Case Report: Temporary pacing using active fixation lead and invasive electrophysiology studies for immune checkpoint inhibitor associated reversible advanced atrioventricular block.

A case of immune checkpoint inhibitors (ICIs)-associated myocarditis with reversible advanced atrioventricular block (AVB) was reported. We innovatively used active fixation lead connected to an external device for prolonged temporary pacing until atrioventricular conduction recovered. Invasive electrophysiology studies were performed to evaluate atrioventricular conduction in detail. Long-term follow-up for nearly 120-days and repeated long-term electrocardiography was conducted to ensure the conduction system was truly recovered.

Three-dimensional High-Resolution Dark-Blood Late Gadolinium Enhancement Imaging for Improved Atrial Scar Evaluation.

Background Radiofrequency ablation (RFA) is a widely used treatment for atrial fibrillation, reducing the risk of cardiac arrhythmia. Detailed visualization and quantification of atrial scarring has the potential to improve preprocedural decision-making and postprocedural prognosis. Conventional bright-blood late gadolinium enhancement (LGE) MRI can help detect atrial scars; however, its suboptimal myocardium to blood contrast inhibits accurate scar estimation. Purpose To develop and test a free-breathing LGE cardiac MRI approach that simultaneously provides high-spatial-resolution dark-blood and bright-blood images for improved atrial scar detection and quantification. Materials and Methods A free-breathing, independent navigator-gated, dark-blood phase-sensitive inversion recovery (PSIR) sequence with whole-heart coverage was developed. Two coregistered high-spatial-resolution (1.25 × 1.25 × 3 mm3) three-dimensional (3D) volumes were acquired in an interleaved manner. The first volume combined inversion recovery and T2 preparation to achieve dark-blood imaging. The second volume functioned as the reference for phase-sensitive reconstruction with built-in T2 preparation for improved bright-blood contrast. The proposed sequence was tested in prospectively enrolled participants who had undergone RFA for atrial fibrillation (mean time since RFA, 89 days ± 26 [SD]) from October 2019 to October 2021. Image contrast was compared with conventional 3D bright-blood PSIR images using the relative signal intensity difference. Furthermore, native scar area quantification obtained from both imaging approaches was compared with measurements obtained with electroanatomic mapping (EAM) as the reference standard. Results A total of 20 participants (mean age, 62 years ± 9; 16 male) who underwent RFA for atrial fibrillation were included. The proposed PSIR sequence successfully acquired 3D high-spatial-resolution volumes in all participants, with a mean scan time of 8.3 minutes ± 2.4. The developed PSIR sequence improved scar to blood contrast compared with conventional PSIR sequence (mean contrast, 0.60 arbitrary units [au] ± 0.18 vs 0.20 au ± 0.19, respectively; P < .01) and correlated with EAM regarding scar area quantification (r = 0.66 [P < .01] vs r = 0.13 [P = .63]). Conclusion In participants who had undergone RFA for atrial fibrillation, an independent navigator-gated dark-blood PSIR sequence produced high-spatial-resolution dark-blood and bright-blood images with improved image contrast and native scar quantification compared with conventional bright-blood images. © RSNA, 2023 Supplemental material is available for this article.

Case Report: Left bundle branch pacing in an amyloid light-chain cardiac amyloidosis patient with atrioventricular block.

Introduction: Amyloid light-chain cardiac amyloidosis is a progressive infiltrative disease characterized by the deposition of amyloid fibrils in the cardiac tissue, which can cause serious atrioventricular block requiring pacemaker implantation. Left bundle branch pacing has emerged as an alternative method for delivering physiological pacing to achieve electrical synchrony of the left ventricle. However, left bundle branch pacing in patients with amyloid light-chain cardiac amyloidosis has not been studied in detail. Therefore, in this study, we present a case of left bundle branch pacing in a patient with amyloid light-chain cardiac amyloidosis. Case summary: A 66-year-old male patient with amyloid light-chain cardiac amyloidosis presented with syncope for 1 month. Holter monitoring revealed intermittent third-degree atrioventricular block. Left bundle branch pacing was performed successfully. During the 1-year follow-up, it was observed that the left bundle branch capture threshold remained stable without any pacemaker-related complications or left ventricle systolic dysfunction, and there was no recurrence of syncope. Conclusion: Left bundle branch pacing appears to be a safe and feasible option for patients with amyloid light-chain cardiac amyloidosis experiencing atrioventricular block.

Case report: Recurrent syncope as initial symptom in a patient with neck lymphoma.

Syncope may have many different causes, requiring careful identification. Recurrent syncope is uncommon as an initial symptom of neck lymphoma. Head and neck tumors involving the carotid artery cause syncope associate with carotid sinus syndrome. We report the case of a 72-year-old man who suffered from recurrent syncope due to compression of the right carotid sinus by diffuse large B-cell lymphoma and was successfully treated with immunochemotherapy. Syncope may be an early or sole sign of a neck or head tumor. We should be aware of the possibility of an underlying malignancy in patients with unexplained syncope after initial evaluation.

Relationship between the distribution of left atrial low-voltage zones and post-ablation atrial arrhythmia recurrence in patients with atrial fibrillation.

BACKGROUND: Low-voltage zones (LVZ) are surrogate markers for cardiac fibrosis, which contribute to the maintenance of atrial fibrillation (AF). The aim of this study was to investigate the effect of the distribution of left atrial (LA) LVZ on the outcome following catheter ablation. METHODS: This retrospective study enrolled patients with AF who underwent initial catheter ablation. LVZ were defined as areas with bipolar voltage amplitude <0.5 mV. The left atrium was divided into six regions (anterior wall, roof, posterior wall, lateral wall, septum, and inferior wall) to describe the distribution of LVZ. The primary endpoint was atrial arrhythmia (AA) recurrence lasting >30 s after the initial catheter ablation. RESULTS: Altogether, 148 patients were included, with a mean age of 61 ± 11 years, of which 53 (35.8%) had persistent AF. During a mean follow-up of 14 ± 3 months post-ablation, AA recurrence occurred in 25 (16.9%) patients after the initial catheter ablation. Kaplan-Meier analysis showed that patients without roof LVZ had a higher AA-free survival rate than those with roof LVZ (P = 0.047). In the multivariate Cox regression analysis, the proportion of LA LVZ ≥6% [hazard ratio (HR) 2.315, 95% confidence interval (CI) 1.048-5.114; P = 0.038] and a longer AF duration (HR 1.008, 95% CI 1.002-1.014; P = 0.006) were independent predictors of AA recurrence. CONCLUSIONS: In patients with AF, LA roof LVZ may increase the risk of AA recurrence after initial catheter ablation.

Mitral valve regurgitation is associated with left atrial fibrosis in patients with atrial fibrillation.

BACKGROUND: Low voltage zones (LVZ) are associated with poor outcomes in patients with atrial fibrillation (AF). The APPLE and DR-FLASH scores predict LVZ in patients undergoing catheter ablation. This study aimed to assess the relationship of mitral valve regurgitation (MR) and LVZ after adjusting for APPLE or DR-FLASH scores. METHODS: This was a retrospective study on patients with AF who underwent their first catheter ablation. All patients underwent a transthoracic echocardiographic examination before ablation. The APPLE and DR-FLASH scores were calculated at baseline. LVZ determined by high-density mapping was defined as bipolar voltage amplitude <0.5 mV. LVZ presence was defined as LVZ covering >5% of the left atrial surface area. RESULTS: Altogether, 152 patients (mean age 62.0 ± 10.8 years, 65.8% men, and 36.2% with persistent AF) were included. Of the 152 patients, 47 (30.9%) had LVZ. The patients with LVZ had more moderate-to-severe MR (17.0% vs. 3.8%, P = 0.014) and higher APPLE scores (1.7 ± 1.1 vs. 1.2 ± 1.1, P = 0.009) and DR-FLASH scores (3.0 ± 1.5 vs. 2.4 ± 1.4, P = 0.010). Using multivariate logistic regression analysis, we found moderate-to-severe MR was related to LVZ presence after adjusting for the APPLE (OR 4.040, P = 0.034) or DR-FLASH (OR 4.487, P = 0.020) scores. Furthermore, moderate-to-severe MR had an incremental predictive value for LVZ presence in addition to the APPLE (P = 0.03) or DR-FLASH (P = 0.02) scores. CONCLUSION: In patients with AF, MR severity was related to LVZ after adjusting the APPLE score or DR-FLASH score.

The prognostic significance of electrocardiography findings in patients with coronavirus disease 2019: A retrospective study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has reached a pandemic level. Cardiac injury is not uncommon among COVID-19 patients. We sought to describe the electrocardiographic characteristics and to identify the prognostic significance of electrocardiography (ECG) findings of patients with COVID-19. HYPOTHESIS: ECG abnormality was associated with higher risk of death. METHODS: Consecutive patients with laboratory-confirmed COVID-19 and definite in-hospital outcome were retrospectively included. Demographic characteristics and clinical data were extracted from medical record. Initial ECGs at admission or during hospitalization were reviewed. A point-based scoring system of abnormal ECG findings was formed, in which 1 point each was assigned for the presence of axis deviation, arrhythmias, atrioventricular block, conduction tissue disease, QTc interval prolongation, pathological Q wave, ST-segment change, and T-wave change. The association between abnormal ECG scores and in-hospital mortality was assessed in multivariable Cox regression models. RESULTS: A total of 306 patients (mean 62.84 ± 14.69 years old, 48.0% male) were included. T-wave change (31.7%), QTc interval prolongation (30.1%), and arrhythmias (16.3%) were three most common found ECG abnormalities. 30 (9.80%) patients died during hospitalization. Abnormal ECG scores were significantly higher among non-survivors (median 2 points vs 1 point, p < 0.001). The risk of in-hospital death increased by a factor of 1.478 (HR 1.478, 95% CI 1.131-1.933, p = 0.004) after adjusted by age, comorbidities, cardiac injury and treatments. CONCLUSIONS: ECG abnormality was common in patients admitted for COVID-19 and was associated with adverse in-hospital outcome. In-hospital mortality risk increased with increasing abnormal ECG scores.

Noninvasive electrocardiography monitoring for very early recurrence predicts long-term outcome in patients after atrial fibrillation ablation.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia, and catheter ablation has been shown to be a highly effective treatment for patients with symptomatic AF. Very early recurrence (VER) of AF within 7 days after catheter ablation is common, but the clinical significance of VER remains unclear. We have examined the usefulness of the noninvasive electrocardiography monitor for the detection of VER and the relationship between VER and late recurrence (LR). METHODS: Eighty-eight patients with paroxysmal or persistent atrial fibrillation were retrospectively included. All patients underwent primary catheter ablation at a large general hospital between March 2016 and August 2018. All patients were followed up in atrial fibrillation clinic at an interval of every 3 months for late recurrence of AF. VER was evaluated by one-lead continuous noninvasive electrocardiography monitoring device for 7 days after ablation. The association between VER and LR was analyzed by univariate and multivariate Cox regression model. RESULTS: Mean age was 62.9 ± 9.7 years, and 39.8% were female. Thirty-two patients (36.4%) experienced VER. After a mean follow-up of 539.36 ± 211.66 days, 17 patients (19.3%) experienced LR. Multivariate Cox regression analysis revealed VER was an independent predictor of LR: HR 3.6 (95% CI, 1.2-10.8), p = .020. In addition, diabetes was also associated with LR of atrial fibrillation. CONCLUSIONS: Noninvasive electrocardiography monitoring was a useful tool for detecting VER and VER after catheter ablation was associated with LR.

Effects of the short-term exposure to ambient air pollution on atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is an important arrhythmia associated with cardiovascular morbidity and mortality. This study is focused on exploring the potential relationship between short-term air pollution exposure and occurrence of AF. METHODS: A case-crossover design was used to investigate the effect of pollutants on AF occurrence among 100 patients from 2013 to 2014. The air pollutants included ambient particulate matter less than 2.5 µm in aerodynamic diameter (PM2.5 ), particulate matter less than 10 µm in aerodynamic diameter (PM10 ), nitrogen dioxide (NO2 ), sulfur dioxide (SO2 ), carbon monoxide (CO), and ozone (O3 ). Participants with cardiac implantable electronic devices implanted were followed-up to December 31, 2014. RESULTS: A 10 µg/m3 increase of PM2.5 and PM10 was associated with 3.8% (95% confidence interval [CI]: 1.4-6.2) and 2.7% (95% CI: 0.6-4.8) increase in the risk of AF occurrence, respectively. No statistically significant association was noted with SO2 , NO2 , CO, and O3 . CONCLUSIONS: Short-term exposure to particular matter, both PM2.5 and PM10 , is associated with an increased risk of AF. This further demonstrates the urgency for air quality monitoring and control in geographical area with intense pollution.

Distribution and predictors of hospital charges for haemorrhagic stroke patients in Beijing, China, March 2012 to February 2015: a retrospective study.

OBJECTIVES: The purpose of this study is to analyse hospital charges for patients with haemorrhagic stroke in China and investigate potential factors associated with inpatient charges. METHODS: The study participants were in-hospital patients with a primary diagnosis of haemorrhagic stroke from all the secondary and tertiary hospitals in Beijing during the period from 1 March 2012 to 28 February 2015. Distribution characteristics of detailed hospital charges were analysed. The influence of potential factors on hospital charges was researched using a stepwise multiple regression model. RESULTS: A total of 34 890 patients with haemorrhagic stroke of mean age 61.19±14.37 years were included in the study, of which 37.2% were female. Median length of hospital stay (LOHS) was 15 days (IQR 9-23) and median hospital cost was 18 577 Chinese yuan (CNY) (IQR 10 442-39 784). The hospital costs for patients in Western medicine hospitals (median 19 651 CNY) were significantly higher (P<0.01) than those in traditional Chinese medicine hospitals (median 14 560 CNY), and were significantly higher (P<0.01) for Level 3 hospitals (median 20 029 CNY) than for Level 2 hospitals (median 16 095 CNY). The proportion of medicine fees and bed fees within total hospital charges showed a decreasing trend during the study period. With stepwise multiple regression, the major factors associated with hospital charges were LOHS, surgery, pulmonary infection, ventilator usage, hospital level, occupation, hyperlipidaemia, hospital type, in-hospital death, sex and age. CONCLUSION: We conclude that medicines form the largest part of hospital charges but are showing a decreasing trend, and LOHS is strongly associated with patient charges for haemorrhagic stroke in China. This implies that the cost structure is very unreasonable in China and medical technology costs fail to be fully manifested. A reasonable decrease in medicine charges and shortening LOHS may be effective ways to reduce hospital charges.

Analysis of Hospital Charges of Inpatients with Acute Ischemic Stroke in Beijing, China, 2012-2015.

BACKGROUND: The study aimed to analyze the hospital charges of the inpatients with acute ischemic stroke in Beijing and determine the factors associated with hospital costs. METHODS: Medical records of hospitalized patients with a primary diagnosis of ischemic stroke according to International Classification of Diseases 10th Revision codes were collected from 121 hospitals in Beijing from March 1, 2012, to February 28, 2015. Distribution characteristics of hospital charges for different hospital levels (level 2 hospitals and level 3 hospitals) and types (Western medicine hospitals and Chinese medicine hospitals) were studied. Linear regression analysis was used to examine the association among hospital costs and factors that influenced total hospital charges. RESULTS: There were 158,781 admissions for ischemic stroke, 63.1% of the patients were male and their mean age was 67.7 ± 12.4 years, the median length of hospital stay (LOHS) was 13.5 days (interquartile range 9.9-18.1 days). The median hospital charge was 2,112 (1,436-3,147) US dollars. Of these, 46.7% were for medicine, 21.1% for laboratory and examination, and 16.3% for therapy. LOHS, hospital level, and pulmonary infection were key determinants of the hospital charges. CONCLUSIONS: The proportion of medicine fees for the ischemic stroke inpatients showed a downward trend during the period from 2012 to 2015, but medicine fees still accounted for the largest percentage of hospital charges in China. LOHS emerged to be the main determinant of the cost. Decreasing medicine fees and LOHS might be strategies to decrease hospital charges and reduce economic burden of stroke in China.

The importance of Purkinje activation in long duration ventricular fibrillation.

BACKGROUND: The mechanisms that maintain long duration ventricular fibrillation (LDVF) are unclear. The difference in distribution of the Purkinje system in dogs and pigs was explored to determine if Purkinje activation propagates to stimulate working myocardium (WM) during LDVF and WM pacing. METHODS AND RESULTS: In-vivo extracellular recordings were made from 1044 intramural plunge and epicardial plaque electrodes in 6 pig and 6 dog hearts. Sinus activation propagated sequentially from the endocardium to the epicardium in dogs but not pigs. During epicardial pacing, activation propagated along the endocardium and traversed the LV wall almost parallel to the epicardium in dogs, but in pigs propagated away from the pacing site approximately perpendicular to the epicardium. After 1 minute of VF, activation rate near the endocardium was significantly faster than near the epicardium in dogs (P<0.01) but not pigs (P>0.05). From 2 to 10 minutes of LDVF, recordings exhibiting Purkinje activations were near the endocardium in dogs (P<0.01) but were scattered transmurally in pigs, and the WM activation rate in recordings in which Purkinje activations were present was significantly faster than the WM activation rate in recordings in which Purkinje activations were absent (P<0.01). In 10 isolated perfused dog hearts, the LV endocardium was exposed and 2 microelectrodes were inserted into Purkinje and adjacent myocardial cells. After 5 minutes of LDVF, mean Purkinje activation rate was significantly faster than mean WM activation rate (P<0.01). CONCLUSION: These extracellular and intracellular findings about activation support the hypothesis that Purkinje activation propagates to stimulate WM during sinus rhythm, pacing, and LDVF.

[Causes of insufficient anticoagulation in Chinese patients with non-valvlar atrial fibrillation].

OBJECTIVE: To evaluate the factors responsible for the insufficient application of oral anticoagulation (OAC) in Chinese patients with non-valvular atrial fibrillation. METHODS: The research is a single center registration study in a tertiary referral hospital in Beijing. The general characteristics, history of atrial fibrillation, comorbidities and anticoagulation treatment were obtained from all patients.Factors affecting the oral Walfarin use were evaluated by univariable and multivariable regression analysis. RESULTS: OAC therapy with Walfarin was applied on Only 214(39.4%) out of 576 consecutive patients with non-valvular atrial fibrillation. The OAC rate was 30.3% among non-ablation patients. Patients with persistent atrial fibrillation, diabetes, chronic heart failure, history of ischemic stroke/TIA and higher CHA2DS2-VASc score were more likely prescribed with Walfarin. Multivariable regression analysis showed that persistent fibrillation, history of chronic heart failure, ischemic stroke/TIA and non-coronary heart disease predicted the treatment with Walfarin. CONCLUSIONS: OAC use is extremely low in Chinese patients with non-valvular atrial fibrillation. More efforts are warranted to improve OAC use in these patients.

The amplitude of fibrillatory waves on leads aVF and V1 predicting the recurrence of persistent atrial fibrillation patients who underwent catheter ablation.

OBJECTIVE: To evaluate whether the amplitude of fibrillatory wave (F wave) on electrocardiography could predict the recurrence in persistent atrial fibrillation (AF) patients who underwent catheter ablation. METHODS: All consecutive persistent AF patients who underwent catheter ablation at Peking Union Medical College Hospital between November 2006 and February 2012, were enrolled. The amplitude of F wave was measured on three orthogonal leads (leads I, V1 and aVF) on the Prucka CardioLab recording system. The primary end point was the recurrence after catheter ablation. RESULTS: A total of 54 persistent AF patients were enrolled. Fifty patients (age: 58 ± 11years, 72% male) constituted the study population after excluding four patients lost of follow-up. The duration of AF was 9 ± 7 (2-18) months. Twenty-four patients (48%) recurred during the follow-up of 25 ± 19 months, constituted recurrence group. The remaining 26 patients constituted control group. The F-wave amplitude in recurrence group was significantly lower than control group (lead aVF, 0.085 ± 0.018 vs. 0.111 ± 0.036mV, P = 0.002; lead V1 , 0.116 ± 0.031 vs. 0.148 ± 0.047mV, P = 0.008). The amplitudes of leads aVF (P = 0.023) and V1 (P = 0.031) were the independent predictors of AF recurrence. The sensitivity and specificity of F-wave amplitude of lead aVF < 0.093mV or V1 < 0.123mV to predict the recurrence were 75% and 73%, 68% and 64%, respectively. CONCLUSION: The low amplitudes of F wave in leads aVF and V1 could predict the recurrence of patients with persistent AF who underwent catheter ablation.

The R-wave deflection interval in lead V3 combining with R-wave amplitude index in lead V1: a new surface ECG algorithm for distinguishing left from right ventricular outflow tract tachycardia origin in patients with transitional lead at V3.

BACKGROUND: To distinguish left ventricular outflow tract (LVOT) from right ventricular outflow tract (RVOT) origin in idiopathic premature ventricular contractions or ventricular tachycardia (PVCs/VT) patients with transitional lead at V3 is still a challenge. We sought to develop a new electrocardiography (ECG) algorithm for distinguishing LVOT from RVOT origin in patients with idiopathic outflow tract PVCs/VT with precordial transitional lead at V3. METHODS: We analyzed the surface ECG characteristics in a retrospective cohort of idiopathic PVCs/VT patients with transitional lead at V3 who underwent successful radiofrequency catheter ablation and developed a new surface ECG algorithm, then validated it in a prospective cohort. RESULTS: A total of 82 consecutive patients (47 ± 17 years, 39% male) underwent radiofrequency catheter ablation of idiopathic outflow tract PVCs/VT between January 2006 and August 2010. Among them, 31 patients (38%) with transitional lead at V3 constituted the retrospective cohort. Based on the areas under the receiver operating characteristic curves, R-wave deflection interval in lead V3>80 ms and R-wave amplitude index in lead V1>0.30 were selected to develop the new surface ECG algorithm. It correctly identified the origin sites of eleven from 12 patients in the prospective cohort, yielding the accuracy of 91.7%. CONCLUSIONS: We presented a new simple surface ECG algorithm, R-wave deflection interval in lead V3>80 ms combining with R-wave amplitude index in lead V1>0.30 which can reliably distinguish LVOT from RVOT origin in idiopathic outflow tract PVCs/VT in patients with transitional lead at V3.

Elimination of fatal arrhythmias through ablation of triggering premature ventricular contraction in type 3 long QT syndrome.

Congenital long QT syndrome (LQTS) is the most common inherited arrhythmia, fatal arrhythmias are the main causes of sudden death, and often induced by the premature ventricular contractions (PVCs). Ablation of the triggering PVCs may eliminate the fatal arrhythmias and prevent the sudden death in patients with LQTS. We report a 19-year-old boy diagnosed with type 3 LQTS, frequent fatal arrhythmias induced by PVCs with the identical QRS morphology. Successful ablation of the triggering PVCs was done and a single-chamber implantable cardioverter defibrillator (ICD) was implanted. There was no fatal arrhythmia events recorded by ICD during 29-month follow-up. Catheter ablation was the effective method to eliminate the fatal arrhythmias through ablation of the triggering PVCs in the present LQT3 patient.

Poor prognosis in chronic heart failure patients with reduced ejection fraction in China.

Most Chinese cardiologists are challenged by the high mortality rate of heart failure (HF) in patients with reduced ejection fraction in China. This study was designed as a single-center, retrospective study. All consecutive HF patients with left ventricular ejection fraction (LVEF) ≤ 45% from January 1, 2007, to December 31, 2009, were enrolled. The primary outcome was all-cause mortality. The secondary outcome was all-cause mortality or the first cardiovascular readmission event. A total of 187 patients comprised the study population, classified into two groups: LVEF ≤ 35% (n=83) and LVEF 36% to 45% (n=104). The median follow-up was 18 months (2-41 months). All-cause mortality was 27% among patients with LVEF ≤ 35%, as compared with 14% among those with LVEF 36% to 45% (P=.025). All-cause mortality or first cardiovascular readmission rates were 53% and 32% among patients with LVEF ≤ 35% and 36% to 45% (P=.003), respectively. The predictors of all-cause mortality were advanced age and New York Heart Association functional class, chronic kidney disease, oral ß-blockers, and statins at discharge. The prognosis of chronic HF patients with LVEF ≤ 45% was poor in China, especially for patients with LVEF ≤ 35%. Cardiologists should provide further efforts to improve the prognosis of HF in Chinese patients.