischemic heart disease (47%), and chronic kidney disease (60%). The mean time to infection following the device implantation was 4.8 years (range: 5 months to 13 years). Fever was detected in 53% of patients, device site swelling in 47%, purulent discharge in 33%, and pain in 27%. The blood culture and serology results were positive in 73% and 80% of patients, respectively. All patients were treated with antibiotics, and the infected device was removed. Seven (46.6%) patients underwent reimplantation with a new device. One patient with dual Brucella and methicillin-sensitive Staphylococcus aureus infection died, and the other 14 patients recovered, with no recurrent infections reported to date. CONCLUSION: Brucella should be considered in CIED infections, particularly in endemic areas. Proper treatment and device removal are essential for good outcomes.

Rescue axillary artery covered stent during transvenous cardiac device implantation.

Injury to axillary and subclavian arteries during cardiac rhythm device implantation might lead to significant mortality and morbidity especially in those with a low body mass index (BMI). We report the case of 65-year-old underweight male patient with BMI of 15.1 (height 166 cm, weight 41.8 kg) with long-standing dilated cardiomyopathy who underwent cardiac resynchronization therapy with defibrillator implantation. Left pre pectoral pocket as well as three separate axillary vein accesses were obtained smoothly. While suturing the right ventricular lead sleeve to the underlying muscle a significant amount of arterial bleed was suddenly encountered without a clear source. Traumatic injury to the axillary artery caused by the suture needle was suspected. An immediate angiography of the left axillary artery via femoral approach showed a significant axillary artery side branch leakage adjacent to the sleeve suture site. A covered stent was deployed to the axillary artery which effectively controlled the bleeding immediately. The procedure was then carried out in the usual manner.

Remotely monitored inactivity due to COVID-19 lockdowns. Potential hazard for heart failure patients.

OBJECTIVES: To study the impact of curfews during the COVID-19 pandemic, on the physical activity in patients of heart failure implanted withcardiac implantable electronic devices (CIEDs). METHODS: This was a retrospective single-center study of heart failure patients inserted with remote monitoring (RM)-capable CIED. We analyzed the transmitted data of physical activity and fluid volume status of all patients, before, and during the lockdown periods between February and April 2020. The clinical status of the patients was also evaluated.  Results: Device data from 429 patients implanted with CIED capable of RM were initially evaluated. Patients with an implantable loop recorder, Brugada or Long QT syndromes, and patients with incomplete transmissions were excluded. Eighty-two patients with heart failure were included. The median age was 65 years (58-72), and 53 (64.6%) subjects were men. There was a 27.1% decline in physical activity, and the median physical activity of patients significantly declined from 2.4 to 1.8 hours/day (p=0.000010).  Conclusion: Data obtained by remotely monitored CIED in heart failure patients suggests a significant decline in physical activity during the country lockdown due to the pandemic. Awareness of the future potential hazards in this group of patients is warranted.

Effects of Ramadan fasting on the symptoms of chronic heart failure.

[No Abstract Available].

Image Quality of Cardiac Magnetic Resonance Imaging in Patients With an Implantable Cardioverter Defibrillator System Designed for the Magnetic Resonance Imaging Environment.

BACKGROUND: Recently, magnetic resonance (MR)-conditional implantable cardioverter defibrillator (ICD) systems have become available. However, associated cardiac MR image (MRI) quality is unknown. The goal was to evaluate the image quality performance of various cardiac MR sequences in a multicenter trial of patients implanted with an MR-conditional ICD system. METHODS AND RESULTS: The Evera-MRI trial enrolled 275 patients in 42 centers worldwide. There were 263 patients implanted with an Evera-MRI single- or dual-chamber ICD and randomized to controls (n=88) and MRI (n=175), 156 of whom underwent a protocol-required MRI (9-12 weeks post implant). Steady-state-free-precession (SSFP) and fast-gradient-echo (FGE) sequences were acquired in short-axis and horizontal long-axis orientations. Qualitative and quantitative assessment of image quality was performed by using a 7-point scale (grades 1-3: good quality, grades 6-7: nondiagnostic) and measuring ICD- and lead-related artifact size. Good to moderate image quality (grades 1-5) was obtained in 53% and 74% of SSFP and FGE acquisitions, respectively, covering the left ventricle, and in 69% and 84%, respectively, covering the right ventricle. Odds for better image quality were greater for right ventricle versus left ventricle (odds ratio, 1.8; 95% confidence interval, 1.5-2.2; P<0.0001) and greater for FGE versus SSFP (odds ratio, 3.5; 95% confidence interval, 2.5-4.8; P<0.0001). Compared with SSFP, ICD-related artifacts on FGE were smaller (141±65 versus 75±57 mm, respectively; P<0.0001). Lead artifacts were much smaller than ICD artifacts (P<0.0001). CONCLUSIONS: FGE yields good to moderate quality in 74% of left ventricle and 84% of right ventricle acquisitions and performs better than SSFP in patients with an MRI-conditional ICD system. In these patients, cardiac MRI can offer diagnostic information in most cases. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02117414.

A delayed spontaneous expulsion of a three teeth bridge after 6 months period of aspiration in the right lung following cardiac surgery.

Aspiration of loose teeth is a well-known complication of endo-tracheal intubation hence the importance of oral check by anesthetist prior to ventilation. Artificaial teeth crown (single) or bridges (multiple) can be fixed or removable by the patient. The presence of a foreign body in the lung tissue or airways is a clinical situation that needs aggressive management as it can lead to refractory infections and possible death. We report this unique case of aspirarin of a three bridge teeth (10 mm × 30 mm) following cardiac surgery. The case is complicated by pneumonia, chronic cough and severe bouts of cyanosis and finally removed by spontaneous expulsion after 6 months following forceful cough.

An Initiative Technique to Facilitate Axillary Vein Puncture During CRT Implantation.

OBJECTIVES: The aim of the study was to describe a new technique to minimize requirement of contrast and the time to puncture the axillary vein during implantation of cardiac resynchronization therapy (CRT) devices. BACKGROUND: One of the challenges to the wide applications of CRT has been the technical difficulty encountered while obtaining venous access utilizing axillary venous puncture. This is mainly due to vague anatomical land marks. The axillary vein is the preferred access point because of fewer associated risks and better lead protection in the future. METHODS: We introduced a 0.035 mm guidewire retrogradely from the femoral vein up to the left axillary vein. A single anteroposterior scene at 7.5 frames/second was captured while the guidewire was in the vein. The scene was kept as a roadmap for the axillary vein puncture during the implantation procedure. RESULTS: The axillary vein was accessed in all patients (100%) and the time to axillary vein puncture was <1 minute in 36 patients (41%) and between 1-5 minutes in the remaining patients. There were no related vascular complications and no contrast venography was required. CONCLUSION: The use of retrograde axillary vein wiring simplifies axillary venous puncture and minimizes the need for contrast media during CRT device implantation without compromising visualized anatomy.

Full-Body MRI in Patients With an Implantable Cardioverter-Defibrillator: Primary Results of a Randomized Study.

BACKGROUND: Magnetic resonance imaging (MRI) of patients with conventional implantable cardioverter-defibrillators (ICD) is contraindicated. OBJECTIVES: This multicenter, randomized trial evaluated safety and efficacy of a novel ICD system specially designed for full-body MRI without restrictions on heart rate or pacing dependency. The primary safety objective was >90% freedom from MRI-related events composite endpoint within 30 days post-MRI. The primary efficacy endpoints were ventricular pacing capture threshold and ventricular sensing amplitude. METHODS: Subjects received either a single- or dual-chamber ICD. In a 2:1 randomization, subjects either underwent MRI at 1.5-T of the chest, cervical, and head regions to maximize radiofrequency exposure up to 2 W/kg specific absorption rate and gradient field exposure to 200 T/m/s per axis (MRI group, n = 175), or they underwent a 1-h waiting period without MRI (control group, n = 88). A subset of MRI patients underwent ventricular fibrillation induction testing post-MRI to characterize defibrillation function. RESULTS: In 42 centers, 275 patients were enrolled (76% male, age 60.4 ± 13.8 years). The safety endpoint was met with 100% freedom from the composite endpoint (p < 0.0001). Both efficacy endpoints were met with minimal differences in the proportion of MRI and control patients who demonstrated a ≤0.5 V increase in ventricular pacing capture threshold (100% MRI vs. 98.8% control, noninferiority p < 0.0001) or a ≤50% decrease in R-wave amplitude (99.3% MRI vs. 98.8% control, noninferiority p = 0.0001). A total of 34 ventricular tachyarrhythmia/ventricular fibrillation episodes (20 induced; 14 spontaneous) occurred in 24 subjects post-MRI, with no observed effect on sensing, detection, or treatment. CONCLUSIONS: This is the first randomized clinical study of an ICD system designed for full-body MRI at 1.5-T. These data support that the system is safe and the MRI scan does not adversely affect electrical performance or efficacy. (Confirmatory Clinical Trial of the Evera MRI System for Conditionally-Safe MRI Access; NCT02117414).

MRI scanning in patients with new and existing CapSureFix Novus 5076 pacemaker leads: randomized trial results.

BACKGROUND: Magnetic resonance imaging (MRI) can be safely performed in patients with magnetic resonance (MR)-conditional pacemaker systems but remains relatively contraindicated with non-MR-conditional pacemaker systems. OBJECTIVE: The purpose of this study was to evaluate the safety of MRI without positioning restrictions in patients with an MR-conditional pacemaker and currently a non-MR-conditional Medtronic CapSureFix Novus 5076 lead(s). METHODS: The study randomized 266 patients in a 2:1 ratio to the MRI group (177 patients) or to the control group (89 patients). At 9-12 weeks postimplant, the MRI group underwent MRI at 1.5 T. Primary end points were MRI-related complication-free rate and noninferiority of the MRI group compared to the control group with regard to the proportion of patients with an increase of ≤0.5 V in right atrial (RA) and right ventricular (RV) pacing capture thresholds from immediately before MRI to 1-month after MRI. RESULTS: No MRI-related complications occurred in 156 MRI-scanned patients who were followed through 1-month post-MRI. Differences in the proportion of patients with ≤0.5 V pacing capture threshold changes from pre-MRI to 1-month post-MRI were minimal between the groups for RA (proportions of 100% in both groups; a P value cannot be calculated) and RV leads (proportions of 99.3% in the MRI group and 100% in the control group; noninferiority test, P < .0001). Proportions of patients with acceptable sensing amplitude changes from pre-MRI to 1-month post-MRI were also similar between the 2 groups for RA and RV leads (noninferiority test, P < .0001 and P = .0004, respectively). No arrhythmias occurred during MRI. CONCLUSION: MRI scans can be performed safely without positioning restrictions in patients with Medtronic CapSureFix Novus 5076 leads connected to an MR-conditional pacemaker.

The Gulf Implantable Cardioverter-defibrillator Registry: Rationale, Methodology, and Implementation.

BACKGROUND: The implantable cardioverter-defibrillator (ICD) is effective in the prevention of sudden cardiac death in high-risk patients. Little is known about ICD use in the Arabian Gulf. We designed a study to describe the characteristics and outcomes of patients receiving ICDs in the Arab Gulf region. METHODS: Gulf ICD is a prospective, multi-center, multinational, and observational study. All adult patients 18 years or older, receiving a de novo ICD implant and willing to sign a consent form will be eligible. Data on baseline characteristics, ICD indication, procedure and programing, in-hospital, and 1-year outcomes will be collected. Target enrollment is 1500 patients, which will provide adequate precision across a wide range of expected event rates. RESULTS: Fifteen centers in six countries are enrolling patients (Saudi Arabia, United Arab Emirates, Kuwait, Oman, Bahrain, and Qatar). Two-thirds of the centers have dedicated electrophysiology laboratories, and in almost all centers ICDs are implanted exclusively by electrophysiologists. Nearly three-quarters of the centers reported annual ICD implant volumes of ≤150 devices, and pulse generator replacements constitute <30% of implants in the majority of centers. Enrollment started in December 2013, and accrual rate increased as more centers entered the study reaching an average of 98 patients per month. CONCLUSIONS: Gulf ICD is the first prospective, observational, multi-center, and multinational study of the characteristics and, the outcomes of patients receiving ICDs in the Arab Gulf region. The study will provide valuable insights into the utilization of and outcomes related to ICD therapy in the Gulf region.

An initiative to minimize amount of contrast media utilizing a novel rotational coronary sinus occlusive venography technique with ordinary cath-lab X-ray machine during CRT implantation.

BACKGROUND: Rotational angiography is one of the latest angiographic modalities to map the coronary venous tree anatomy. It provides a significant reduction in both contrast agent usage and radiation dose (up to 30%), without compromising the clinical utility of images. Hence, the present study was conducted to describe a new technique to minimize the amount of contrast media used during cardiac resynchronization therapy (CRT) implantation. METHOD: The SL3 sheath was inserted into the right atrium via the femoral vein followed by withdrawal of the dilator. The tip of the sheath was manipulated to the vicinity of the coronary sinus (CS) ostium (OS). The CS was entered using a deflated balloon catheter. The sheath was then advanced gently beyond the CS OS. Occlusive venography was performed using 5-8 ml of contrast media in a rotational view starting from 45 degrees LAO to 0 degrees AP while holding the inflated balloon for a few seconds. RESULT: Data from 30 consecutive patients who underwent CRT implantation were analyzed. The feasibility of rotational angiography, while occluding the CS with a specialized long, preshaped sheath and using an ordinary cath-lab imaging machine, was supported by the correctly delineated CS anatomy of all patients without any complications and death related to the placement of the CS catheters or sheaths. The mean contrast dose used for the entire procedure in all patients undergoing CRT was 14.76 +/- 6.8 ml. CONCLUSION: Use of rotational CS occlusive venography utilizing an ordinary cath-lab X-ray machine minimizes the use of contrast media during CRT implantation without compromising the visualized anatomy.

Transient sinus node dysfunction with acute hepatitis of unknown etiology.

We reported a case of a 72-year-old male, known diabetic on insulin, referred because of complete atrioventricular block. He was found to have acute hepatitis during which he developed transient atrial arrhythmia, and sinus node dysfunction. His cardiac symptoms disappeared completely after hepatitis improvement. All of his cardiac investigations were normal including electrocardiogram, echocardiography and thalium stress test. At 3 and 6 months follow up, his Holter monitoring did not show any further arrhythmia, and he denied any further episodes of palpitation or pre-syncope. We reviewed the literature regarding the relationship between hepatitis and atrial arrhythmia.

Maneuvering balloon occlusion technique to deflect LV lead into a target branch during CRT implantation.

Implantation of specifically designed left ventricular (LV) lead is a relatively complex procedure that depends on the anatomy of the coronary veins, available instrumentation, and experience of the operator. In patients with dilated cardiomyopathy (DCM) tortuosity of the selected branch of coronary sinus (CS) leads to difficult or failed LV placement. A case study of a 45-year-old woman with DCM requiring lead placement is presented here. To plan for proper LV lead positioning, CS angiography was obtained through right femoral vein approach with preshaped long sheath (SJM, SL3) and occlusive balloon. For successful implant of LV lead, with no viable alternatives available, the tortuosity of the lateral and posterolateral branch were overcome by advancing and inflating the balloon in the main CS to deflect LV lead into the target branch. A unipolar LV lead (Medtronic 4193) was finally placed in a true posterolateral position with excellent sensing and pacing threshold without phrenic nerve stimulation.

Safe and effective use of conscious sedation for defibrillation threshold testing during ICD implantation.

BACKGROUND: Over a period of years general anesthesia has been a standard anesthetic technique for defibrillation threshold (DFT) testing at the time of implant. DFT testing without general anesthesia cover has gained limited acceptance. Use of local anesthesia combined with deep sedation for DFT testing might facilitate and simplify these procedures by reducing the procedural time, staff time, avoiding inefficient service in organizing anesthetic cover; thereby improving patient compliance. OBJECTIVE: The objective of this study was to evaluate feasibility, safety and efficacy of conscious sedation for DFT testing during Implantable cardioverter defibrillators (ICD) implantation. METHOD: Data of 87 non-selected patients who achieved adequate sedation with titrated doses of midazolam and pethidine were analyzed retrospectively. These medications were administered by a circulating nurse under the supervision of the implanting physicians. All hemodynamic measures, treatment and complications were monitored and recorded throughout the procedure. RESULTS: A retrospective analysis of data from 87 patients who underwent ICD implantation and DFT testing under conscious sedation at our center was reported. The mean dose of midazolam and pethidine administered was 4.9 ± 1.8 and 47.7 ± 20 mg, respectively. During the period of conscious sedation, no patient depicted episode of sustained apnea. No major complication or mortality was reported. CONCLUSION: Use of conscious sedation as an alternative to the use of general anesthesia for DFT testing during ICD implantation is found to be feasible, safe and effective, with an added advantage of reduced procedural time and improved patient compliance.