Long-term, real world experience of ventricular tachycardia and granulomatous cardiomyopathy.

BACKGROUND: Granulomatous cardiomyopathy (GCM) is relatively uncommon in patients presenting with ventricular tachycardia (VT). Sarcoidosis and tuberculosis are the most common causes of GCM with VT. The aim of study was to evaluate their clinical characteristics and the long-term outcomes. METHODS: We retrospectively analyzed patients from March 2004 to January 2020, presenting with VT and subsequently diagnosed to have GCM. Patients were divided into three groups (sarcoid, tuberculosis and indeterminate) based on serologic tests, imaging and histopathology. The response to anti-arrhythmic and disease specific therapy on long-term follow-up were analyzed. RESULTS: There were 52 patients, comprising 27 males and 25 females, age 40 ± 10 years. The follow-up period was 5.9 ± 3.9 years. Sarcoidosis was diagnosed in 20 (38%); tuberculosis (TB) in 15(29%) and 17(33%) patients were indeterminate. Left ventricular ejection fraction (LVEF) of the entire cohort was 0.45 ± 0.14. Erythrocyte Sedimentation Rate(ESR) was found to be significantly higher in TB(43.6 ± 18.4) patients vs sarcoid(18.9 ± 6.7)p < 0.0001, but not the indeterminate group (36.2 ± 21.1), p = 0.3. Implantable Cardioverter Defibrillator (ICD) implantation was performed in 12/20(60%) patients in the sarcoid group, in 4/15(27%) patients in the TB group and in 10/17(59%) patients in the indeterminate group. At a mean follow-up of six years, VT recurrences were noted in 6, 2, and 7 patients in the sarcoid, TB and indeterminate groups respectively. CONCLUSION: Despite the advances in diagnostic modalities for tuberculosis and sarcoidosis, in real-world practice, almost one-third of the patients with VT and GCM have uncertain etiology. Long term outcomes of patients presenting with GCM and VT with mild left ventricle dysfunction treated appropriately seems favorable.

Correlation of newer indices of dyssynchrony with clinical response in patients undergoing cardiac resynchronisation therapy.

The benefits of CRT in select subsets of systolic heart failure patients with LBBB are proven. We prospectively evaluated conventional and newer echocardiographic parameters of left ventricular dyssynchrony in 35 patients who underwent CRT and were followed up after 6 months. Of the 33 surviving patients, 21 were echocardiographic responders and 24 were clinical responders. The parameters in clinical responders and non-responders were compared. The anatomic M Mode parameters of delays improved, while the radial strain and the mitral valve velocity time integral (MVVTI) did not show any significant change after CRT.

Is the right ventricular function affected by permanent pacemaker?

AIMS: The effect of right ventricular (RV) pacing on left ventricular (LV) function has been extensively evaluated, but the effect on RV function per se has not been evaluated systematically. We aimed to assess the effect of dual chamber pacemaker on RV function. METHODS AND RESULTS: All consecutive patients undergoing dual chamber pacemaker from January 2018 to March 2019 for AV block with a structurally normal heart were included. They underwent pre-procedure detailed echocardiography (including three-dimensional [3D] RV ejection fraction [RVEF]), a screening echocardiogram 2 days after pacemaker implantation and again a detailed echocardiogram at 6-month follow-up. We compared the baseline echocardiographic RV parameters with those 6 months after the pacemaker implantation. A total of 60 patients underwent successful pacemaker implantation. At 6 months, most of the patients were pacemaker dependent with pacing percentage of 98.9% ± 2.4%; there was a significant increase in TR and a mean drop in RVEF by 2.8 ± 5%, with 23 (38.3%) having at least a 5% decrease in RVEF. The drop in RVEF positively correlated with TR vena contracta at 6 months but did not correlate with pulmonary artery systolic pressure at 6 months. CONCLUSION: Our study shows the presence of demonstrable RV dysfunction as early as 6 months in a majority of patients who have undergone pacemaker implantation.

Ventricular tachycardia as the presenting feature in two patients with cardiac lipoma and cardiac fibroma.

We hereby present two patients with benign cardiac tumours presenting as ventricular tachycardia (VT). Most such tumours have a favorable prognosis, unless complicated by arrhythmias. Intracavitary tumours are easily diagnosed by echocardiography. Intramural tumours as in our patients may be missed at times by echocardiography. Multimodality imaging helped confirm the diagnosis and etiology, since biopsy was not safe. Surgical removal was not feasible due to extensive infiltration. The patients are so far doing well on medical therapy.

Validation of electrocardiographic criteria for identifying left ventricular dysfunction in patients with previous myocardial infarction.

BACKGROUND: Eleven criteria correlating electrocardiogram (ECG) findings with reduced left ventricular ejection fraction (LVEF) have been previously published. These have not been compared head-to-head in a single study. We studied their value as a screening test to identify patients with reduced LVEF estimated by cardiac magnetic resonance (CMR) imaging. METHODS: ECGs and CMR from 548 patients (age 61 + 11 years, 79% male) with previous myocardial infarction (MI), from the DETERMINE and PRE-DETERMINE studies, were analyzed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each criterion for identifying patients with LVEF ≤ 30% and ≤ 40% were studied. A useful screening test should have high sensitivity and NPV. RESULTS: Mean LVEF was 40% (SD = 11%); 264 patients (48.2%) had LVEF ≤ 40%, and 96 patients (17.5%) had LVEF ≤ 30%. Six of 11 criteria were associated with a significant lower LVEF, but had poor sensitivity to identify LVEF ≤ 30% (range 2.1%-55.2%) or LVEF ≤ 40% (1.1%-51.1%); NPVs were good for LVEF ≤ 30% (range 82.8%-85.9%) but not for LVEF ≤ 40% (range 52.1%-60.6%). Goldberger's third criterion (RV4/SV4 < 1) and combinations of maximal QRS duration > 124 ms + either Goldberger's third criterion or Goldberger's first criterion (SV1 or SV2 + RV5 or RV6 ≥ 3.5 mV) had high specificity (95.4%-100%) for LVEF ≤ 40%, although seen in only 48 (8.8%) patients; predictive values were similar on subgroup analysis. CONCLUSIONS: None of the ECG criteria qualified as a good screening test. Three criteria had high specificity for LVEF ≤ 40%, although seen in < 9% of patients. Whether other ECG criteria can better identify LV dysfunction remains to be determined.

Simple electrocardiographic measures improve sudden arrhythmic death prediction in coronary disease.

AIMS: To determine whether the combination of standard electrocardiographic (ECG) markers reflecting domains of arrhythmic risk improves sudden and/or arrhythmic death (SAD) risk stratification in patients with coronary heart disease (CHD). METHODS AND RESULTS: The association between ECG markers and SAD was examined in a derivation cohort (PREDETERMINE; N = 5462) with adjustment for clinical risk factors, left ventricular ejection fraction (LVEF), and competing risk. Competing outcome models assessed the differential association of ECG markers with SAD and competing mortality. The predictive value of a derived ECG score was then validated (ARTEMIS; N = 1900). In the derivation cohort, the 5-year cumulative incidence of SAD was 1.5% [95% confidence interval (CI) 1.1-1.9] and 6.2% (95% CI 4.5-8.3) in those with a low- and high-risk ECG score, respectively (P for Δ < 0.001). A high-risk ECG score was more strongly associated with SAD than non-SAD mortality (adjusted hazard ratios = 2.87 vs. 1.38 respectively; P for Δ = 0.003) and the proportion of deaths due to SAD was greater in the high vs. low risk groups (24.9% vs. 16.5%, P for Δ = 0.03). Similar findings were observed in the validation cohort. The addition of ECG markers to a clinical risk factor model inclusive of LVEF improved indices of discrimination and reclassification in both derivation and validation cohorts, including correct reclassification of 28% of patients in the validation cohort [net reclassification improvement 28 (7-49%), P = 0.009]. CONCLUSION: For patients with CHD, an externally validated ECG score enriched for both absolute and proportional SAD risk and significantly improved risk stratification compared to standard clinical risk factors including LVEF. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT01114269. ClinicalTrials.gov ID NCT01114269.

Estimating Myocardial Infarction Size With a Simple Electrocardiographic Marker Score.

Background Myocardial infarction (MI) size is a key predictor of prognosis in post-MI patients. Cardiovascular magnetic resonance (CMR) is the gold standard test for MI quantification, but the ECG is less expensive and more widely available. We sought to quantify the relationship between ECG markers and cardiovascular magnetic resonance infarct size. Methods and Results Patients with prior MI enrolled in the DETERMINE (Defibrillators to Reduce Risk by Magnetic Resonance Imaging Evaluation) and PRE-DETERMINE Trial and Registry were included. ECG leads were analyzed for markers of MI: Q waves, fragmented QRS, and T wave inversion. DETERMINE Score=number of leads with [Q waves×2]+[fragmented QRS]+[T wave inversion]. Left ventricular ejection fraction (LVEF) and infarct size as a percentage of left ventricular mass (MI%) were quantified by cardiovascular magnetic resonance. The Modified Selvester Score estimates MI size from 37 ECG criteria. In 551 patients (aged 62.1±10.9 years, 79% men, and LVEF=40.3±11.0%), MI% increased as the number of ECG markers increased (P<0.001). By univariable linear regression, the DETERMINE Score (range 0-26) estimated MI% (R2=0.18, P<0.001) with an accuracy approaching that of LVEF (R2=0.22, P<0.001) and higher than the Modified Selvester Score (R2=0.09, P<0.001). By multivariable linear regression, addition of the DETERMINE Score improved estimation of MI% over LVEF alone (P<0.001) and over Modified Selvester Score alone (P<0.001). Conclusions In patients with prior MI, a simple ECG score estimates infarct size and improves infarct size estimation over LVEF alone. Because infarct size is a powerful prognostic indicator, the DETERMINE Score holds promise as a simple and inexpensive risk assessment tool.

Amlodipine alters hemorheological parameters: Increased efficacy at the cost of edema?

BACKGROUND: Despite several decades of use of calcium channel blockers, the side effect of edema persists as a class effect, and its mechanism is unresolved. Amlodipine has effects on hemorheology (HR), and its hemodilutory property may partly contribute to its antihypertensive action. This aspect is not well studied, and the literature is sparse in this regard. OBJECTIVE: This experiment was planned to determine effect of a single-dose administration of amlodipine on HR parameters in normal human volunteers. METHODS AND RESULTS: Amlodipine (5 mg) or S (-) amlodipine (2.5 mg) was administered to 27 normal human volunteers. Whole-blood viscosity (WBV) at different shear rates, plasma viscosity (PV), red cell rigidity (RCR), red cell aggregation (RCA), hematocrit (Hct), plasma hemoglobin, along with plasma drug concentration were determined at time intervals, t = 0, 4, 8, 12, and 24 h. Statistically significant reductions were observed at tmax = 4 h in WBV at shear rates of 0.512 s-1 (p < 0.005), WBV at shear rates of 5.26 s-1 (p < 0.01), PV (p < 0.05), and Hct (p < 0.01). At t = 8 h, as drug concentration reduced, some of the changes persisted and later slowly decreased with the decreasing drug concentration till t = 24 h. Red blood cell-related parameters such as RCA and RCR remained unaltered. WBV values at all shear rates, when corrected for Hct = 0.45, did not show deviation from their original values at any time. CONCLUSIONS: Amlodipine causes a reduction in Hct and blood viscosity, along with hemodilution. These effects persist as long as the drug remains in plasma. Edema resulting from chronic dosing may be explained by the aforementioned effects. It is possible that antihypertensive action of the drug may be due to a combination of vasodilatation and an improvement in the HR properties.

Reference values of ECG parameters derived from 906 echocardiographically confirmed healthy Indian children: A population-based study from Gujarat.

INTRODUCTION: There are few published studies on reference ranges of ECG parameters in children; some ethnic differences have been described. METHODS: We studied digital 12­lead ECGs (1000 samples/s) from 906 healthy rural Indian children (467 boys: 439 girls) aged 5-15 years. PR, QRS, and QT were measured using superimposed median beat. Age-wise normal limits (median, 2nd and 98th percentile) were defined. RESULTS: Heart rate decreased while PR interval and QRS duration increased with age. QTcB interval remained unchanged from 5 to 12 years and decreased thereafter due to QTcB shortening in boys but not in girls. "Juvenile T wave pattern" was seen in 95% of children aged 5-8 years in lead V1 and 55-60% in V2, V3; it decreased with age. RV dominance (R/S > 1) in lead V1 was seen in 13% at 5 years, 1% at 10 years and none at 14 years. CONCLUSION: Reference ranges in Indian children are similar to those in other ethnic groups.

A pilot study comparing two sites for incision during pacemaker implantation and their influence on the scar.

OBJECTIVE: There are two most common incisions that are used during most pacemaker implantation procedures, with the first type of incision being inferior and parallel to the clavicle (Group C) and the second type of incision along the deltopectoral groove (Group D). We evaluated the scars resulting from the two types of incision to objectively evaluate the degree of superiority in cosmetic outcomes, between these two types of incisions. METHODS: Seventy-six patients who underwent left pre-pectoral pacemaker insertion were evaluated, close to 6 months after the date of the pacemaker implantation, using a simple scoring system based on atrophy, contour and colour of the scar. The likelihood of reduced severity in scar scores were compared between the two groups and the number of patients with elevation or inversion of the scar and with keloid formation were quantified. RESULTS: Seventy-six patients, with 47 belonging to the 'Group C' and 29 belonging to the 'Group D' were evaluated. The average length (C: 25 ±â€¯2 mm; D: 24 ±â€¯3 mm) and thickness (C: 25 ±â€¯3 mm; D: 26 ±â€¯2 mm) of the scars were not significantly different. The mean cumulative total scores in 'Group C' (1.98 ±â€¯1.50) and 'Group D' (1.93 ±â€¯1.31) were comparable. The odds ratio (OR) estimate showed that outcomes for atrophy (OR:0.73), contour (OR:0.53) and the cumulative total scores (OR:0.72) were also comparable. CONCLUSION: This pilot study showed that the deltopectoral groove incision as a site of incision is comparable to the infraclavicular incision.

Iatrogenic subclavian arteriovenous fistula during permanent pacemaker implantation: Closed by endovascular coiling.

Iatrogenic arteriovenous fistula is a unique complication during pacemaker implantation. A 55-year-old man was posted for pacemaker implantation for recurrent unexplained syncope with trifascicular AV block. After axillary/subclavian venous puncture and introduction of RV lead, arterial spurting was immediately noticed as the the sheath was peeled away. After dissecting the overlying pectoralis muscle, deep sutures and manual compression achieved hemostasis. However, Subclavian arteriogram revealed an arteriovenous fistula from a lateral thoracic artery branch to the innominate vein. Hilal coils were deployed near the fistulous orifice, leading to complete resolution of the leak. After 3 days, pacemaker was implanted from right side. A multidisciplinary approach was the key to successful outcome.

For neonatal ECG screening there is no reason to relinquish old Bazett's correction.

Aims: There is an almost endless controversy regarding the choice of the QT correction formula to be used in electrocardiograms (ECG) in neonates for screening for long QT syndrome (LQTS). We compared the performance of four commonly used formulae and a new formula derived from neonates. Methods and results: From a cohort of 44 596 healthy neonates prospectively studied in Italy between 2001 and 2006, 5000 ECGs including 17 with LQTS-causing mutation identified by genotyping were studied using four QT correction formulae [Bazett's (QTcB), Fridericia's (QTcF), Framingham (QTcL), and Hodges (QTcH)]. A neonate-specific exponential correction (QTcNeo) was derived using 2500 randomly selected ECGs and validated for accuracy in the remaining 2500 ECGs. Digital ECGs were recorded between the 15th and 25th day of life; QT interval was measured manually in leads II, V5, and V6. To assess the ability to provide heart rate (HR) independent QT correction, regression analysis of the QTc-HR plots for all 5000 ECGs with each correction formula was done. QTcB provided the most HR independent correction with a slope closest to zero (slope +0.086 ms/b.p.m.) followed by QTcF (slope -0.308 ms/b.p.m.), QTcL (slope -0.364 ms/b.p.m.), and QTcH (slope +0.962 ms/b.p.m.). The QTc-HR slope of QTcNeo (QT/RR0.467) was similar to QTcB. The ability to correctly identify neonates with LQTS was best with QTcB, QTcF, and QTcNeo (comparable areas under the receiver operating characteristic curves) with positive predictive value of 39-40% and sensitivity of 100%. Cut-off values were 460 ms for QTcB, 394 ms for QTcF, and 446 ms for QTcNeo. Conclusions: The Bazett's correction provides an effective HR independent QT correction and also accurately identifies the neonates affected by LQTS. It can be used with confidence in neonates, although other methods could also be used with appropriate cut-offs.

Sudden Death in Patients With Coronary Heart Disease Without Severe Systolic Dysfunction.

Importance: The majority of sudden and/or arrhythmic deaths (SAD) in patients with coronary heart disease occur in those without severe systolic dysfunction, for whom strategies for sudden death prevention are lacking. Objective: To provide contemporary estimates of SAD vs other competing causes of death in patients with coronary heart disease without severe systolic dysfunction to search for high-risk subgroups that might be targeted in future trials of SAD prevention. Design, Setting, and Participants: This prospective observational cohort study included 135 clinical sites in the United States and Canada. A total of 5761 participants with coronary heart disease who did not qualify for primary prevention implantable cardioverter defibrillator therapy based on left ventricular ejection fraction (LVEF) of more than 35% or New York Heart Association (NYHA) heart failure class (LVEF >30%, NYHA I). Exposures: Clinical risk factors measured at baseline including age, LVEF, and NYHA heart failure class. Main Outcomes and Measures: Primary outcome of SAD, which is a composite of SAD and resuscitated ventricular fibrillation arrest. Results: The mean (SD) age of the cohort was 64 (11) years. During a median of 3.9 years, the cumulative incidence of SAD and non-SAD was 2.1% and 7.7%, respectively. Sudden and/or arrhythmic death was the most common mode of cardiovascular death accounting for 114 of 202 cardiac deaths (56%), although noncardiac death was the primary mode of death in this population. The 4-year cumulative incidence of SAD was lowest in those with an LVEF of more than 60% (1.0%) and highest among those with LVEF of 30% to 40% (4.9%) and class III/IV heart failure (5.1%); however, the cumulative incidence of non-SAD was similarly elevated in these latter high-risk subgroups. Patients with a moderately reduced LVEF (40%-49%) were more likely to die of SAD, whereas those with class II heart failure and advancing age were more likely to die of non-SAD. The proportion of deaths due to SAD varied widely, from 14% (18 of 131 deaths) in patients with NYHA II to 49% (37 of 76 deaths) in those younger than 60 years. Conclusions and Relevance: In a contemporary population of patients with coronary heart disease without severe systolic dysfunction, SAD accounts for a significant proportion of overall mortality. Moderately reduced LVEF, age, and NYHA class distinguished SAD and non-SAD, whereas other markers were equally associated with both modes of death. Absolute and proportional risk of SAD varied significantly across clinical subgroups, and both will need to be maximized in future risk stratification efforts.

Individual-Specific QT Interval Correction for Drugs With Substantial Heart Rate Effect Using Holter ECGs Extracted Over a Wide Range of Heart Rates.

Although fixed QT correction methods are typically used to adjust for the effect of heart rate on the QT interval in thorough QT/QTc studies, individual-specific QT correction (QTcI = QT/RRI ) is advisable for drugs that increase the heart rate by >5 to 10 beats/minute (bpm). QTcI is traditionally derived using resting drug-free electrocardiograms (ECGs) collected at prespecified times. However, the resting heart rate range in healthy individuals is narrow, and extrapolation of inferences from these data to higher heart rates could be inappropriate. Accordingly, the QTcI derived from triplicate ECGs extracted at prespecified times (the traditional [T] method, yielding QTcIT) was compared with QTcIs obtained using ECGs with a wider heart rate range (alternative Holter [H] method, yielding QTcIH) from 24-hour Holter recordings from 40 healthy individuals selected from a central ECG laboratory database. For QTcIH, 10-second ECGs were extracted at stable heart rates in the ranges of 51-60, 61-70, 71-80, and 81-90 bpm (9 ECGs in each bin = 36 ECGs). An independent set of 40 ECGs with heart rates from 51 to 90 bpm was extracted from each individual to validate the accuracy of QTcI by the 2 methods. For the validation set, the QTcIH was a better QT correction method (slope of QTc vs heart rate closer to zero) than QTcIT. The mean difference between QTcIT and QTcIH increased from 3.1 milliseconds at 65 bpm to 10.0 milliseconds at 90 bpm (P < 0.01). The QTcIT exceeded QTcIH at heart rates > 60 bpm. Employment of the QTcIH may be more appropriate for studies involving drugs that increase heart rate.

Atypical Variants of Takotsubo Cardiomyopathy: Twin Case Reports.

Takotsubo cardiomyopathy (TTC) is a well-known entity. We present two rare presentations of the same. Our first patient was diagnosed to have hypertrophic cardiomyopathy with ventricular tachycardia (VT), for which an ICD had been implanted. He later developed acute TTC with a large left ventricular (LV) apical thrombus. Our second patient was a 59 year old lady diagnosed to have TTC 2 years ago, from which she had recovered completely. She recently developed a recurrence of the same.

Occult etiologies of complete atrioventricular block: Report of two cases.

In patients presenting with complete atrioventricular (AV) block, the common causes are degeneration of the conduction system, acute myocardial infarction, congenital and metabolic disorders (such as azotemia). However, at times, no cause can be ascribed and the label congenital or degenerative is applied depending on the patient's age and the QRS complex width. We present two cases of patients with complete AV block, who were subsequently found to have rare etiologies - sarcoidosis (with isolated feature of AV block) and non-Hodgkin's lymphoma.

Routine health check-ups: A boon or a burden?

Healthcare provider institutions in India now offer structured health check-up 'packages' for routine screening of common diseases. While some tests included within their ambit are in keeping with international and Indian recommendations, some are entirely unwarranted. Unnecessary and inappropriate screening tests may cause more harm than benefit. Besides financial and resource burden, there may be over-diagnosis and over-treatment, psychological distress due to false-positive test results, harm from invasive follow-up tests, and false reassurance due to false-negative test results. Clinicians must ensure a net benefit from tests and interventions in order to efficiently deliver preventive services. We reviewed current screening guidelines for cardiovascular disease and common cancers, and surveyed multiple 'packages' provided at 8 centres in Mumbai, India. We put forth our recommendations for routine health screening in asymptomatic adults in India.