Ripple mapping: Initial multicenter experience of an intuitive approach to overcoming the limitations of 3D activation mapping.

BACKGROUND: Ripple mapping (RM) displays electrograms as moving bars over a three-dimensional surface displaying bipolar voltage, and has shown in a single-center series to be effective for atrial tachycardia (AT) mapping without annotation of local activation time or window-of-interest assignment. We tested the reproducibility of these findings in operators naïve to RM, using it for the first time in postablation AT. METHODS: Maps were collected with multielectrode catheters and CARTO ConfiDENSE. A diagnosis of the tachycardia mechanism was made using RM and an assessment of operator confidence was made according to a three-grade scale (1 highest-3 lowest). RESULTS: The first 20 patients (64 ± 9 years, median two previous ablations) undergoing RM-guided AT ablation across five sites were studied. High-density maps (2,935 ± 1,328 points) in AT (CL = 296 ± 95 milliseconds) were collected. Macroreentrant ATs bordered by scar or anatomical obstacles were identified in n = 12 (60%), small reentrant ATs around scar in n = 3 (15%), and focal ATs from scar in n = 5 (25%). Diagnostic confidence with RM was grade 1 in n = 13 (65%), where operators felt confident to proceed to ablation without entrainment. Ablation offered the correct diagnosis n = 18 (90%). Retrospective review of the accompanying LAT maps demonstrated potential sources for error related to the window of interest selection, interpolation, and differentiating regions of scar during tachycardia on the voltage map. CONCLUSION: RM was easy to adopt by operators using it for the first time, and identified the correct target for ablation with high diagnostic confidence in most cases of complex AT.

Dual-site right ventricular pacing in patients undergoing cardiac resynchronization therapy: Results of a multicenter propensity-matched analysis.

BACKGROUND: Dual-site right ventricular pacing (Dual RV) has been proposed as an alternative for patients with heart failure undergoing cardiac resynchronization therapy (CRT) with a failure to deliver a coronary sinus (CS) lead. Only short-term hemodynamic and echocardiographic results of Dual RV are available. We aimed to assess the long-term results of Dual RV and its impact on survival. METHODS: Multicenter retrospective assessment of all CRT implants during a 12-year period. Patients with failed CS lead implantation, treated with Dual RV, were followed and assessed for the primary endpoint of all-cause mortality and/or heart transplant. A control group was obtained from contemporary patients using propensity matching for all available baseline variables. RESULTS: Ninety-three patients were implanted with Dual RV devices and compared with 93 matched controls. During a median of 1,273 days (interquartile range 557-2,218), intention-to-treat analysis showed that all-cause mortality and/or heart transplant was higher in the Dual RV group (adjusted hazard ratio [HR] = 1.66, 95% confidence interval [CI] 1.12-2.47, P = 0.012). As-treated analysis yielded similar results (HR = 1.97, 95% CI 1.31-2.96, P = 0.001). Cardiac device-related infections occurred seven times more frequently in the Dual RV site group (HR = 7.60, 95% CI 1.51-38.33, P = 0.014). Among Dual RV nonresponders, four had their apical leads switched off, five required an epicardial LV lead insertion, a transseptal LV lead was implanted in two, and in nine patients, after reviewing the CS venogram, a new CS lead insertion was successfully attempted. CONCLUSION: Dual RV pacing is associated with worse clinical outcomes and higher complication rates than conventional CRT.

Extended bipolar left ventricular pacing as a possible therapy for late electrical storm induced by cardiac resynchronization therapy.

Although cardiac resynchronization therapy (CRT) has become a well-established treatment option for patients with drug-refractory severe systolic heart failure, there has been some evidence of adverse proarrhythmic events. We report a case of a patient with ischemic cardiomyopathy who underwent CRT with a defibrillator for primary prevention of sudden cardiac death. Two years after the implantation, the patient presented with electrical storm, which was completely terminated by modifying the left ventricular (LV) pacing configuration from true to extended bipolar LV pacing. We discuss the possible pathophysiologic mechanisms of this phenomenon through a brief review of the literature on CRT-induced proarrhythmia.

Ventricular stimulus site influences dynamic dispersion of repolarization in the intact human heart.

The spatial variation in restitution properties in relation to varying stimulus site is poorly defined. This study aimed to investigate the effect of varying stimulus site on apicobasal and transmural activation time (AT), action potential duration (APD) and repolarization time (RT) during restitution studies in the intact human heart. Ten patients with structurally normal hearts, undergoing clinical electrophysiology studies, were enrolled. Decapolar catheters were placed apex to base in the endocardial right ventricle (RVendo) and left ventricle (LVendo), and an LV branch of the coronary sinus (LVepi) for transmural recording. S1-S2 restitution protocols were performed pacing RVendo apex, LVendo base, and LVepi base. Overall, 725 restitution curves were analyzed, 74% of slopes had a maximum slope of activation recovery interval (ARI) restitution (Smax) > 1 (P < 0.001); mean Smax = 1.76. APD was shorter in the LVepi compared with LVendo, regardless of pacing site (30-ms difference during RVendo pacing, 25-ms during LVendo, and 48-ms during LVepi; 50th quantile, P < 0.01). Basal LVepi pacing resulted in a significant transmural gradient of RT (77 ms, 50th quantile: P < 0.01), due to loss of negative transmural AT-APD coupling (mean slope 0.63 ± 0.3). No significant transmural gradient in RT was demonstrated during endocardial RV or LV pacing, with preserved negative transmural AT-APD coupling (mean slope -1.36 ± 1.9 and -0.71 ± 0.4, respectively). Steep ARI restitution slopes predominate in the normal ventricle and dynamic ARI; RT gradients exist that are modulated by the site of activation. Epicardial stimulation to initiate ventricular activation promotes significant transmural gradients of repolarization that could be proarrhythmic.

Ventricular Arrhythmia Burden in Patients With Heart Failure and Cardiac Resynchronization Devices: The Importance of Renal Function.

BACKGROUND: Chronic kidney disease (CKD) is a risk factor for arrhythmias in patients with heart failure (HF). However, the effects of CKD on ventricular arrhythmia (VA) burden in patients with cardiac resynchronization therapy and defibrillator (CRT-D) devices in a primary prevention setting are unknown. OBJECTIVE: To determine whether baseline CKD is associated with increased risk of VA in patients implanted with primary prevention CRT-D devices. METHODS AND RESULTS: In this retrospective study, 199 consecutive primary prevention CRT-D recipients (2005-2010) were stratified by estimated glomerular filtration rate (eGFR) levels prior to device implantation with 106 (53.2%) ≥CKD III (eGFR < 60 mL/min/1.73 m2 ) (CKD group). CKD group patients were significantly older (70.0 ± 10 years vs. 61.3 ± 12 years, P < 0.05) with higher prevalence of ischemic cardiomyopathy (56.2% vs. 40.2%, P < 0.05). Detected ventricular tachycardia (VT)/ventricular fibrillation (VF) episodes resulting in device therapy occurred significantly more frequently in the CKD group [40/106(37.8%)] than controls [24/93(25.8%)], (odd ratio [OR] = 1.74, 95% confidence interval [CI] = 1.01-3.2, P = 0.05). At 5-year follow-up, interval censored data analysis showed 41% VT/VF incidence in the CKD group compared to 24% incidence in controls (P < 0.05). Cox proportional hazards model identified CKD > III as the only predictor of sustained VA in this group (adjusted hazard ratio [HR] 2.92, CI = 1.39-6.1, P = 0.004). CONCLUSION: Baseline CKD is a strong independent risk factor for VA in primary prevention CRT-D recipients. Further understanding of the underlying arrhythmogenic mechanisms relating to CKD may be of interest to allow appropriate correction and prevention. Device programming in this cohort may need to reflect this increased risk.

Use of electroconvulsive therapy (ECT) in postpartum psychosis--a naturalistic prospective study.

Postpartum psychosis (PPP) is a severe psychiatric condition requiring rapid restoration of health in view of significant risks to both mother and the infant. Electroconvulsive therapy (ECT) is often used for treatment of severe PPP. The aims of the study were to describe the indications for ECT among women admitted with PPP to a psychiatric hospital in India. It also aimed at assessing whether women with PPP who received ECT differed in their clinical history, diagnosis, severity of illness, psychopathology, drug dosage, and duration of hospital stay, compared to women who did not receive ECT. Infants of mothers who were breast-feeding their infants while receiving ECT were assessed for adverse effects. This was a naturalistic prospective study of 78 women admitted with PPP, 34 (43.6 %) of whom received ECT. Presence of catatonia, augmentation of medications, and suicidality were common indications for ECT. Catatonic symptoms were significantly higher among women who received ECT. There was no significant difference in duration of hospitalization or severity of psychopathology between women who did and did not receive ECT. Transient side effects to ECT were observed in few women, with no adverse effects noted in infants who were breast-fed. The current study supports the use of ECT as an effective and safe treatment for women with severe PPP.

Sudden Cardiac Death in Ischaemic Cardiomyopathy and the Primary Prevention ICD: Time for a More a Personalised Approach?

Guidelines recommend primary prevention implantable cardioverter defibrillator (PPICD) for left ventricular ejection fraction (LVEF) <35% only after 3 months of optimal medical therapy (OMT) or 6 weeks after acute MI with persistent LVEF dysfunction. A 73-year-old woman presented with decompensated heart failure secondary to ischaemic cardiomyopathy. Severe coronary disease with sufficient dysfunctional myocardial segments on cardiac MRI suggested potential benefit from revascularisation. Following discussion with the heart team, she underwent percutaneous coronary intervention (PCI). PPICD implantation was deferred as per guideline recommendations. However, 20 days post-PCI, the patient died from malignant ventricular arrhythmia captured on a Holter monitor. This case demonstrates that some high-risk patients may not receive a potentially life-saving PPICD if guidelines are stringently adhered to. We highlight evidence that LVEF alone is of limited value in a risk assessment of arrhythmogenic death, and postulate that a more personalised ICD prescription should be considered using scar characteristics on cardiac MRI to prompt upstream ICD implantation in high-risk patients.

Peri-procedural myocardial injury during percutaneous coronary intervention: an important target for cardioprotection.

Percutaneous coronary intervention (PCI) has become the predominant procedure for coronary revascularization in patients with both stable and unstable coronary artery disease (CAD). Over the past two decades, technical advances in PCI have resulted in a better and safer therapeutic procedure with minimal procedural complications. However, about 30% of patients undergoing elective PCI sustain myocardial injury arising from the procedure itself, the extent of which is significant enough to carry prognostic importance. The peri-procedural injury which accompanies PCI might therefore reduce some of the beneficial effects of coronary revascularization. The availability of more sensitive serum biomarkers of myocardial injury such as creatine phosphokinase MB isoenzyme (CK-MB), Troponin T, and Troponin I has enabled the quantification of previously undetectable myocardial injury. Peri-procedural myocardial injury (PMI) can also be visualized by cardiac magnetic resonance imaging, a technique which allows the detection and quantification of myocardial necrosis following PCI. The identification of CAD patients at greatest risk of sustaining PMI during PCI would allow targeted treatment with novel therapies capable of limiting the extent of PMI or reducing the number of patients experiencing PMI.

Detection of Cognitive Impairment by Choice Auditory Reaction Time (ART) and Visual Reaction Time (VRT)s during Acute Mental Stress in Young Hypertensives: A Case Control Study.

BACKGROUND: Acute stress is known to be associated with both negative and positive influences on cognitive performance. Hypertension is one of the risk factors for lowered cognitive performance. Mental stress testing is easier to administer and can be regulated by the investigator. Mental arithmetic using serial subtraction is the most widely used method to administer stress. Reaction time (RT) is widely used to assess cognitive domains like attention, execution and psychomotor speed. Researchers have shown choice reaction times are delayed in hypertension. It is not known whether acute mental stress improves or deteriorates attention, execution and psychomotor speed in hypertension. We hypothesized in the present study that acute mental stress deteriorates cognitive function in hypertensives without overt cerebrovascular disease or other vascular risk factors. METHODS: After getting medical ethical clearance from our institution, this case-control study was carried out over eight months (January 2017 to September 2017). 60 subjects between the age group of 35 to 55 years were included in the study. They were divided into 2 groups. Group 1 consisted of 30 diagnosed cases of hypertension at least two years of duration. Group 2 consisted of 30 sex and age-matched controls. MMSE was performed to assess the cognitive function in these groups. Simple (S) and choice (C) auditory reaction time (ART) and visual reaction time (VRT)s were measured at rest and acute mental stress in these groups to assess cognitive function. Predictive value of VRTC resting and VRTC during acute mental stress among hypertensives for cognitive dysfunction was calculated using the receiver operating characteristic (ROC) curve. RESULTS: There was significant difference ART and VRT, both simple and choice, in hypertensive and nonhypertensive subjects and these reaction times further increased during mental stress (P<0.001). VRTC can be a predictor of cognitive dysfunction in hypertensives and during acute mental stress. CONCLUSION: A significant difference in cognitive functions in hypertensive and nonhypertensive subjects exists and this further deteriorates with acute mental stress.

Failure to recapture cardioprotection with high-dose atorvastatin in coronary artery bypass surgery: a randomised controlled trial.

The acute administration of atorvastatin has been reported to reduce myocardial infarct size in animal studies. However, this cardioprotective effect is lost with the chronic administration of atorvastatin, although it can be recaptured by administering an acute high-dose of atorvastatin. We hypothesised that pre-treatment with high-dose atorvastatin, on a background of chronic standard 'statin' therapy, would reduce myocardial injury in patients undergoing elective coronary artery bypass graft (CABG) surgery. One hundred and one consenting patients undergoing elective CABG surgery at a single tertiary cardiac centre were recruited into two randomised controlled, single-blinded clinical studies. Study 1: 45 patients were randomised to receive either 160 mg of atorvastatin 2 h preoperatively and 24 h following surgery or their standard statin therapy. Study 2: 56 patients were randomised to receive either 160 mg of atorvastatin 12 h preoperatively and 24 h following surgery or their standard statin therapy. Blood samples for troponin T and creatine kinase were taken prior to surgery and then at 6, 12, 24, 48 and 72 h post-surgery. Cardiac enzyme levels at each time point and the total area-under curve (AUC) were calculated. The group characteristics and surgical methods were well matched. High-dose atorvastatin was not associated with any significant side effects. There was no significant difference in serum troponin T or creatine kinase in either study at each time point or over 72 h. Study 1: AUC, troponin T: atorvastatin 29.6 ± 34.8 µg/L versus control 25.0 ± 22.0 µg/L:P > 0.05. Creatine kinase: atorvastatin 33,544 ± 20,063 IU/L versus control 30,620 ± 10,776 IU/L:P > 0.05. Study 2: AUC, troponin T: atorvastatin 21.8 ± 14.3 µg/L versus control 20.9 ± 8.7 µg/L:P > 0.05. Creatine kinase: atorvastatin 36,262 ± 28,821 IU/L versus control 33,448 ± 14,984:P > 0.05. There were no differences in postoperative outcomes. We report that the administration of high-dose atorvastatin to low risk patients undergoing elective CABG surgery, who are already on standard dose 'statin' therapy is safe, but does not further reduce perioperative myocardial injury.

Pacemaker-induced ventricular fibrillation during radiofrequency catheter ablation for ventricular tachycardia.

Prior to ventricular tachycardia ablation, this patient's cardiac implantable electronic device (CIED) was temporarily programmed to backup pacing mode with tachycardia therapies disabled. During radiofrequency energy delivery, the patient developed ventricular fibrillation requiring emergent cardioversion. Electrogram interrogation showed that the CIED switched to noise reversion mode during ablation. The consequent asynchronous pacing resulted in a paced QRS landing on an intrinsic T wave, inducing ventricular fibrillation. This serves as an important reminder that asynchronous pacing consequent to CIED oversensing could occur in any procedure that could cause electromagnetic interference such as radiofrequency cathteter ablation.

A New Era in Epicardial Access for the Ablation of Ventricular Arrhythmias: The Epi-Co2 Registry.

OBJECTIVES: This multicenter registry aimed to assess the reproducibility and safety of intentional coronary vein exit and carbon dioxide insufflation to facilitate subxiphoid epicardial access in the setting of ventricular tachycardia ablation. BACKGROUND: Epicardial ablation for ventricular tachycardia is not a widespread technique due to the significant potential complications associated with subxiphoid puncture. The first experience in 12 patients showed that intentional coronary vein exit and carbon dioxide insufflation was technically feasible. METHODS: A branch of the coronary sinus was cannulated by means of a diagnostic JR4 coronary catheter. Intentional perforation at the distal portion of that branch was performed with a high tip load 0.014-inch angioplasty wire. A microcatheter was advanced over the wire into the pericardial space. Carbon dioxide was then insufflated into the pericardial space, allowing direct visualization of the anterior pericardial space to facilitate subxiphoid puncture. RESULTS: Intentional coronary vein exit was attempted in 102 consecutive patients in 16 different centers and successfully completed in 101 patients. Significant pericardial adhesions were confirmed in 3 patients, preventing carbon dioxide insufflation and epicardial ablation. None of the punctures were complicated with inadvertent right ventricular puncture or damage to a coronary artery. Significant bleeding (>80 ml) due to coronary vein exit occurred in 5 patients, without hemodynamic compromise. None of the patients required surgery. CONCLUSIONS: Coronary vein exit and carbon dioxide insufflation can be safely and reproducibly achieved to facilitate subxiphoid pericardial access in the setting of ventricular tachycardia ablation.

Multicenter Study of Dynamic High-Density Functional Substrate Mapping Improves Identification of Substrate Targets for Ischemic Ventricular Tachycardia Ablation.

OBJECTIVES: The goal of this study was to evaluate the role of dynamic substrate changes in facilitating conduction delay and re-entry in ventricular tachycardia (VT) circuits. BACKGROUND: The presence of dynamic substrate changes facilitate functional block and re-entry in VT but are rarely studied as part of clinical VT mapping. METHODS: Thirty patients (age 67 ± 9 years; 27 male subjects) underwent ablation. Mapping was performed with the Advisor HD Grid multipolar catheter. A bipolar voltage map was obtained during sinus rhythm (SR) and right ventricular sense protocol (SP) single extra pacing. SR and SP maps of late potentials (LP) and local abnormal ventricular activity (LAVA) were made and compared with critical sites for ablation, defined as sites of best entrainment or pace mapping. Ablation was then performed to critical sites, and LP/LAVA identified by the SP. RESULTS: At a median follow-up of 12 months, 90% of patients were free from antitachycardia pacing (ATP) or implantable cardioverter-defibrillator shocks. SP pacing resulted in a larger area of LP identified for ablation (19.3 mm2 vs. 6.4 mm2) during SR mapping (p = 0.001), with a sensitivity of 87% and a specificity of 96%, compared with 78% and 65%, respectively, in SR. CONCLUSIONS: LP and LAVA observed during the SP were able to identify regions critical for ablation in VT with a greater accuracy than SR mapping. This may improve substrate characterization in VT ablation. The combination of ablation to critical sites and SP-derived LP/LAVA requires further assessment in a randomized comparator study.

The complete array of electrocardiogram abnormalities secondary to myocardial contusion in a single case.

Myocardial contusion is a complication of blunt thoracic injuries. Transthoracic echocardiography and electrocardiography (ECG) monitoring are important in suspected cases. We report a 54-year-old man, who sustained a number of injuries including blunt chest injury as a consequence of a road traffic accident. Electrocardiography monitoring over a 48 h period demonstrated sequential degrees of conduction system block coupled with a temporary cardio-version from persistent atrial fibrillation to sinus rhythm, suggesting coincident pulmonary vein contusion.

Chitrachanchala (pictures of unstable mind): mental health themes in Kannada cinema.

Regional movies in India play an important role in portraying mental illness and also depict awareness and attitudes of society towards people with mental health problems. Kannada (the language spoken by 50 million people from the state of Karnataka in South India) cinema has produced a range of movies depicting conditions ranging from psychosis to personality disorders. However, the descriptions of mental illness in several of these movies is vague and often stigmatizing. Some landmark films have involved psychiatrists in producing and directing the movies, including helping with the story line, which have added value to these films. Despite Karnataka being home to some of the important psychiatrists in the country and to some of the most famous and advanced mental health training and treatment centres, depictions of treatment and the portrayal of psychiatrists continues to be caricatured. As is true of many parts of India, treatment methods are often magico-religious, which is what Kannada cinema also reflects.

Prevalence of Adult ADHD Co-morbidity in Alcohol Use Disorders in a General Hospital Setup.

BACKGROUND: Attention deficit hyperactive disorder (ADHD) symptoms persisting into adulthood can influence the course and outcome of alcohol use disorders (AUDs). A cross-sectional study was conducted to assess the prevalence of adult ADHD in patients admitted with AUDs in a general hospital setup. METHODS: In this study, 100 consecutive inpatients with alcohol use disorder (AUD) were evaluated for the diagnosis of ADHD. Patients with AUD were assessed with Severity of Alcohol Dependence Questionnaire, Clinical Institute Withdrawal Assessment for Alcohol and Adult ADHD Self Report Scale. Among the subjects who screened positive for adult ADHD on ASRS, diagnosis of adult ADHD was confirmed using the DSM 5 diagnostic interview. Epi-Info Version 7.2 was used for data entry and analysis. Mann Whitney test and Chi-square test (or Fisher's Exact test) were used for statistical analysis. RESULTS: Twenty-one subjects screened positive for adult ADHD. Among them, 19 subjects had a confirmative diagnosis of adult ADHD. Patients with adult ADHD comorbid with AUDs showed accelerated progression towards dependence, and early relapses. CONCLUSIONS: In all, 19% of treatment-seeking inpatients with AUDs have co-morbid adult ADHD. Regular screening of AUD patients for adult ADHD and addressing the psychopathology may improve the treatment outcome.

Ventricular tachycardia ablation in structural heart disease: Impact of ablation strategy and non-inducibility as an end-point on long term outcome.

BACKGROUND: To investigate the long term outcomes after catheter ablation (CA) of ventricular tachycardia (VT) in the context of structural heart disease in a multicenter cohort. The impact of different ablation strategies (substrate ablation versus activation guided versus combined) and non-inducibility as an end-point was evaluated. METHODS: Data was pooled from prospective registries at 5 centres over a 5 year period. Success was defined as survival free from recurrent ventricular arrhythmias (VA). Multivariate analysis of factors predicting survival free from VA was analysed by Cox regression. RESULTS: Five hundred sixty-six patients underwent CA for VT. Patients were 64 ±â€¯15 years. Left ventricular ejection fraction was 35 ±â€¯15% and 66% had ischaemic heart disease. At 2.3 (IQR 1.0-4.2) years, success was achieved in 44% after a single procedure, rising to 60% after repeat procedures. Mortality at final follow up was 22%. Multivariate analysis showed that higher left ventricular ejection fraction, younger age, ischaemic heart disease, and non-inducibility of VA predicted long term survival free from VA (all p < 0.05). There was no impact of the approach to ablation. CONCLUSION: CA eliminates VT in a large proportion of patients long term. Ablation strategy did not impact outcome and hence substrate ablation is a reasonable initial strategy. Non-inducibility of VA predicted survival free from VA and may be worth pursuing as a procedural end-point.

Prevalence and correlates of suicidality among Indian women with post-partum psychosis in an inpatient setting.

OBJECTIVE: The aims of the present study were twofold: first, to determine the prevalence of suicidal ideation and suicide attempts among women inpatients with post-partum-onset psychosis; and second, to describe the clinical, childbirth-related and demographic correlates of suicidal ideation in this group. METHOD: A total of 82 post-partum women consecutively admitted to the psychiatric unit of the National Institute of Mental Health and Neurosciences, India during 18 months were assessed using the Comprehensive Psychopathology Rating Scale (CPRS) for psychopathology and suicidality. RESULTS: Thirty-one women (38%) reported suicidal ideation, of whom 15 (18%) had attempted suicide in the current episode. Suicidal ideation and suicide attempts were more frequent in women with depression, an insidious onset of the current illness and those with higher scores on the depressive dimension. On logistic regression analysis, however, only higher scores on the depressive symptom dimension of CPRS, irrespective of diagnosis, emerged as significant (p<0.001). Suicidal ideation was also significantly associated with ideas of harm to the infant (p<0.05). CONCLUSIONS: There is a high prevalence of suicidal ideation and suicide attempts in this group of patients. Depressive symptoms in post-partum psychosis appear to be the most important risk factor predicting suicidal ideation and attempts.