RESUMO
BACKGROUND: Bradyarrhythmias including sinus node dysfunction (SND) and atrioventricular block (AVB) can necessitate pacemaker (PPM) implantation in orthotopic heart transplant (OHT) recipients. Prior studies have shown conflicting findings regarding the effect of PPM implantation on survival. We evaluated the effect of PPM indication on long-term re-transplant-free survival in OHT patients. METHODS: We conducted a retrospective cohort study of OHT patients at UCLA Medical Center from 1985 to 2018. Indication for PPM (SND, AVB) was identified. Cox proportional hazards model with pacemaker implantation as a time-varying covariate was used to evaluate its effect on the primary endpoint of retransplant or death. We included 1609 OHTs in 1511 adult patients with median follow-up of 12 years. RESULTS: At transplant, patients were aged 53 ± 13 years and 1125 (74.5%) were male. Pacemakers were implanted in 109 (7.2%) patients; 65 for SND (4.3%) and 43 for AVB (2.8%). Repeat OHT was performed in 103 (6.4%) cases and 798 (52.8%) patients died during the follow-up period. The risk of the primary endpoint was significantly higher in patients requiring PPM for AVB (HR 3.0, 95% CI 2.1-4.2, p < .01) after controlling for age at OHT, gender, hypertension, diabetes, renal disease, history of repeat OHT, acute rejection, transplant coronary vasculopathy, and atrial fibrillation, but not PPM for SND (HR 1.0, 95% CI 0.70-1.4, p = 1.0). CONCLUSIONS: Patients who required PPM for AVB, but not SND, were at significantly higher risk of death or retransplant compared to patients who did not require PPM.
Assuntos
Fibrilação Atrial , Bloqueio Atrioventricular , Transplante de Coração , Marca-Passo Artificial , Adulto , Humanos , Masculino , Feminino , Estudos Retrospectivos , Fatores de Risco , Transplante de Coração/efeitos adversos , Bloqueio Atrioventricular/terapia , Bloqueio Atrioventricular/etiologia , Fibrilação Atrial/etiologia , Síndrome do Nó Sinusal/terapiaRESUMO
BACKGROUND: The use of left bundle branch pacing (LBBP) has dramatically increased since it was first described in 2016, but to date there are no published data on the safety of performing magnetic resonance imaging (MRI) in these patients. METHODS: Patients with LBBP who underwent MRI between January 2016 and October 2022 were retrospectively studied in our clinical center, which has a special program for imaging patients with cardiac devices. All patients underwent close cardiac monitoring throughout the MRI scans. Occurrence of arrhythmias or other adverse effects during MRI were assessed. LBBP lead parameters immediately pre- and post-MRI and at an outpatient follow-up were compared. RESULTS: Fifteen patients with LBBP underwent a total of 19 MRI sessions during the study period. Lead parameters did not significantly change after the MRI or on follow-up, which took place at a median of 91 days after the MRI. No patient developed arrhythmias during the MRI sessions, and no adverse effects such as lead dislodgement were reported. CONCLUSION: Although larger studies are necessary to verify our findings, MRI in patients with LBBP appears safe based on this initial case series.
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Fascículo Atrioventricular , Bloqueio de Ramo , Humanos , Bloqueio de Ramo/diagnóstico por imagem , Bloqueio de Ramo/terapia , Bloqueio de Ramo/etiologia , Estimulação Cardíaca Artificial/métodos , Estudos Retrospectivos , Eletrocardiografia/métodos , Resultado do TratamentoRESUMO
BACKGROUND: The presence of a cardiovascular implantable electronic device has long been a contraindication for the performance of magnetic resonance imaging (MRI). We established a prospective registry to determine the risks associated with MRI at a magnetic field strength of 1.5 tesla for patients who had a pacemaker or implantable cardioverter-defibrillator (ICD) that was "non-MRI-conditional" (i.e., not approved by the Food and Drug Administration for MRI scanning). METHODS: Patients in the registry were referred for clinically indicated nonthoracic MRI at a field strength of 1.5 tesla. Devices were interrogated before and after MRI with the use of a standardized protocol and were appropriately reprogrammed before the scanning. The primary end points were death, generator or lead failure, induced arrhythmia, loss of capture, or electrical reset during the scanning. The secondary end points were changes in device settings. RESULTS: MRI was performed in 1000 cases in which patients had a pacemaker and in 500 cases in which patients had an ICD. No deaths, lead failures, losses of capture, or ventricular arrhythmias occurred during MRI. One ICD generator could not be interrogated after MRI and required immediate replacement; the device had not been appropriately programmed per protocol before the MRI. We observed six cases of self-terminating atrial fibrillation or flutter and six cases of partial electrical reset. Changes in lead impedance, pacing threshold, battery voltage, and P-wave and R-wave amplitude exceeded prespecified thresholds in a small number of cases. Repeat MRI was not associated with an increase in adverse events. CONCLUSIONS: In this study, device or lead failure did not occur in any patient with a non-MRI-conditional pacemaker or ICD who underwent clinically indicated nonthoracic MRI at 1.5 tesla, was appropriately screened, and had the device reprogrammed in accordance with the prespecified protocol. (Funded by St. Jude Medical and others; MagnaSafe ClinicalTrials.gov number, NCT00907361 .).
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Desfibriladores Implantáveis , Imageamento por Ressonância Magnética/efeitos adversos , Marca-Passo Artificial , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/etiologia , Flutter Atrial/etiologia , Contraindicações , Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de RegistrosRESUMO
INTRODUCTION: Cardiac sympathetic denervation (CSD) is utilized for the management of ventricular tachycardia (VT) in structural heart disease when refractory to radiofrequency ablation (RFA) or when patient/VT characteristics are not conducive to RFA. METHODS: We studied consecutive patients who underwent CSD at our institution from 2009 to 2018 with VT requiring repeat RFA post-CSD. Patient demographics, VT/procedural characteristics, and outcomes were assessed. RESULTS: Ninety-six patients had CSD, 16 patients underwent RFA for VT post-CSD. There were 15 male and 1 female patients with mean age of 54.2 ± 13.2 years. Fourteen patients had nonischemic cardiomyopathy. A mean of 2.0 ± 0.8 RFAs for VT was unsuccessful before the patient undergoing CSD. The median time between CSD and RFA was 104 days (interquartile range [IQR] = 15-241). The clinical VT cycle length was significantly increased after CSD both spontaneously on ECG and/or ICD interrogation (355 ± 73 ms pre-CSD vs. 422 ± 94 ms post-CSD, p = .001) and intraprocedurally (406 ± 86 ms pre-CSD vs. 457 ± 88 ms post-CSD, p = .03). Two patients had polymorphic and 14 had monomorphic VT (MMVT) pre-CSD, and all patients had MMVT post-CSD. The proportion of mappable, hemodynamically stable VTs increased from 35% during pre-CSD RFA to 58% during post-CSD RFA (p = .038). At median follow-up of 413 days (IQR = 43-1840) after RFA, eight patients had no further VT. CONCLUSION: RFA for recurrent MMVT post-CSD is a reasonable treatment option with intermediate-term clinical success in 50% of patients. Clinical VT cycle length was significantly increased after CSD with associated improvement in mappable, hemodynamically tolerated VT during RFA.
Assuntos
Ablação por Cateter , Taquicardia Ventricular , Adulto , Idoso , Arritmias Cardíacas/cirurgia , Ablação por Cateter/efeitos adversos , Feminino , Coração , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Simpatectomia , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/cirurgia , Resultado do TratamentoRESUMO
The Symbol Nomenclature for Glycans (SNFG) is a community-curated standard for the depiction of monosaccharides and complex glycans using various colored-coded, geometric shapes, along with defined text additions. It is hosted by the National Center for Biotechnology Information (NCBI) at the NCBI-Glycans Page (www.ncbi.nlm.nih.gov/glycans/snfg.html). Several changes have been made to the SNFG page in the past year to update the rules for depicting glycans using the SNFG, to include more examples of use, particularly for non-mammalian organisms, and to provide guidelines for the depiction of ambiguous glycan structures. This Glycoforum article summarizes these recent changes.
Assuntos
National Library of Medicine (U.S.)/organização & administração , Polissacarídeos/química , Terminologia como Assunto , Animais , Internet , Polissacarídeos/classificação , Estados UnidosRESUMO
INTRODUCTION: Frequent premature ventricular complexes (PVCs) can lead to symptoms, such as cardiomyopathy and increased mortality. Beta-blockers are recommended as first-line therapy to reduce PVC burden; however, the response is unpredictable. The objective of this study is to determine whether PVC diurnal-variability patterns are associated with different clinical profiles and predict drug response. METHODS: Consecutive patients with frequent PVCs (burden ≥ 1%), referred for Holter monitoring between 2014 and 2016, were included. Follow-up Holters, when available, were assessed after beta-blocker initiation to assess response (≥50% reduction). Patients were divided into three groups on the basis of relationship between hourly PVC count and mean HR during each of the 24 Holter hours: (1) fast-HR-dependent-PVC (F-HR-PVC) for positive correlation (Pearson, P < 0.05), (2) slow-HR-dependent-PVC (S-HR-PVC) for a negative, and (3) independent-HR-PVC (I-HR-PVC) when no correlation was found. RESULTS: Of the 416 patients included, 50.2% had F-HR-PVC, 35.6% I-HR-PVC, and 14.2% S-HR-PVC with distinct clinical profiles. Beta-blocker therapy was successful in 34.0% patients overall: patients with F-HR-PVC had a decrease in PVC burden (18.8 ± 10.4% to 9.3 ± 6.6%, P < 0.0001; 62% success), I-HR-PVC had no change (18.4 ± 17.9% to 20.6 ± 17.9%, P = 0.175; 0% success), whereas S-HR-PVC had an increase in burden (14.6 ± 15.3% to 20.8 ± 13.8%, P = 0.016; 0% success). The correlation coefficient was the only predictor of beta-blocker success (AUC = 0.84, sensitivity = 100%, specificity = 67.7%; r ≥ 0.4). CONCLUSIONS: A simple analysis of Holter PVC diurnal variability may provide incremental value to guide clinical PVC management. Only patients displaying a F-HR-PVC profile benefited from beta-blockers. An alternative strategy should be considered for others, as beta-blockers may have no effect or can even be harmful.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Antiarrítmicos/uso terapêutico , Ritmo Circadiano , Frequência Cardíaca/efeitos dos fármacos , Complexos Ventriculares Prematuros/tratamento farmacológico , Potenciais de Ação , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Eletrocardiografia Ambulatorial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Complexos Ventriculares Prematuros/diagnóstico , Complexos Ventriculares Prematuros/fisiopatologiaRESUMO
INTRODUCTION: The safety of ventricular tachycardia (VT) ablation in patients with laminated left ventricular (LV) thrombus has not been examined. METHODS: Patients with laminated LV thrombus on transthoracic echocardiogram who underwent scar-mediated VT ablation at two centers from 2010 to 2013 were retrospectively analyzed. All patients had failed medical therapy. Acute procedural outcomes, complications, and clinical outcomes at 1 year were assessed. RESULTS: Eight patients (four ischemic, four nonischemic cardiomyopathy) underwent VT ablation in the presence of laminated intracavitary thrombus. Six out of eight (75%) had electrical storm (ES). The mapping and ablation approach was LV endocardial-only in three patients, epicardial-only in two, combined epicardial-RV endocardial in two, and combined epicardial-LV endocardial in one. Major complication (ischemic stroke) occurred in one patient 9 days post-procedure. There was no procedural mortality. Complete acute procedural success (noninducibility of any VT after ablation) was achieved in five (63%), and partial success (ablation of only clinical VT) in an additional three (37%). At 1 year, freedom from VT and survival were achieved in six (75%) and seven (88%) patients, respectively. CONCLUSION: Initial data suggest that ablation of VT in the presence of intracavitary thrombus is feasible, is associated with a similar success rate to historical studies in patients without thrombus, and has an acceptable risk of complications given the high-risk nature of patients with ES. Further data are needed; however, the presence of a laminated thrombus should not necessarily preclude ablation in patients who have failed medical therapy for VT in whom ablation is otherwise indicated.
Assuntos
Ablação por Cateter/mortalidade , Complicações Pós-Operatórias/mortalidade , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/cirurgia , Trombose/mortalidade , Trombose/cirurgia , Idoso , Intervalo Livre de Doença , Feminino , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Prevalência , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Taquicardia Ventricular/diagnóstico , Trombose/diagnóstico , Resultado do Tratamento , Estados Unidos/epidemiologia , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/cirurgiaRESUMO
INTRODUCTION: Reversible premature ventricular complexes-induced cardiomyopathy (PVC-CMP) is a well-described, multi-factorial entity. Single predictors, such as PVC burden or QRS duration, may not apply equally to all patients in contemporary unselected populations including patients with structural heart disease (SHD) or with particular origin such as epicardial (EPI) PVC. We sought to evaluate clinical criteria associated with PVC-CMP notably focusing on the EPI origin impact and ECG recognition and the value of a new composite predictor of PVC-CMP, the PVC-CMP-Index. METHODS AND RESULTS: We studied 107 consecutive patients (69 men; mean age = 56 ± 16 years) with frequent PVC (23.1 ± 11.5%) referred for PVC ablation. Thirty-six patients (33.6%) had an underlying SHD and 25 patients (23.4%) an EPI PVC origin. After a mean follow-up of 22.7 ± 15.3 months, 72.9% achieved a long-term successful ablation and 54.2% had PVC-CMP. PVC-CMP prevalence was significantly higher in patients with an EPI compared to endocardial PVC focus (84.0% vs. 45.1%, respectively, P < 0.001). EPI PVC origin (OR = 68.7 IC95% [3.5-1363], P = 0.005), as well as SHD (OR = 12.3 IC95% [1.6-92.6], P = 0.015), was independent predictor of PVC-CMP. While PVC burden (AUC = 0.78) or PVC-QRS width (AUC = 0.68) independently predicted PVC-CMP, the PVC-CMP-Index (values ≥39) defined as: PVC burden (0-1) × PVC-QRS width (milliseconds) × a constant C (1.28 for SHD or 2 for ECG suggesting EPI origin based on our ECG 3-step algorithm), highly correlated with PVC-CMP (AUC = 0.91, sensitivity = 93%, specificity = 80%). CONCLUSION: We developed a new index, which incorporates PVC burden, QRS width, and presence of SHD or suspected EPI origin that best predicted PVC-CMP.
Assuntos
Cardiomiopatias/complicações , Eletrocardiografia , Pericárdio/fisiopatologia , Complexos Ventriculares Prematuros/diagnóstico , Potenciais de Ação , Adulto , Idoso , Cardiomiopatias/diagnóstico , Cardiomiopatias/fisiopatologia , Ablação por Cateter , Distribuição de Qui-Quadrado , Feminino , Frequência Cardíaca , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda , Complexos Ventriculares Prematuros/etiologia , Complexos Ventriculares Prematuros/fisiopatologia , Complexos Ventriculares Prematuros/cirurgiaRESUMO
AIMS: The precise localization of the site of origin of a premature ventricular contraction (PVC) prior to ablation can facilitate the planning and execution of the electrophysiological procedure. In clinical practice, the targeted ablation site is estimated from the standard 12-lead ECG. The accuracy of this qualitative estimation has limitations, particularly in the localization of PVCs originating from the papillary muscles. Clinical available electrocardiographic imaging (ECGi) techniques that incorporate patient-specific anatomy may improve the localization of these PVCs, but require body surface maps with greater specificity for the epicardium. The purpose of this report is to demonstrate that a novel cardiac isochrone positioning system (CIPS) program can accurately detect the specific location of the PVC on the papillary muscle using only a 12-lead ECG. METHODS AND RESULTS: Cardiac isochrone positioning system uses three components: (i) endocardial and epicardial cardiac anatomy and torso geometry derived from MRI, (ii) the patient-specific electrode positions derived from an MRI model registered 3D image, and (iii) the 12-lead ECG. CIPS localizes the PVC origin by matching the anatomical isochrone vector with the ECG vector. The predicted PVC origin was compared with the site of successful ablation or stimulation. Three patients who underwent electrophysiological mapping and ablation of PVCs originating from the papillary muscles were studied. CIPS localized the PVC origin for all three patients to the correct papillary muscle and specifically to the base, mid, or apical region. CONCLUSION: A simplified form of ECGi utilizing only 12 standard electrocardiographic leads may facilitate accurate localization of the origin of papillary muscle PVCs.
Assuntos
Eletrocardiografia , Modelos Cardiovasculares , Músculos Papilares/fisiopatologia , Modelagem Computacional Específica para o Paciente , Complexos Ventriculares Prematuros/fisiopatologia , Potenciais de Ação , Adulto , Ablação por Cateter , Ecocardiografia , Estudos de Viabilidade , Feminino , Frequência Cardíaca , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Músculos Papilares/cirurgia , Projetos Piloto , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Processamento de Sinais Assistido por Computador , Complexos Ventriculares Prematuros/diagnóstico , Complexos Ventriculares Prematuros/cirurgiaRESUMO
Patient monitors in modern hospitals have become ubiquitous but they generate an excessive number of false alarms causing alarm fatigue. Our previous work showed that combinations of frequently co-occurring monitor alarms, called SuperAlarm patterns, were capable of predicting in-hospital code blue events at a lower alarm frequency. In the present study, we extend the conceptual domain of a SuperAlarm to incorporate laboratory test results along with monitor alarms so as to build an integrated data set to mine SuperAlarm patterns. We propose two approaches to integrate monitor alarms with laboratory test results and use a maximal frequent itemsets mining algorithm to find SuperAlarm patterns. Under an acceptable false positive rate FPRmax, optimal parameters including the minimum support threshold and the length of time window for the algorithm to find the combinations of monitor alarms and laboratory test results are determined based on a 10-fold cross-validation set. SuperAlarm candidates are generated under these optimal parameters. The final SuperAlarm patterns are obtained by further removing the candidates with false positive rate>FPRmax. The performance of SuperAlarm patterns are assessed using an independent test data set. First, we calculate the sensitivity with respect to prediction window and the sensitivity with respect to lead time. Second, we calculate the false SuperAlarm ratio (ratio of the hourly number of SuperAlarm triggers for control patients to that of the monitor alarms, or that of regular monitor alarms plus laboratory test results if the SuperAlarm patterns contain laboratory test results) and the work-up to detection ratio, WDR (ratio of the number of patients triggering any SuperAlarm patterns to that of code blue patients triggering any SuperAlarm patterns). The experiment results demonstrate that when varying FPRmax between 0.02 and 0.15, the SuperAlarm patterns composed of monitor alarms along with the last two laboratory test results are triggered at least once for [56.7-93.3%] of code blue patients within an 1-h prediction window before code blue events and for [43.3-90.0%] of code blue patients at least 1-h ahead of code blue events. However, the hourly number of these SuperAlarm patterns occurring in control patients is only [2.0-14.8%] of that of regular monitor alarms with WDR varying between 2.1 and 6.5 in a 12-h window. For a given FPRmax threshold, the SuperAlarm set generated from the integrated data set has higher sensitivity and lower WDR than the SuperAlarm set generated from the regular monitor alarm data set. In addition, the McNemar's test also shows that the performance of the SuperAlarm set from the integrated data set is significantly different from that of the SuperAlarm set from the regular monitor alarm data set. We therefore conclude that the SuperAlarm patterns generated from the integrated data set are better at predicting code blue events.
Assuntos
Alarmes Clínicos , Coleta de Dados , Processamento Eletrônico de Dados , Adulto , Idoso , Algoritmos , California , Simulação por Computador , Sistemas Computacionais , Cuidados Críticos/métodos , Mineração de Dados , Reações Falso-Positivas , Feminino , Parada Cardíaca/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas On-Line , Distribuição de Poisson , Curva ROC , Insuficiência Respiratória/diagnósticoRESUMO
Non-invasive electrocardiographic imaging (ECGI) of the cardiac muscle can help the pre-procedure planning of the ablation of ventricular arrhythmias by reducing the time to localize the origin. Our non-invasive ECGI system, the cardiac isochrone positioning system (CIPS), requires non-intersecting meshes of the heart, lungs and torso. However, software to reconstruct the meshes of the heart, lungs and torso with the capability to check and prevent these intersections is currently lacking. Consequently the reconstruction of a patient specific model with realistic atrial and ventricular wall thickness and incorporating blood cavities, lungs and torso usually requires additional several days of manual work. Therefore new software was developed that checks and prevents any intersections, and thus enables the use of accurate reconstructed anatomical models within CIPS. In this preliminary study we investigated the accuracy of the created patient specific anatomical models from MRI or CT. During the manual segmentation of the MRI data the boundaries of the relevant tissues are determined. The resulting contour lines are used to automatically morph reference meshes of the heart, lungs or torso to match the boundaries of the morphed tissue. Five patients were included in the study; models of the heart, lungs and torso were reconstructed from standard cardiac MRI images. The accuracy was determined by computing the distance between the segmentation contours and the morphed meshes. The average accuracy of the reconstructed cardiac geometry was within 2mm with respect to the manual segmentation contours on the MRI images. Derived wall volumes and left ventricular wall thickness were within the range reported in literature. For each reconstructed heart model the anatomical heart axis was computed using the automatically determined anatomical landmarks of the left apex and the mitral valve. The accuracy of the reconstructed heart models was well within the accuracy of the used medical image data (pixel size <1.5mm). For the lungs and torso the number of triangles in the mesh was reduced, thus decreasing the accuracy of the reconstructed mesh. A novel software tool has been introduced, which is able to reconstruct accurate cardiac anatomical models from MRI or CT within only a few hours. This new anatomical reconstruction tool might reduce the modeling errors within the cardiac isochrone positioning system and thus enable the clinical application of CIPS to localize the PVC/VT focus to the ventricular myocardium from only the standard 12 lead ECG.
Assuntos
Algoritmos , Mapeamento Potencial de Superfície Corporal/métodos , Diagnóstico por Computador/métodos , Software , Complexos Ventriculares Prematuros/patologia , Complexos Ventriculares Prematuros/fisiopatologia , Adulto , Idoso , Simulação por Computador , Feminino , Humanos , Imageamento Tridimensional/métodos , Masculino , Pessoa de Meia-Idade , Modelos Anatômicos , Modelos Cardiovasculares , Modelagem Computacional Específica para o Paciente , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: About 200,000 patients suffer from in-hospital cardiac arrest (IHCA) annually. Identification of at-risk patients is key to improving outcomes. The use of continuous ECG monitoring in identifying patients at risk for developing IHCA has not been studied. OBJECTIVE: To describe the profile and timing of ECG changes prior to IHCA. DESIGN: Retrospective, observational. SETTING: Single 520-bed tertiary care hospital. PATIENTS: IHCA in adults between April 2010 and March 2012 with at least 3 hours of continuous telemetry data immediately prior to IHCA. MEASUREMENTS: We evaluated up to 24 hours of telemetry data preceding IHCA for changes in PR, QRS, ST segment, arrhythmias, and QTc in ventricular tachycardia cases. We determined mechanism and likely clinical cause of the arrest by chart and telemetry review. RESULTS: We studied 81 IHCA patients, in whom the mechanism was ventricular tachycardia/fibrillation in 14 (18%), bradyasystolic in 21 (26%), and pulseless electrical activity (PEA) in 46 (56%). Preceding ECG changes were ST segment changes (31% of cases), atrial tachyarrhythmias (21%), bradyarrhythmias (28%), P wave axis change (21%),QRS prolongation (19%), PR prolongation (17%), isorhythmic dissociation (14%), nonsustained ventricular tachycardia (6%), and PR shortening (5%). At least one of these was present in 77% of all cases, and in 89% of IHCA caused by respiratory or multiorgan failure. Bradyarrhythmias were primarily seen with IHCA in the setting of respiratory or multiorgan failure, and PR and QRS prolongation with IHCA and concomitant multiorgan failure. LIMITATIONS: This is a retrospective study with a limited number of cases; each patient serves as their own control, and a separate control population has not yet been studied. CONCLUSIONS: ECG changes are commonly seen preceding IHCA, and have a pathophysiologic basis. Automated detection methods for ECG changes could potentially be used to better identify patients at risk for IHCA.
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Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Eletrocardiografia/estatística & dados numéricos , Parada Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Telemetria/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , California , Causalidade , Comorbidade , Diagnóstico Precoce , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Taxa de Sobrevida , TelemedicinaRESUMO
We report three cases of vascular injury during laser lead extractions, requiring urgent surgical correction. Immediate sternotomy and cardiopulmonary bypass were possible because of an institutional collaboration where cardiac surgeon and cardiac electrophysiologist jointly perform these cases, and all patients survived. We propose this joint approach is ultimately the best option for patients undergoing lead extraction.
Assuntos
Eletrofisiologia Cardíaca , Procedimentos Cirúrgicos Cardiovasculares/métodos , Comportamento Cooperativo , Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/métodos , Eletrodos Implantados/efeitos adversos , Lasers/efeitos adversos , Monitorização Intraoperatória , Equipe de Assistência ao Paciente , Médicos , Cirurgiões , Cirurgia Torácica , Veia Cava Superior/lesões , Veia Cava Superior/cirurgia , Adolescente , Adulto , Idoso , Ponte Cardiopulmonar , Emergências , Feminino , Átrios do Coração/lesões , Átrios do Coração/cirurgia , Humanos , Masculino , Esternotomia , Resultado do TratamentoRESUMO
The NPY5 receptor binding and pharmacokinetic properties of a novel series of cis-1-oxo-heterocyclyl-4-amido-cyclohexane derivatives are described.
Assuntos
Cicloexanos/química , Receptores de Neuropeptídeo Y/antagonistas & inibidores , Animais , Cicloexanos/síntese química , Cicloexanos/farmacocinética , Meia-Vida , Humanos , Isomerismo , Camundongos , Microssomos Hepáticos/metabolismo , Receptores de Neuropeptídeo Y/metabolismo , Relação Estrutura-AtividadeRESUMO
Generative models are undergoing rapid research and application to de novo drug design. To facilitate their application and evaluation, we present MolScore. MolScore already contains many drug-design-relevant scoring functions commonly used in benchmarks such as, molecular similarity, molecular docking, predictive models, synthesizability, and more. In addition, providing performance metrics to evaluate generative model performance based on the chemistry generated. With this unification of functionality, MolScore re-implements commonly used benchmarks in the field (such as GuacaMol, MOSES, and MolOpt). Moreover, new benchmarks can be created trivially. We demonstrate this by testing a chemical language model with reinforcement learning on three new tasks of increasing complexity related to the design of 5-HT2a ligands that utilise either molecular descriptors, 266 pre-trained QSAR models, or dual molecular docking. Lastly, MolScore can be integrated into an existing Python script with just three lines of code. This framework is a step towards unifying generative model application and evaluation as applied to drug design for both practitioners and researchers. The framework can be found on GitHub and downloaded directly from the Python Package Index.Scientific ContributionMolScore is an open-source platform to facilitate generative molecular design and evaluation thereof for application in drug design. This platform takes important steps towards unifying existing benchmarks, providing a platform to share new benchmarks, and improves customisation, flexibility and usability for practitioners over existing solutions.
RESUMO
Epicardial mapping and ablation is increasingly being performed for the treatment of complex arrhythmias. Right ventricular (RV) puncture remains the most common complication, with damage to surrounding non-cardiac structures also a concern. We describe the standard techniques used in our lab essential for safe epicardial access, as well as a novel technique incorporating electroanatomic mapping (EAM) guidance. In a series of 8 patients referred for ventricular tachycardia ablation, an RV endocardial voltage map was created using EAM systems. EAM images were fused with preprocedure CT scans when available. A 17G Tuohy needle was integrated with the EAM system by attaching the needle to sterile electrode clamps. EAM location points were used in conjunction with standard access techniques until epicardial access was obtained. Epicardial access was successfully obtained in 8/8 (100%) patients. Successful access without RV puncture was achieved in 7/8 (88%) cases. This proof of concept study demonstrates that EAM systems can be used as an adjunct to standard access techniques to visualize and facilitate pericardial access.
Assuntos
Ablação por Cateter/métodos , Mapeamento Epicárdico/métodos , Taquicardia Ventricular/cirurgia , Adulto , Idoso , Ablação por Cateter/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: We investigated whether additional electrocardiographic (ECG) metrics not available on current patient monitors could predict bradyasystolic cardiac arrest in hospitalized adult patients. METHODS: A retrospective case-control design was used to study eight ECG metrics from 22 adult bradyasystolic patients and their 45 control patients. The eight ECG metrics included heart rate, QRS width, interval from P-wave peak to QRS onset (PRp), heart rate-corrected interval from QRS onset to T-wave peak (QTpc), amplitude of QRS peak (rAmp), amplitude of P-wave (pAmp), amplitude of T-wave (tAmp), and absolute difference in the ECG amplitudes at QRS onset and offset divided by rAmp, that is, relative J-point amplitude (relJAmp). We derived the maximal true-positive rate (TPR) of detecting cardiac arrest at a globally minimal false-positive rate (FPR) for each metric and for the absolute slope values resulted from a linear fitting of the time series of these metrics. We also recorded the first time crossing the detection threshold to the time of arrest as lead time. RESULTS: Conditions of relJAmp >20% and PRp >196.6 ms, respectively, achieved a TPR of 22.7% and 27.3% with zero FPRs. The lead prediction time of these two conditions was 5.7 ± 6.8 hours and 8.0 ± 7.2 hours, respectively. Performance of triggers based on the absolute slope values depended on the window length used for linear fitting. rAmp slope of a 2-hour window, PRp slope of a 30-minute window, and relJAmp slope of a 2-hour window achieved the best TPR of 27.3% (FPR = 2.3%, lead time = 6.5 ± 5.7 hours), 14.3% (FPR=0.0%, lead time = 10.9 ± 10.9), and 18.2% (FPR = 2.3%, lead time = 8.8 ± 9.8), respectively. McNemar test showed that only relJAmp >20.0% is significantly different from the baseline trigger of HR >149.3 bpm (p=0.046). In addition, metrics-based and slope-based triggers were complementary as an "OR" combination of two single-metric triggers raised the TPR up to 45.4% with zero FPR. CONCLUSIONS: It is feasible to compute additional metrics from continuous ECG from bedside monitors. These additional parameters can provide highly specific triggers for predicting bradyasystolic cardiac arrest. Complementary triggers based on the slope of trending of these ECG metrics can further increase the sensitivity without incurring false positives.
Assuntos
Bradicardia/diagnóstico , Bradicardia/epidemiologia , Alarmes Clínicos , Eletrocardiografia/métodos , Eletrocardiografia/estatística & dados numéricos , Parada Cardíaca/diagnóstico , Parada Cardíaca/epidemiologia , California/epidemiologia , Estudos de Casos e Controles , Diagnóstico por Computador/métodos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
We describe the case of a 92-year-old male patient presenting with shortness of breath and an electrocardiogram showing bradycardia with irregular rhythm and varying QRS morphology. A differential diagnosis is discussed. (Level of Difficulty: Advanced.).
RESUMO
BACKGROUND: Positron emission tomography computed tomography (PET-CT) is not routinely used for premature ventricular complexes (PVCs). Whether specific clinical factors are associated with abnormal PET-CT results is not clear. METHODS: The treatment courses and baseline characteristics of consecutive patients in a single center between 2012 and 2021, age > 18 years old, and who received 18F-fluorodeoxyglucose (FDG) PET-CT imaging for evaluation of PVCs were retrospectively analyzed. RESULTS: A total of 102 patients was included. Of these, 27 patients (26.4%) had abnormal PET-CT and 61 (59.8%) had normal imaging. Abnormal PET-CT findings were associated with non-sustained ventricular tachycardia (NSVT) (95.2% vs. 52.6%, p = 0.001), higher number of PVC morphologies (2.29 ± 0.7 vs. 1.31 ± 0.6, p < 0.001), greater PVC coupling interval dispersion (72.47 ± 66.4 ms vs. 13.42 ± 17.9 ms, p < 0.001), and greater likelihood of fast heart rate dependent PVCs (78.5% vs. 38.2%, p = 0.017). Fourteen (51.8%) patients had an abnormal PET-CT and abnormal late gadolinium enhancement (LGE). Patients with abnormal PET-CT were more frequently treated with immunosuppression (81.4% vs. 3.2%, p < .0001) than with catheter ablation (11.1% vs. 45.9%, p = 0.002) compared to the normal PET-CT group. Over a median follow-up of 862 days (IQR 134, 1407), PVC burden decreased in both groups [from 23 ± 16% to 9 ± 10% (p < 0.001) in abnormal PET-CT group and from 21 ± 15% to 7 ± 10% (p < 0.001) in normal PET-CT group]. CONCLUSIONS: Abnormal PET-CT findings were more commonly associated with NSVT, multiform PVCs, greater PVC coupling interval dispersion, and fast heart rate dependent PVCs. LGE was not sensitive for detecting inflammation. Immunosuppression was effective in managing PVCs with abnormal PET-CT.
Assuntos
Ablação por Cateter , Complexos Ventriculares Prematuros , Humanos , Adulto , Pessoa de Meia-Idade , Complexos Ventriculares Prematuros/diagnóstico por imagem , Complexos Ventriculares Prematuros/cirurgia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Estudos Retrospectivos , Meios de Contraste , Volume Sistólico/fisiologia , Gadolínio , Tomografia por Emissão de Pósitrons , Inflamação , Ablação por Cateter/métodosRESUMO
Sudden cardiac arrest (SCA) is the leading cause of death in young athletes. Despite efforts to improve preparedness for cardiac emergencies, the incidence of out-of-hospital cardiac arrests in athletes remains high, and bystander awareness and readiness for SCA support are inadequate. Initiatives such as designing an emergency action plan (EAP) and mandating training in cardiopulmonary resuscitation (CPR) and automated external defibrillator use (AED) for team members and personnel can contribute to improved survival rates in SCA cases. This review provides an overview of SCA in athletes, focusing on identifying populations at the highest risk and evaluating the effectiveness of different screening practices in detecting conditions that may lead to SCA. We summarize current practices and recommendations for improving the response to SCA events, and we highlight the need for ongoing efforts to optimize preparedness through the implementation of EAPs and the training of individuals in CPR and AED use. Additionally, we propose a call to action to increase awareness and training in EAP development, CPR, and AED use for team members and personnel. To improve outcomes of SCA cases in athletes, it is crucial to enhance bystander awareness and preparedness for cardiac emergencies. Implementing EAPs and providing training in CPR and AED use for team members and personnel are essential steps toward improving survival rates in SCA cases.