Systemic Brucellosis with Arrhythmogenic Cardiac Inflammatory Pseudotumor.

BACKGROUND Cardiac inflammatory pseudotumors are rarely observed. Their etiology might include immunologic abnormalities, fibrogenetic disorders, specific reactions to infections or abnormalities related to trauma, necrosis, or neoplasm. Life-threatening ventricular tachycardia and cases of sudden death related to cardiac tumors have been reported. The present report describes and discusses diagnostic and therapeutic solutions for the treatment of nonsarcoid multiorgan pseudotumors with cardiac involvement. CASE REPORT A 38-year-old woman presented to the clinic with symptomatic ventricular tachycardia. As coronary artery disease, cardiomyopathy, and channelopathy were ruled out, and electrocardiograms were not typical of idiopathic arrhythmia, the patient underwent detailed diagnostics which included targeted endomyocardial biopsy, which revealed a cardiac inflammatory pseudotumor. Laborious testing (and eventually, antibiotic therapy) led to ex juvantibus diagnosis of multiorgan disseminated brucellosis with cardiac involvement. Treatment with ceftriaxone, doxycycline, and rifampicin resulted in a complete resolution of all lesions after 3 months, and sustained recovery was observed during a 5-year follow-up. As the risk of ventricular tachycardia could not be reliably predicted, the patient had a subcutaneous implantable cardioverter-defibrillator implanted. CONCLUSIONS A vast diagnostic armamentarium of modern medicine allowed us to diagnose an unsuspected and rare cardiac inflammatory pseudotumor. In the case of travelers, the possibility of regionally specific illnesses, especially infections, must be taken into consideration as possible causes of arrhythmias. Cardiac magnetic resonance imaging may be useful in patients with 'idiopathic ventricular tachycardias' to detect non-apparent myocardial lesions which may result from the underlying cause of the arrhythmia.

Clinical valuation of ST changes in a group of patients with ventricular arrhythmias: The inSighT Study.

BACKGROUND: The inSighT study was designed to determine the prevalence of ischemic changes as recorded by implantable cardioverter-defibrillator (ICD) ST deviations in intracardiac electrocardiograms (EGM) over the 24 h preceding malignant ventricular arrhythmias (VT/VF). METHODS: The study enrolled patients with known coronary artery disease (CAD) or high risk of future development of CAD implanted with an ICD equipped with an ST monitoring feature (Ellipse™/Fortify Assura™, St. Jude Medical). Device session records were collected at each in-clinic follow-up. EGM ST levels of the beats over the 15 minutes prior to VT/VF events were compared using a t test with those from a baseline period of 23-24 h prior to the VT/VF event. All events with p < .05 were visually inspected to confirm they were evaluable; additional criteria for exclusion from further analysis included inappropriate therapy, aberrant conduction, and occurrence of VT/VF within 24h prior to the current event. RESULTS: The study enrolled 481 ICD patients (64 ± 11 years, 83% male) in 14 countries and followed them for 15±5 months. A total of 165 confirmed VT/VF episodes were observed, of which 71 events (in 56 patients, 34% of all patients with VT/VF) were preceded by significant (p < .05) ST-segment changes unrelated to known non-ischemic causes. None of the analyzed demographic and clinical factors proved to be associated with greater odds of presenting with ST-segment changes prior to VT/VF episode. CONCLUSION: In this exploratory study, characteristic ST-segment changes, likely representative of ischemic events, were observed in 34% of all patients with VT/VF episodes.

The safety, efficacy, and cost-effectiveness of gentamycin-collagen sponge in multicomponent prevention strategy of cardiac implantable electronic device infections - a single-center experience.

BACKGROUND: Cardiac implantable electronic device(CIED)infections are associated with significant morbidity, mortality, and increased healthcare expenses. Apart from standard systemic antibiotic therapy, locally acting agents are under investigation as a potential approach for the prevention of this complication. AIMS: The study aimed to summarize our experience with a gentamycin-collagen sponge (GCS) in a multi-component prevention strategy of cardiac implantable electronic device infection. METHODS: We retrospectively analyzed medical records of 312 consecutive patients who underwent CIED-related surgery and had at least a 6-month follow-up. All the individuals had GCS applied during surgery. An incidence of CIEDs-related infection in our group was compared to the risk level calculated according to the commonly used scores. Analysis of cost-effectiveness was also performed. RESULTS: Incidence of CIED-related infection, defined as a primary endpoint, occurred relatively rarely (0.33%) as compared to the infection risk calculated according to commonly used scores Prevention of Arrythmia Device Infection Trial (PADIT) - 0.83%; CIED-AI - 0.90% or Mittal score - 1.00%; P<0.001 - for all). We did not record any complications related to GCS. We analyzed the cost-effectiveness of our GCS-based approach, which appeared to be financially beneficial (number needed to treat 149-200; difference of CIED infection treatment cost and GCSs price was 5093-26525 $). CONCLUSIONS: We conclude that: (1) the use of GCS to reduce CIEDs infections is feasible and safe; (2) our multicomponent prevention strategy involving the GCS application seems to significantly reduce the rate of CIED infection, and it is cost-effective.

Multicentre early experience with totally subcutaneous cardioverter-defibrillators in Poland.

INTRODUCTION: Implantable cardioverter-defibrillators (ICD) have a strong position in the prevention of sudden death. Nowadays, the most commonly used high-energy cardiac devices are transvenous ICDs. A new technology of totally subcutaneous ICDs (S-ICD) was invented and recently introduced into clinical practice in order to reduce lead-related complications of conventional ICDs. The aim of this paper is to present early experience with this new technology implemented in a few centres in Poland. MATERIAL AND METHODS: Medical records of patients who had S-ICD-related interventions in Poland were retrospectively analysed. RESULTS: During the first year of S-ICD introduction into the Polish health system 18 patients underwent surgery connected with S-ICDs. Majority of them (17 patients) were implanted de novo. In one patient surgical revision of a device implanted abroad was performed. Most of patients (78%) had S-ICDs implanted for secondary prevention. Inability of transvenous system implantation due to venous access obstruction or high risk of infection related with transvenous leads accounted for 83% of indications for S-ICD. Only in three patients were S-ICDs implanted due to young age and active mode of life. The implantations of S-ICDs were performed without important early or late complications. During follow-up one patient had episodes of ventricular arrhythmia successfully terminated with high-energy shocks. One patient died due to progression of heart failure. CONCLUSIONS: S-ICD implantation procedure has been successfully and safely introduced in Polish clinical routine. Nevertheless, despite clear indications in recent ESC guidelines, this therapy is not directly reimbursed in Poland and needs individual application for refund.

A counterpoint paper: Comments on the electrocardiographic part of the 2018 Fourth Universal Definition of Myocardial Infarction.

The Fourth Universal Definition of Myocardial Infarction (FUDMI) [published simultaneously in 2018 in numerous journals including Circulation, Journal of the American College of Cardiology and European Heart Journal] focuses mainly on the distinction between non-ischemic myocardial injury and myocardial infarction (MI), along with the role of cardiovascular magnetic resonance, in order to define the etiology of myocardial injury. As a consequence, there is less emphasis on updating the parts of the definition concerning the electrocardiographic (ECG) changes related to MI. Evidence of myocardial ischemia is a prerequisite for the diagnosis of MI and the ECG is the main available tool for i) detecting acute ischemia, ii) triage and iii) risk stratification upon presentation. This review focuses on multiple aspects of ECG interpretation that we firmly believe should be considered for incorporation in any future update to the Universal Definition of MI. Our counterpoint view is that: a) the use of the ECG following coronary artery bypass surgery should be better explored and defined; b) the emphasis in the FUDMI on convex versus concave ST-elevation, which is questionable, should be balanced by the fact that many patients with true ST-elevation MI (STEMI) present with a concave form of ST elevation; c) reciprocal ST-depression in STEMI caused by right coronary artery or left circumflex artery occlusion, should be set against the fact that not all anterior STEMIs present with reciprocal ST-depression which can also be seen in cardiomyopathy and left ventricular hypertrophy; d) the "posterior" leads V7-V9 should be placed on a horizontal line from V4, rather than follow the 5th intercostal space; e) ST-depression in V1-V3 is not a manifestation of ischemia of the basal inferior segment, placed horizontally; f) Interpreting ST-T changes in patients with conduction abnormalities and pacemakers should be further defined.

Conventional and alternative preimplantation ECG screening for subcutaneous ICD in high risk hypertrophic cardiomyopathy patients.

INTRODUCTION: Patients with hypertrophic cardiomyopathy (HCM) relatively often fail preimplantation ECG screening for subcutaneous implantable cardioverter-defibrillator (S-ICD). We aimed to evaluate impact of conventional and alternative ECG electrodes placement on eligibility for S-ICD implantation in HCM patients at high risk of sudden cardiac death (SCD). We hypothesized that modified electrodes placement will influence QRS-T morphology and thus it will increase S-ICD eligibility in the screening process. MATERIAL AND METHODS: This study enrolled 17 HCM patients at high risk of SCD (5-year SCD risk above 5%) referred for an ICD implantation. ECG screening for S-ICD eligibility in horizontal and vertical position was performed in each patient, in two different screening electrodes configuration: conventional (recommended by manufacturer) and alternative (precordial electrodes shifted rightwards and lateral electrodes dorsally). We evaluated QRS and T waves amplitude as well as T wave index. Primary, secondary and alternate sensing vectors were assessed. RESULTS: Preimplantation ECG screening with alternative electrodes placement resulted in more sensing vectors that were screened successfully (77 vs. 88, p = 0.05). Modified screening combined with a standard one allowed more patients to qualify for S-ICD implantation (17/17 vs. 12/17, p = 0.04). Electrocardiographically, the alternative positioning of ECG electrodes resulted in significant decrease in absolute values of QRS complex and T waves amplitudes in almost all sensing vectors, which was responsible for successful screening. CONCLUSIONS: The use of alternative placement of screening electrodes may be a valuable method to increase eligibility for S-ICD implantation in HCM patients at high risk of SCD.

[Long-term prognosis in patients with vasovagal syncope after pacemaker implantation]. / Rokowanie odlegle u pacjentów z omdleniami wazowagalnymi po implantacji kardiostymulatora.

Patients with syncope, without presence of a structural or primary electrical disease, have a very good prognosis. On the other hand, recurring syncope has a negative impact on quality of life and involves a real risk of physical injuries. Vasovagal syncope usually requires no medical therapy and the most commonly recommended instruction include avoidance of fainting triggers, exercise that mainly provoke leg muscles tension, increase salt consumption and drink indicated amount of fluids. In the case cardioinhibitory type of vasovagal syncope the pacemaker implantation can consider. Unfortunately, not all patients benefit from this treatment. Medical society clearly highlights that proper qualification of VVS patients is the most important factor for cardiostimulator implantation. This article aims to summarize the most important research and guidelines concerning cardiac pacing for patients with vasovagal syncope.

[Technical options of electrotherapy in patients with vasovagal syncope]. / Techniczne mozliwosci elektroterapii u osób z omdleniami wazowagalnymi.

Syncope is a symptom of the disease with diverse etiology and can be evidence of both benign and very serious life-threatening conditions. Vasovagal syncope(VVS), with prevalence about 35% of the general population, is most frequent causes of transient loss of consciousness (T-LOC). Most cases of vasovagal syncope requires conservative treatment. Although cardioinhibitory type of VVS characterized by a significant bradycardia or pause of the heart rate and can be treated with continuous electrotherapy. This article discuss cardiac pacing and technical solutions for the treatment of VVS. Available cardiac pacing methods used to detect and break VVS such as Rate Drop Response (RDR), Closed Loop Stimulation (CLS) and rate response driven by variations of myocardial contractility like Peak Endocardial Acceleration (PEA), has been presented.

Automatic SVM classification of sudden cardiac death and pump failure death from autonomic and repolarization ECG markers.

BACKGROUND: Considering the rates of sudden cardiac death (SCD) and pump failure death (PFD) in chronic heart failure (CHF) patients and the cost-effectiveness of their preventing treatments, identification of CHF patients at risk is an important challenge. In this work, we studied the prognostic performance of the combination of an index potentially related to dispersion of repolarization restitution (Δα), an index quantifying T-wave alternans (IAA) and the slope of heart rate turbulence (TS) for classification of SCD and PFD. METHODS: Holter ECG recordings of 597 CHF patients with sinus rhythm enrolled in the MUSIC study were analyzed and Δα, IAA and TS were obtained. A strategy was implemented using support vector machines (SVM) to classify patients in three groups: SCD victims, PFD victims and other patients (the latter including survivors and victims of non-cardiac causes). Cross-validation was used to evaluate the performance of the implemented classifier. RESULTS: Δα and IAA, dichotomized at 0.035 (dimensionless) and 3.73 µV, respectively, were the ECG markers most strongly associated with SCD, while TS, dichotomized at 2.5 ms/RR, was the index most strongly related to PFD. When separating SCD victims from the rest of patients, the individual marker with best performance was Δα≥0.035, which, for a fixed specificity (Sp) of 90%, showed a sensitivity (Se) value of 10%, while the combination of Δα and IAA increased Se to 18%. For separation of PFD victims from the rest of patients, the best individual marker was TS ≤ 2.5 ms/RR, which, for Sp=90%, showed a Se of 26%, this value being lower than Se=34%, produced by the combination of Δα and TS. Furthermore, when performing SVM classification into the three reported groups, the optimal combination of risk markers led to a maximum Sp of 79% (Se=18%) for SCD and Sp of 81% (Se=14%) for PFD. CONCLUSIONS: The results shown in this work suggest that it is possible to efficiently discriminate SCD and PFD in a population of CHF patients using ECG-derived risk markers like Δα, TS and IAA.

Prinzmetal angina: ECG changes and clinical considerations: a consensus paper.

BACKGROUND: We will focus our attention in this article in the ECG changes of classical Prinzmetal angina that occur during occlusive proximal coronary spasm usually in patients with normal or noncritical coronary stenosis. RESULTS: The most important ECG change during a focal proximal coronary spasm is in around 50% of cases the appearance of peaked and symmetrical T wave that is followed, if the spasm persist, by progressive ST-segment elevation that last for a few minutes, and later progressively resolve. The most frequent ECG changes associated with ST-segment elevation are: (a) increased height of the R wave, (b) coincident S-wave diminution, (c) upsloping TQ in many cases, and (d) alternans of the elevated ST-segment and negative T wave deepness in 20% of cases. The presence of arrhythmias is very frequent during Prinzmetal angina crises, especially ventricular arrhythmias. The prevalence and importance of ventricular arrhythmias were related to: (a) duration of episodes, (b) degree of ST-segment elevation, (c) presence of ST-T wave alternans, and (d) the presence of >25% increase of the R wave. CONCLUSIONS: The incidence of Prinzmetal angina is much lower then 50 years ago for many reasons including treatment with calcium channel blocks to treat hypertension and ischemia heart disease and the decrease of smoking habits.

Influence of coronary artery bypass grafting on heart rate turbulence parameters.

This study evaluated the influence of coronary artery bypass grafting on heart rate turbulence (HRT) parameters assessed during 1-year follow-up in patients with coronary artery disease. HRT and heart rate variability (HRV) parameters significantly worsened 3 months after surgery. After 1 year, HRV parameters and turbulence onset returned to preoperative values, whereas turbulence slope remained significantly attenuated. Our results show that there is a marked attenuation of HRT parameters in the early postoperative period, indicating an impairment of baroreflex sensitivity after coronary artery bypass grafting. Concomitant depression of HRV parameters points to dysfunction of the autonomic nervous system, provoked by perioperative attenuation, as a potential underlying cause of impaired baroreflex response.

Sex steroids and heart rate variability in patients after myocardial infarction.

BACKGROUND: Although the relationship between sex steroid levels and coronary artery disease (CAD) has been the subject of many studies there are still controversies concerning the role of sex steroids in CAD. In patients with CAD, especially after a myocardial infarction, there is evidence for autonomic nervous system dysfunction. However, there is no data detailing the relationship between sex steroids and cicardian autonomic activity in patients with CAD. The aim of the study was to evaluate the association between sex steroids and heart rate variability (HRV) parameters in postinfarction patients. METHODS: In 88 postinfarction men (aged 36-73, average 53 years), 24-hour Holter monitoring was performed to assess HRV parameters: SDNN, SDNNI, SDANN, rMSSD, pNN50, and levels of the following hormones were measured: testosterone, estradiol, free testosterone index, and estradiol/testosterone ratio. Univariate and multivariate regression analyses were used to investigate the relationship between HRV parameters and levels of tested hormones. RESULTS: Increased testosterone levels were associated with increased SDNN (r = 0.38, P = 0.03), increased rMSSD (r = 0.51, P = 0.002), and increased pNN50 (r = 0.45, P = 0.007). These associations remained significance after adjustment for age, ejection fraction, and other relevant clinical covariates. There was no significant association between estradiol and HRV parameters. CONCLUSION: In men with a history of myocardial infarction, higher levels of testosterone are associated with higher HRV measures of parasympathetic activity. These findings suggest that testosterone beneficially influences autonomic regulation of the heart.

[Sex steroids and heart rate variability in men with coronary artery disease after myocardial infarction]. / Steroidy plciowe a zmiennosc rytmu serca u mezczyzn z choroba wiencowa po zawale serca.

The role of sex steroids in coronary artery disease (CAD) has been studied for years. In patients after myocardial infarction autonomic nervous system dysfunction has been described. Heart rate variability (HRV) analysis is one of the method of autonomic nervous system evaluation. The aim of the study was to evaluate correlations between sex steroids and HRV in 88 men (aged 36-73, av. 53 yrs), with the history of MI, with angiographically documented CAD. In all the patients 24-hour Holter monitoring was performed to assess HRV time domain parameters: SDNN, SDNNI, SDANN, rMSSD, pNN50. Levels of testosterone and estradiol were measured in two subsequent blood samples, taken with 30 min interval. Free testosterone index as well as estradiol/testosterone ratio were assessed. For statistics r-Spearman test was used. Positive correlations were found between testosterone and SDNN (r = 0.38, p = 0.03), testosterone and rMSSD (r = 0.51, p = 0.002) and between testosterone and pNN50 (r = 0.45, p = 0.007). Since rMSSD and pNN50 are parameters describing parasympathetic activity, our results suggest that in CAD men with the history of myocardial infarction, testosterone may influences the function of autonomic nervous system promoting parasympathetic dominance. It can be favorable for the circulatory system function.