Artificial Intelligence-Enhanced Electrocardiogram for the Early Detection of Cardiac Amyloidosis.

OBJECTIVE: To develop an artificial intelligence (AI)-based tool to detect cardiac amyloidosis (CA) from a standard 12-lead electrocardiogram (ECG). METHODS: We collected 12-lead ECG data from 2541 patients with light chain or transthyretin CA seen at Mayo Clinic between 2000 and 2019. Cases were nearest neighbor matched for age and sex, with 2454 controls. A subset of 2997 (60%) cases and controls were used to train a deep neural network to predict the presence of CA with an internal validation set (n=999; 20%) and a randomly selected holdout testing set (n=999; 20%). We performed experiments using single-lead and 6-lead ECG subsets. RESULTS: The area under the receiver operating characteristic curve (AUC) was 0.91 (CI, 0.90 to 0.93), with a positive predictive value for detecting either type of CA of 0.86. By use of a cutoff probability of 0.485 determined by the Youden index, 426 (84%) of the holdout patients with CA were detected by the model. Of the patients with CA and prediagnosis electrocardiographic studies, the AI model successfully predicted the presence of CA more than 6 months before the clinical diagnosis in 59%. The best single-lead model was V5 with an AUC of 0.86 and a precision of 0.78, with other single leads performing similarly. The 6-lead (bipolar leads) model had an AUC of 0.90 and a precision of 0.85. CONCLUSION: An AI-driven ECG model effectively detects CA and may promote early diagnosis of this life-threatening disease.

Childhood Tobacco Smoke Exposure and Risk of Atrial Fibrillation in Adulthood.

BACKGROUND: Cigarette smoking is known to increase the risk of atrial fibrillation (AF), and a recent cross-sectional analysis suggested that parental smoking may be an AF risk factor. OBJECTIVES: The purpose of this study was to assess if parental smoking predicts offspring AF in the Framingham Heart Study. METHODS: This study analyzed Framingham Offspring cohort participants with parents in the Original cohort with known smoking status during the offspring's childhood. Framingham participants were evaluated every 2 to 8 years and were under routine surveillance for incident AF. The authors assessed AF incidence among Offspring participants exposed to parental smoking through age 18 years and performed a mediation analysis to determine the extent to which offspring smoking might explain observed associations. RESULTS: Of 2,816 Offspring cohort participants with at least 1 parent in the Original cohort, 82% were exposed to parental smoking. For every pack/day increase in parental smoking, there was an 18% increase in offspring AF incidence (adjusted hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39; p = 0.04). Additionally, parental smoking was a risk factor for offspring smoking (adjusted odds ratio [OR]: 1.34; 95% CI: 1.17 to 1.54; p < 0.001). Offspring smoking mediated 17% (95% CI: 1.5% to 103.3%) of the relationship between parental smoking and offspring AF. CONCLUSIONS: Childhood secondhand smoke exposure predicted increased risk for adulthood AF after adjustment for AF risk factors. Some of this relationship may be mediated by a greater propensity among offspring of smoking parents to smoke themselves. These findings highlight potential new pathways for AF risk that begin during childhood, offering new evidence to motivate smoking avoidance and cessation.

Consecutive episodes of heart and kidney failure in an "otherwise" healthy young man.

BACKGROUND: Acute renal failure is a rare occurrence in a patient with an unremarkable past medical history and should always lead to an in depth clinical study. The occurrence in the same healthy young subject, of consecutive episodes of heart failure and of acute renal failure is an even rarer event and should prompt diagnostic tests and restrict the diagnostic hypotheses. CASE PRESENTATION: We present the case of a 28 year-old man who, while waiting to undergo assessment for a mild chronic kidney disease, was diagnosed with decompensated dilated cardiomyopathy and placed on diuretics and ß-blockers. After few weeks he developed a non oligoanuric acute renal failure with a slight elevation of serum calcium. Renal biopsy proved suggestive for renal sarcoidosis; thus the hypothesis of systemic sarcoidosis with cardiac and renal involvement was possible avoiding further delay in initiation of therapy. CONCLUSIONS: Cardiac sarcoidosis is usually silent but the majority of cases are diagnosed when cardiac symptoms are present in a patient with systemic sarcoidosis. Renal involvement with granulomatous interstitial nephritis is also quite rare and can be an unexpected finding at kidney biopsy. This case highlights the need to evaluate thoroughly clinical problems that do not fit in a specific scenario and emphasizes the importance of performing a kidney biopsy in case of kidney failure of unknown etiology.

Predictors of Increased Length of Hospital Stay in Patients with Severe Cardiomyopathy Undergoing Coronary Artery Bypass Grafting.

OBJECTIVE: Predictors of operative outcome in patients with severely depressed left ventricular ejection fraction (LVEF) undergoing coronary artery bypass grafting (CABG) remain poorly defined. This study aims to identify preoperative variables that are associated with increased postoperative length of hospital stay or operative mortality in this patient population. DESIGN: Retrospective study. SETTING: Single tertiary care university hospital. PARTICIPANTS: Patients undergoing isolated CABG between January 2012 and March 2017 with an LVEF ≤ 25%. INTERVENTIONS: Isolated CABG. MEASUREMENTS AND MAIN RESULTS: Primary endpoint was a composite of prolonged length of stay, defined as postoperative length of stay >7 days or operative mortality. Of the 201 patients, 99 (49.3%) met the primary endpoint. Patient comorbidities, clinical presentation, presence of Q-waves on electrocardiogram, and echocardiographic parameters including ventricular dimensions and right heart dysfunction were not associated with the primary endpoint. On multivariable analysis, patients who were not on preoperative beta-blockers, patients with preoperative albumin of <3.5 g/dL, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score were associated with increased prolonged length of stay or death. CONCLUSIONS: More than half of patients with severely depressed LVEF undergoing isolated CABG are able to be discharged within 7 days postoperatively. The absence of preoperative beta-blockers, low preoperative albumin levels, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score are associated with more complicated or slower postoperative recovery after CABG in this patient population.

Underuse of ECG monitoring in oncology patients receiving QT-interval prolonging drugs.

OBJECTIVE: We examined use of ECG monitoring in oncology patients prescribed QT-prolonging drugs. METHODS: Patients ≥66 years diagnosed with cancer between 2005 and 2011 were identified through the Ontario Cancer Registry and linked to multiple population-based administrative databases to ascertain demographics, comorbidities, prescription drug use, systemic therapy and ECG. QT-prolonging drugs were identified as per drug lists developed by the Arizona Center for Education and Research on Therapeutics. Univariable and multivariable analyses were used to examine factors associated with ECG use in patients on first-line systemic therapy. RESULTS: A total of 48 236 patients (median age 74; 49% women) received one or more drugs associated with a risk of QT-interval prolongation but only 27% of patients had an ECG performed. Factors associated with more ECG use on multivariable analysis included recent cancer diagnosis (p for trend <0.001 between 2005 and 2011), use of concurrent QT-prolonging drugs (OR=1.15 per each additional QT-prolonging drug, 95% CI 1.12 to 1.17) and the presence of coronary artery disease (OR 1.31; 95% CI 1.25 to 1.38) and heart failure (OR 1.25; 95% CI 1.17 to 1.35). Use of anticancer (OR 0.74; 95% CI 0.70 to 0.79) and antiemetic (OR 0.93; 95% CI 0.88 to 0.99) QT-prolonging drugs was paradoxically associated with less ECG use. CONCLUSIONS: Our study highlights common use of QT-prolonging drugs and underuse of ECG in oncology patients. Since ECG is an inexpensive, non-invasive and widely available test, it may be readily incorporated in the monitoring of patients for toxicities in routine clinical practice.

Subcutaneous implantable cardioverter defibrillator in patients with arrhythmogenic right ventricular cardiomyopathy: Results from an Italian multicenter registry.

BACKGROUND: Despite expanding indication of the subcutaneous implantable cardioverter defibrillator (S-ICD) in clinical practice, limited data exists on safety and efficacy of S-ICD in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. The aim of this multicenter study was to evaluate the safety and efficacy of S-ICD in ARVC patients. METHODS: The study population included 44 consecutive patients with definite ARVC diagnosis according to the 2010 ITF criteria (57% male, mean age 37 ±â€¯17 years [range 10-75 years]) who received an S-ICD. Eighteen (41%) patients were implanted for secondary prevention. RESULTS: At implant, all inducible patients (34/44) had conversion of ventricular fibrillation at 65 J. No early complications occurred. During a median follow-up of 12 months (7-19), 3 (6.8%) patients experienced complications requiring surgical revision. No local or systemic device-related infections were observed. Six patients (14%) received a total of 61 appropriate and successful shocks on ventricular arrhythmias. Six (14%) patients experienced 8 inappropriate shocks for oversensing of cardiac signal (4 cases) and non-cardiac signal (4 cases) with one patient requiring device explantation. No patients had the device explanted due to the need for antitachycardia pacing. CONCLUSIONS: The study shows that S-ICD provides safe and effective therapy for termination of both induced and spontaneous malignant ventricular tachyarrhythmias with high energy shocks in ARVC patients, but the risk of inappropriate shocks and complications needing surgical revision should be considered.

Age-and-sex stratified prevalence of atrial fibrillation in rural Western India: Results of SMART-India, a population-based screening study.

BACKGROUND: Early detection of Atrial Fibrillation (AF) is a public health priority across the globe because AF-related strokes are preventable. Despite an ongoing stroke epidemic in India, a public health strategy for AF screening and treatment is missing because the epidemiology of AF in India remains poorly defined. METHODS: This population-based study used mobile technology to derive age and sex-stratified AF prevalence by screening 7 participants in each of six age and sex strata (age 40-55, 56-65, 65+, and male and female) from 50 villages (2100 participants). A health worker from each village used a handheld digital electrocardiogram (iECG) device (Kardia) to screen for AF on 3 separate days, and administered a questionnaire. All abnormal (AF or unclassified) iECGs were reviewed by the Indian cardiologist and AF determination confirmed by a US-based cardiac electrophysiologist. RESULTS: Of the 2100 individuals enrolled, iECGs were collected from 2074 participants (98.8%) and 1947 (92.7%) participants responded to the questionnaire. AF was identified in 33 participants (1.6%), two-thirds on the first iECG. AF prevalence was higher among males (2.3% vs 1.0%, p = 0.03) and in older people (0.6%, 0.9%, 2.1%, 5.6%; p < 0.01). CONCLUSIONS: The prevalence of AF observed in our population-based sample is comparable to rates found in studies from North America and Western Europe and increases similarly with age. AF screening using village health workers in rural India is feasible and presents an opportunity for a strategy to address the stroke epidemic in India through primary prevention.

Cancellation of the Cardiac Catheterization Lab After Activation for ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment-elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCLX) remain a challenging problem. We examined the reasons for CCLX, clinical characteristics, and outcomes of patients presenting as ST-segment-elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCLX. METHODS AND RESULTS: We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCLX (n=866; 65%). Reasons for CCLX included bundle branch block (21%), poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCLX (C statistic, 0.985). CCLX subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P<0.0001 for all). All-cause mortality did not differ between groups at 1 year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA versus 16.2% CCLX; P=0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P<0.0001). After adjusting for clinical variables associated with survival, CCLX was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28-2.59; P=0.0009). CONCLUSIONS: In this study, prehospital ECG without overreading or transmission lead to frequent CCLX. CCLX subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCLX patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCLX and influence clinical outcomes.

Epicardial ventricular tachycardia in ischemic cardiomyopathy: Prevalence, electrophysiological characteristics, and long-term ablation outcomes.

INTRODUCTION: The characteristics of the epicardial (EPI) substrate responsible for ventricular tachycardia (VT) in ischemic cardiomyopathy (ICM) are undefined, and data on the long-term outcomes of EPI catheter ablation limited. We evaluated the prevalence, electrophysiologic features, and outcomes of catheter ablation of EPI VT in ICM. METHODS AND RESULTS: From December 2010 to June 2013, a total of 13 of 93 (14%) patients with ICM underwent catheter ablation at our institution and had conclusive evidence of critical EPI substrate demonstrated to participate in VT with activation, entrainment and/or pace mapping during sinus rhythm (two other patients underwent EPI mapping but had no optimal ablation targets). The electrophysiologic substrate characteristics and activation/entrainment mapping data were compared with a reference group of ICM patients without evidence of critical EPI substrate (N = 44), defined as a complete procedural success (noninducibility of any VT at programmed stimulation) after endocardial (ENDO)-only ablation. Patients with failed EPI access (N = 2) or history of cardiac surgery (N = 92) were excluded from the study. All 13 patients had evidence of abnormal EPI substrate with fractionated/late/split electrograms and low-bipolar voltage areas. The critical VT ablation sites were all located within the EPI bipolar "dense" scar (<1.0 mV) opposite the ENDO bipolar scar in 77% of cases and extending beyond the ENDO bipolar scar (within the ENDO unipolar low-voltage area) in the remaining patients. Compared with the reference ENDO-only group, patients with EPI VT had a smaller ENDO bipolar scar area, 54.0 (37.1-84) vs 86.7 (55.6-112) cm2 ; P = 0.0159, with a similar extent of ENDO unipolar low voltage. No other substrate characteristics or location differed between the two groups. After 35.2 ± 24.2 months of follow-up, VT-free survival was 73% in patients with EPI VT compared with 66% in the ENDO-only group (log-rank P = 0.56). CONCLUSIONS: The presence of the critical EPI substrate responsible for VT can be demonstrated in at least 14% of patients with ICM. The majority of EPI critical ablation sites are distributed opposite the ENDO bipolar scar area and catheter ablation is effective in achieving long-term arrhythmia control.

10-Year Outcomes of Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Artery Disease.

BACKGROUND: Comparative outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for left main coronary artery (LMCA) disease were previously reported. However, data on very long-term (>10 years) outcomes are limited. OBJECTIVES: The authors compare 10-year outcomes after PCI and CABG for LMCA disease. METHODS: In this observational study of the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization) registry, the authors evaluated 2,240 patients with unprotected LMCA disease who underwent PCI (n = 1,102) or underwent CABG (n = 1,138) between January 2000 and June 2006. Adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) were compared with the use of propensity scores and inverse-probability-weighting adjustment. The follow-up was extended to at least 10 years of all patients (median 12.0 years). RESULTS: In the overall cohort, there was no significant difference in adjusted risks of death and the composite outcome between the groups up to 10 years. The risk of target-vessel revascularization was significantly higher in the PCI group. In the cohort comparing drug-eluting stents and concurrent CABG, the 2 study groups did not differ significantly in the risks of death and the composite outcome at 5 years. However, after 5 years, drug-eluting stents were associated with higher risks of death (hazard ratio: 1.35; 95% confidence interval: 1.00 to 1.81) and the composite outcome (hazard ratio: 1.46; 95% confidence interval: 1.10 to 1.94) compared with CABG. CONCLUSIONS: In patients with significant LMCA disease, as compared with CABG, PCI showed similar rates of death and serious composite outcomes, but a higher rate of target-vessel revascularization at 10 years. However, CABG showed lower mortality and serious composite outcome rates compared with PCI with drug-eluting stents after 5 years. (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization [MAIN-COMPARE]; NCT02791412).

Dysregulated Network of Immune, Endocrine and Metabolic Markers is Associated to More Severe Human Chronic Chagas Cardiomyopathy.

Individuals who are infected with Trypanosoma cruzi develop chronic Chagas cardiomyopathy (CCC), which is a complication involving a series of immune pathogenetic mechanisms, although an association between immune and metabolic alterations was more recently proposed. Accordingly, we investigated the immuno-metabolic response in chagasic patients and their possible influence on CCC pathogenesis. To this end, T. cruzi-seropositive (asymptomatic or with CCC) and sero-negative individuals were studied. Serum tumour necrosis factor (TNF)-α, interleukin (IL)-6, adipocytokines and the expression of their receptors in peripheral blood mononuclear cell (PBMC) were evaluated, together with other factors influencing the immune response. CCC patients showed major metabolic and hormonal abnormalities, in parallel with increased IL-6 and leptin serum levels. TNF-α receptor s, leptin and adiponectin receptors (ObR and Adipo-Rs respectively), as well as PPAR-γ expression in PBMCs from CCC patients were compatible with a counteracting response leading to an unfavourable immune-metabolic profile. These results suggest that persistently increased levels of immune-metabolic pro-inflammatory mediators along with the adverse endocrine anti-inflammatory response of CCC individuals, may contribute to the underlying mechanisms dealing with myocardial tissue damage.

Advanced interatrial block is an electrocardiographic marker for recurrence of atrial fibrillation after electrical cardioversion.

BACKGROUND: Early recurrence of atrial fibrillation (AF) is common following a successful electrical cardioversion (ECV). The purpose of this study was to investigate the hypothesis that AF recurrence is related to atrial electrical inhomogeneity, which may influence the P wave characteristics. METHODS: Two hundred ninety-one consecutive persistent AF patients who underwent ECV were enrolled, and evaluated for AF recurrences one month after the ECV. Patients with open-heart surgery, a history of catheter ablation, and an unsuccessful ECV were excluded. The P wave duration, dispersion and P wave morphology were evaluated by 12­lead ECGs 30 min after the ECV. RESULTS: In total, 141 patients were investigated. One month after the ECV, 60 (43%) patients maintained sinus rhythm. The advanced interatrial block (aIAB; P wave duration >120 ms and biphasic P waves in the inferior leads) (Hazard ratio [HR], 4.51; 95% confidence interval [CI] 1.45-14.01, P = 0.009), P wave dispersion (HR, 1.06; 95%CI 1.02-1.09, P = 0.001), and duration of AF per month (HR, 1.03; 95%CI 1.01-1.04, P = 0.004) were independent predictors of AF recurrence. An aIAB was not associated with structural parameters such as the left atrial volume index or right atrial area. There were no differences in the serum BNP level and frequency of administering anti-arrhythmic drugs between the patients with and without recurrence. CONCLUSIONS: The risk of AF recurrence after the ECV can be predicted by the P wave characteristics. A longer P wave dispersion and the duration of AF also had a tendency for recurrence.

Does second-generation cryoballoon ablation using the current single short freeze strategy produce pulmonary vein stenosis?

BACKGROUND: Few data are available regarding pulmonary vein (PV) stenosis after second-generation cryoballoon PV isolation (CB2-PVI). Currently, a single short freeze strategy is standard for CB2-PVI owing to enhanced cooling effects. This study aimed to evaluate the incidence of PV stenosis after CB2-PVI with the current standard strategy. METHODS: Two hundred seventy-six atrial fibrillation patients underwent CB2-PVI using one 28-mm balloon and single 3-minute freeze strategy. If balloon temperatures reached -60 °C or phrenic nerve injury was suspected, freezing was terminated. Enhanced cardiac computed tomography (CT) was obtained before and >3 months after the procedure. RESULTS: Overall, 1067 of 1101 (96.9%) PVs were isolated with cryoballoons, while the remaining 34 PVs required touch-up ablation. The total application number/patient was 5.1 ±â€¯1.4, and total application time 216 ±â€¯104, 205 ±â€¯77, 186 ±â€¯68, and 246 ±â€¯142 s for the left superior (LSPV), left inferior (LIPV), right superior (RSPV), and right inferior PVs, respectively. Follow-up CT obtained a median of 5.0 [3.3-7.0] months post-procedure revealed no PVs with moderate or severe stenosis. Asymptomatic mild stenosis was documented in 16 total (1.4%) PVs (5 LSPVs, 5 LIPVs, and 6 RSPVs), but not in right inferior, left common, right middle, or PVs requiring touch-up ablation. Mild stenosis did not progress during the follow-up. Among the potential factors associated with PV stenosis, longer application times were the sole significant factor associated with mild RSPV stenosis. CONCLUSIONS: In CB2-PVI with the current single short freeze strategy, the risk of PV stenosis is extremely low, and routine follow-up imaging for evaluation seems not to be necessary.

A relation between ablation area and outcome of ablation using 28-mm cryoballon ablation: Importance of carina region.

INTRODUCTION: Pulmonary vein isolation (PVI) with wide antral ablation leads to better outcomes in atrial fibrillation ablation therapy, but the ablation area is relatively small during cryoballoon ablation (CBA). The present study tested the hypothesis that wide ablation can lead to better outcomes in CBA. METHODS AND RESULTS: Ninety-six patients with atrial fibrillation were enrolled (paroxysmal 76%, 64.1 ± 11.7 years). All patients underwent preprocedural computed tomography and the PV diameter at left atrial PV junction was measured. PV isolation was performed using a 28-mm CB for 3 minutes with single freezing. Sinus rhythm bipolar voltage amplitude maps with the NavX mapping system were generated after ablation. According to the voltage map, patients were divided into 3 subgroups (68 in the extensive isolation group, 17 in the individual isolation group, and 10 in the incomplete isolation group). Atrial tachyarrhythmias recurred in 9 patients of the extensive isolation group and 6 in the individual isolation group. The rate of 12-month freedom from tachyarrhythmia after a single ablation procedure was 84% (95% confidence interval [C.I.], 72%-91%) in the extensive group and 57% (95% C.I., 28%-78%) in the individual group (P = 0.048). Multiple logistic regression analyses revealed that maximal PV diameter was the only predictor to achieve extensive PVI (odds ratio, 1.57; 95% C.I. 1.08-2.29 P = 0.018). CONCLUSION: Extensive isolation is superior to individual isolation for achieving freedom from atrial arrhythmia in long term follow-up by CBA. Evaluating PV diameter at the left atrial PV junction is essential for applying CBA.

Vasovagal responses during cryoballoon pulmonary vein isolation in paroxysmal atrial fibrillation predict favorable mid-term outcomes.

BACKGROUND: Vasovagal responses (VR) encountered during radiofrequency pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF) suggest ablation of the atrial tissue subjacent to the ganglionic plexi (GP) and confer durability of PVI. OBJECTIVE: We hypothesized that VR during cryoballoon PVI (CB-PVI) in PAF can predict mid-term AF recurrence. METHODS: We enrolled 39 patients who underwent PVI using 2nd generation cryoballoon for PAF from November 2014 to July 2016. We evaluated the long term outcomes for those who had VR during index procedure. RESULTS: A total of 39 patients (76% male, mean age 57 ±â€¯9 years) underwent CB-PVI for PAF and 66.67% (26/39) had VR. VR was frequently observed in the LSPV (100%), followed by RSPV (64%), LIPV (60%), and less frequently, RIPV (28%). Overall, the mean difference in the HR and SBP, and the relative differences in the HR and SBP were observed during CB-PVI in the LSPV (mean difference in HR, p < 0.001; mean difference in SBP, p < 0.001; relative difference in HR, p < 0.001); relative difference in SBP, p < 0.001). After PVI, 22/26 (84.62%) and 5/13 (38.46%) of patients in the VR and NVR group, respectively, maintained SR at 14 ±â€¯6 months follow-up. The Kaplan-Meier analysis showed statistical difference in favor of patients with VR during CB-PVI (log rank p < 0.01) with a better mid-term outcome. CONCLUSION: In a small cohort of patients, VR during CB-PVI in PAF is a surrogate marker for ablation of atrial tissue subjacent to the GP and predicts a favorable mid-term outcome for AF recurrence.

Model-based directional analysis of cardiovascular variability identifies patients developing atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Postoperative atrial fibrillation (AF) might be favored by cardiovascular control impairment. We hypothesize that cardiovascular regulation indexes derived from directional model-based analysis of the spontaneous fluctuations of heart period (HP) and systolic arterial pressure (SAP) can identify subjects at risk to develop AF after coronary artery bypass graft (CABG) surgery. METHODS: Beat-to-beat HP and SAP series were derived from electrocardiogram (ECG) and invasive arterial pressure recorded for 5 min just before CABG surgery in conscious condition. The group comprised subjects who did develop AF (AF, n = 37, 71 ±â€¯8 years, 27 males) or did not (noAF, n = 92, 65 ±â€¯10 years, 85 males). From HP and SAP variabilities we computed classical time-domain, spectral, cross-spectral and complexity indexes characterizing autonomic function and cardiac baroreflex control. Moreover, we performed model-based directional analysis assessing the gain and strength of the relations from SAP to HP along cardiac baroreflex feedback and from HP to SAP along the feedforward pathway while disambiguating the effect of respiration as estimated from respiratory-related ECG modulations. RESULTS: Classical HP and SAP variability indexes and baroreflex sensitivity could not separate AF from noAF individuals. Causality markers, and more specifically, the strength of the dynamical interactions from SAP to HP and vice versa, could distinguish the two groups: indeed, AFs have a lower degree of association from SAP to HP and vice versa. CONCLUSIONS: An impairment of the feedforward and feedback arms of the HP-SAP closed loop relation predisposes subjects undergoing CABG surgery to develop postoperative AF. PERSPECTIVES: Competency in medical knowledge: Atrial fibrillation (AF) is a frequent complication after coronary artery bypass graft (CABG) surgery lengthening hospitalization duration and increasing healthcare system costs. Translational outlook 1: CABG patients who developed AF had a less preserved cardiovascular interactions due to less active physiological control mechanisms as resulting from the lower degree of dependence of systolic arterial pressure on heart period and vice versa before CABG surgery. Translational outlook 2: Cardiovascular control markers improve stratification of the AF risk after CABG surgery above and beyond more traditional demographic and clinical indexes.

Long-duration general anesthesia influences the intelligence of school age children.

BACKGROUND: General anesthesia has been linked to impaired brain development in immature animals and young children. In this study the influence of orthopedic surgery under general anesthesia on the intelligence of school age children has been evaluated. METHODS: A total of 209 subjects aged 6-12 years were recruited and allocated into 4 groups according to the duration of general anesthesia, including a control group (n = 30), short (< 1 h, n = 49), moderate- (1-3 h, n = 51) and long-duration groups (> 3 h, n = 79), respectively. The intelligence quotient (IQ) of the subjects was measured by the Raven's Standard Progressive Matrices (RSPM) before and after orthopedic surgery under general anesthesia of various durations (vide supra). RESULTS: The IQ score decreased significantly in the long-duration group at 1 month post-operation compared with the pre-operation score (P < 0.001), and IQ did not recover completely at 3 months postoperatively (P < 0.05), but had recovered when measured at the 1-year follow-up. Moreover, this study showed that the development of children's intelligence was affected by the exposure time to anesthetics at a younger age (OR = 5.26, 95% CI:2.70-8.41, P < 0.001), having a mother with a low education level (OR = 2.71, 95% CI:1.24-6.14, P = 0.014) and premature birth (OR = 2.76, 95% CI:1.34-5.46, P = 0.005). CONCLUSIONS: More than 3 h general anesthesia influenced the IQ of school age children for up to 3 months after orthopedic surgery. Beside extended exposure time to anesthetics additional factors for post-operative IQ reduction were younger children age, mothers with low educational levels and premature birth. TRIAL REGISTRATION: Chinese Clinical Trial Registry with registration number ChiCTR-OOC-17013497  retrospectively registered on 11/23/2017.

Clinical characteristics, risk factors and outcomes of South-East Asian patients with acute pulmonary embolism.

BACKGROUND: The clinical features of acute PE have not been well studied in South-East Asia. We therefore sought to evaluate the clinical characteristics, risk factors and outcomes of patients diagnosed with acute pulmonary embolism (PE) in our region. METHODS: From January 2008 to March 2013, 343 patients were admitted to our tertiary institution with acute PE. Data were collected retrospectively on baseline clinical characteristics, presenting signs and symptoms, results of electrocardiographic and imaging studies, therapeutic modality and hospital course. RESULTS: 91% of the patients presented with submassive PE. 6.1% of patients had saddle PE. The most common presenting symptom was dyspnea (72.3%) followed by chest pain (12.8%), hemoptysis (2.6%), syncope (2.6%) and cardiovascular collapse (1.2%). Risk factors for PE were idiopathic cause (33.5%), immobilization (21%), malignancy (6.1%) and hypercoagulable state (2.9%). The overall in-hospital mortality was 5%. Factors associated with mortality were massive PE, tachycardia at presentation, right ventricular dysfunction and cardiogenic shock. Bleeding complications occurred in 10.2% of patients (major bleeding in 3.5%). CONCLUSION: Acute PE in the South-East Asian patients is associated with an overall mortality rate of 5%. The bleeding complications from treatment are also high.