A stepwise external cardioversion protocol for atrial fibrillation to maximize acute success rate.

AIMS: Cardioversion is a very commonly performed procedure for persistent atrial fibrillation (AF). However, there is no well-defined protocol to address failed external electrical direct current cardioversion. The aim of the study is to test the efficacy of a pre-defined stepwise cardioversion protocol for patients with persistent AF of ≤12 months. Success was the achievement of sinus rhythm. METHODS AND RESULTS: The study population included patients with persistent AF of ≤12 months duration requiring rhythm management. Patients were offered cardioversion using a pre-defined stepwise protocol using different electrode placement locations, applying compression at end of expiration, and higher energy delivered simultaneously through two defibrillators. : A total of 414 patients were included in the study, of which 362 (87.4%) required a single successful cardioversion. The remaining 52 (12.5%) patients required additional cardioversion attempts using the stepwise cardioversion protocol with an overall success rate of 99.3%. Two simultaneous defibrillators were required in 14 patients (3.4%). Patients with multiple cardioversions (13.5%) experienced more local skin irritation and pain compared with patients with single cardioversion (13.5% vs. 3.5%, P = 0.004). The predictor for the need for multiple cardioversion attempts is high body mass index, while high transthoracic impedance is associated with failed cardioversion. No major complications were observed during the study. CONCLUSION: The stepwise cardioversion protocol has a high success rate of >99% and can be safely performed in outpatient or inpatient settings.

Alcohol-related cirrhosis is associated with high coronary artery calcium scores in patients undergoing evaluation for orthotopic liver transplantation.

BACKGROUND AND AIMS: Coronary artery disease is a major cause of morbidity and mortality in liver transplant patients. Coronary artery calcium (CAC) score has been used to evaluate the risk of CAD in non-cirrhotic patients. However, its significance in cirrhotic patients is unknown. This study aimed to identify factors associated with elevated CAC scores in patients with end-stage liver disease undergoing liver transplant evaluation. METHODS: We retrospectively reviewed all patients who underwent liver transplantation evaluation and had coronary CT scan between January 2015 and December 2018. Patients with prior history of CAD were excluded. CAC score was calculated based on the method described by Agatston. RESULTS: Sixty-two patients were included. 37.1% had alcohol-related liver disease and 27.4% had NASH cirrhosis. Mean CAC score was 261.1 ± SD, 463.84. Alcohol-related liver disease, male gender, and hypertension were significantly associated with CAC score >100 and only alcohol-related liver disease was associated with CAC score >300. In logistic regression, patients with alcohol-related liver disease had more than sixfold increase in risk of having CAC scores >100 and 300 (OR 6.14, and 6.70, respectively). CONCLUSION: Alcohol-related liver disease, male gender, and hypertension were significantly associated with an increased CAC score >100. However, alcohol-related liver disease was the only factor associated with CAC score >300.

Incidental Coronary Artery Calcification and Stroke Risk in Patients With Atrial Fibrillation.

OBJECTIVE. Atrial fibrillation (AF) is a major risk factor for stroke. The CHA2DS2-VASc score is used to risk stratify patients, and the score includes known coronary artery disease (CAD) as a variable. The aim of this study was to assess if the presence of incidental coronary artery calcification (CAC), without known CAD, is associated with stroke independent of CHA2DS2-VASc variables. MATERIALS AND METHODS. A retrospective review of health records was performed for patients who had AF, a chest CT scan performed within 1 year, and a subsequent visit for stroke. Patients with CAD and other vascular disease, a mechanical valve, or who were older than 74 years old were excluded. Included patients were one-to-one matched by age and CHA2DS2-VASc risk factors to patients who had had similar follow-up but who did not have a stroke. Nongated CT images were reviewed for CAC. Univariate and Cox regression analyses were performed. RESULTS. A total of 203 patients met the study criteria, and 203 matched patients without stroke were identified. Median age was 61 years old with stroke and 62 years old without stroke (p = 0.99). In both groups, 82 (39.0%) were women and the median CHA2DS2-VASc was 2 (interquartile range, 1-2). Anticoagulation medication was prescribed to 46 (22.7%) patients in the group who had had a stroke and 52 (25.6%) in the group without stroke (p = 0.49). On Cox regression analysis, CAC was associated with stroke (hazard ratio [HR], 1.47; 95% CI, 1.10-1.97; p < 0.01) and mortality (adjusted HR, 1.41; 95% CI, 1.02-1.95; p = 0.04). CONCLUSION. Patients with AF and incidental CAC depicted on chest CT have an increased risk of stroke and mortality beyond established risk factors.

Outcomes of Heart Block in Myocarditis: A Review of 31,760 Patients.

BACKGROUND: Various electrocardiographic abnormalities, including atrioventricular conduction block, have been reported in patients with myocarditis. We performed an observation study to describe the characteristics and outcomes of inpatients diagnosed with myocarditis complicated by heart block (HB) in a large national cohort. METHODS: We identified patients with primary ICD-9 codes for myocarditis HB from the Nationwide Inpatient Sample (NIS) Database from 1998 to 2013. We compared the baseline characteristics and compared clinical outcomes between patients with and without HB, and in patients with/without high degree atrioventricular block (HDAVB). RESULTS: From the NIS database, 31,760 patients had a principal diagnosis of myocarditis and HB was reported in 1.7% of these patients (n=540). Female gender and Asian race were independently associated with HB. Out of 540 patients, 363 patients had HDAVB (67.2%) and 177 patients had not advanced HB (32.8%). Not advanced HB was not associated with an increased mortality rate compared to patients without HB (0% vs. 2.7%, p=0.315). On the other hand, the incidence of cardiogenic shock, respiratory failure and renal failure were higher in patients with HDAVB (26.2% vs. 5.0%, 33.9% vs. 5.9% and 29.2% vs. 5.5%, p<0.001 respectively). Patients with HDAVB required more procedural support (incidence of intra-aortic balloon pump 17.8% vs. 3.3%). They also had significantly longer lengths of hospital stay (9.4±9.4 vs. 4.3±8.4, p<0.001) and higher mortality (15.5% vs. 2.7%, p<0.001). Compared to myocarditis patients without HB, the odds for mortality in myocarditis patients with HDAVB 1.58 (95% CI=1.03-2.49, p=0.039). CONCLUSIONS: The incidence of HB and HDAVB among patients with acute myocarditis was 1.7% and 1.1% respectively. Female gender and Asian race were both independently associated with significant odds for the occurrence of HB and HDAVB. High degree atrioventricular block was independently associated with increased morbidity and mortality.

Atrioventricular dyssynchrony from empiric device settings is common in cardiac resynchronization therapy and adversely impacts left ventricular morphology and function.

BACKGROUND: Echocardiographic atrioventricular (AV) optimization after cardiac resynchronization therapy (CRT) is uncommon due to time constraints and the use of vendor-specific device algorithms. It remains unclear whether optimization of mitral inflow velocities can still be useful. We aimed to investigate post implantation left ventricular (LV) inflow patterns to determine the incidence of AV dyssynchrony from empirically set devices. METHODS: This was a retrospective study of patients undergoing CRT using empiric device settings. Forty-eight patients with clinical, echocardiographic, and pacemaker follow-up were grouped by their post implantation LV filling pattern. Baseline characteristics and echocardiographic measurements were compared with post implantation findings at median 6.3 months (interquartile range [IQR], 3.9-17.0). RESULTS: Twenty-four patients demonstrated AV dyssynchrony (Group 1) after CRT, and 24 patients did not (Group 2). Group 1 patients had less LV reverse remodeling compared to Group 2 patients (ΔLV end-diastolic volume: -3.6 mL vs -49.5 mL, P<.05; ΔLV end-systolic volume: -16.9 mL vs -53.5 mL, P<.05) and did not experience significant improvements in LV outflow tract velocity time integral, stroke volume, or LV ejection fraction. There were no differences in new-onset atrial fibrillation, heart failure readmissions, or mortality between groups. CONCLUSION: Our study suggests that up to 50% of patients with empiric device settings have AV dyssynchrony at 6 months despite atrioventricular delay optimization (AVO) algorithms. As AV dyssynchrony is common and has proven to be modifiable, a strategic approach to Doppler echocardiography-guided AVO after CRT is warranted, particularly in nonresponders where the LV filling pattern is fused or truncated.

Role of Echocardiography in the Diagnostic Assessment and Etiology of Heart Failure in Older Adults: Opacify, Quantify, and Rectify.

Echocardiography allows the assessment of systolic and diastolic function and identifies many of the common causes of heart failure (HF). Patients with minimally symptomatic or unsuspected left ventricular systolic dysfunction may be identified and receive the benefits of angiotensin-converting enzyme inhibitor therapy. Echocardiography is also for assessing prognosis and can be used serially to evaluate treatment. Ventricular filling pressures, pulmonary artery pressures, and cardiac output can be sequentially determined. The authors believe that all patients with HF should receive careful assessment echocardiography. The authors believe using echocardiography is especially valuable in the elderly.

An interactive videogame designed to improve respiratory navigator efficiency in children undergoing cardiovascular magnetic resonance.

BACKGROUND: Advanced cardiovascular magnetic resonance (CMR) acquisitions often require long scan durations that necessitate respiratory navigator gating. The tradeoff of navigator gating is reduced scan efficiency, particularly when the patient's breathing patterns are inconsistent, as is commonly seen in children. We hypothesized that engaging pediatric participants with a navigator-controlled videogame to help control breathing patterns would improve navigator efficiency and maintain image quality. METHODS: We developed custom software that processed the Siemens respiratory navigator image in real-time during CMR and represented diaphragm position using a cartoon avatar, which was projected to the participant in the scanner as visual feedback. The game incentivized children to breathe such that the avatar was positioned within the navigator acceptance window (±3 mm) throughout image acquisition. Using a 3T Siemens Tim Trio, 50 children (Age: 14 ± 3 years, 48 % female) with no significant past medical history underwent a respiratory navigator-gated 2D spiral cine displacement encoding with stimulated echoes (DENSE) CMR acquisition first with no feedback (NF) and then with the feedback game (FG). Thirty of the 50 children were randomized to undergo extensive off-scanner training with the FG using a MRI simulator, or no off-scanner training. Navigator efficiency, signal-to-noise ratio (SNR), and global left-ventricular strains were determined for each participant and compared. RESULTS: Using the FG improved average navigator efficiency from 33 ± 15 to 58 ± 13 % (p < 0.001) and improved SNR by 5 % (p = 0.01) compared to acquisitions with NF. There was no difference in navigator efficiency (p = 0.90) or SNR (p = 0.77) between untrained and trained participants for FG acquisitions. Circumferential and radial strains derived from FG acquisitions were slightly reduced compared to NF acquisitions (-16 ± 2 % vs -17 ± 2 %, p < 0.001; 40 ± 10 % vs 44 ± 11 %, p = 0.005, respectively). There were no differences in longitudinal strain (p = 0.38). CONCLUSIONS: Use of a respiratory navigator feedback game during navigator-gated CMR improved navigator efficiency in children from 33 to 58 %. This improved efficiency was associated with a 5 % increase in SNR for spiral cine DENSE. Extensive off-scanner training was not required to achieve the improvement in navigator efficiency.

Coronary artery calcification in CKD-5D patients is tied to adverse cardiac function and increased mortality
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BACKGROUND: Coronary artery calcification (CAC) is common in patients with chronic kidney disease on hemodialysis (CKD-5D) and is an important predictor of mortality. However, cardiac functional links between CAC and mortality have not been well established. This study tested the hypothesis that CAC increases mortality by adversely affecting cardiac function. METHODS: Patients were recruited from 37 regional dialysis centers. 2-D and Doppler echocardiographic analyses were performed, and CAC was measured using 64-slice computed tomography. Relationships between CAC and echocardiographic measures of left ventricular (LV) function were analyzed. Survival was assessed with median follow-up of 37 months. RESULTS: There were 157 patients: 59% male, 46% Caucasian, 48% diabetic. Median age was 55 years, and median duration of CKD-5D was 45 months. Agatston CAC scores 100 were found in 69% of patients, with 51% having a score  400. CAC was associated with measures of LV systolic and diastolic function (global longitudinal strain (GLS; rho = 0.270, p = 0.004)), peak LV systolic velocity (rho = -0.259, p = 0.004), and estimate of LV filling pressure (E:E'; rho = 0.286, p = 0.001). Multivariate regression confirmed these relationships after adjustment for age, gender, LV ejection fraction, and coronary artery disease. Valvular calcification varied linearly with CAC (p < 0.05). Both LV diastolic and systolic functional measures were significant predictors of mortality, the strongest of which was LV diastolic dysfunction. CONCLUSIONS: These findings show a link between CAC, cardiac function, and mortality in CKD-5D. LV diastolic function (E:E'), peak LV systolic velocity, and GLS are independent predictors of mortality. Valvular calcification may be an important marker of CAC in CKD-5D. These effects on cardiac function likely explain the high mortality with CKD-5D and describe a potentially-valuable role for echocardiography in the routine management of these patients.
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Gadolinium free cardiovascular magnetic resonance with 2-point Cine balanced steady state free precession.

BACKGROUND: Cardiovascular magnetic resonance (CMR) of ventricular structure and function is widely performed using cine balanced steady state free precession (bSSFP) MRI. The bSSFP signal of myocardium is weighted by magnetization transfer (MT) and T1/T2-relaxation times. In edematous and fibrotic tissues, increased T2 and reduced MT lead to increased signal intensity on images acquired with high excitation flip angles. We hypothesized that acquisition of two differentially MT-weighted bSSFP images (termed 2-point bSSFP) can identify tissue that would enhance with gadolinium similar to standard of care late gadolinium enhancement (LGE). METHODS: Cine bSSFP images (flip angles of 5° and 45°) and native-T1 and T2 maps were acquired in one mid-ventricular slice in 47 patients referred for CMR and 10 healthy controls. Afterwards, LGE images and post-contrast T1 maps were acquired and gadolinium partition coefficient (GPC) was calculated. Maps of ΔS/So were calculated as (S45-S5)/S5*100 (%), where Sflip_angle is the voxel signal intensity. RESULTS: Twenty three patients demonstrated areas of myocardial hyper-enhancement with LGE. In enhanced regions, ΔS/So, native-T1, T2, and GPC were heightened (p < 0.05 vs. non-enhanced tissues). ΔS/So, native-T1, and T2 all demonstrated association with GPC, however the association was strongest for ΔS/So. Bland-Altman analysis revealed a slight bias towards larger volume of enhancement with ΔS/So compared to LGE, and similar transmurality. Subjective analysis with 2-blinded expert readers revealed agreement between ΔS/So and LGE of 73.4 %, with false positive detection of 16.7 % and false negative detection of 15.2 %. CONCLUSIONS: Gadolinium free 2-point bSSFP identified tissue that enhances at LGE with strong association to GPC. Our results suggest that with further development, MT-weighted CMR could be used similar to LGE for diagnostic imaging.

QRS duration predicts death and hospitalization among patients with atrial fibrillation irrespective of heart failure: evidence from the AFFIRM study.

AIMS: The association of QRS duration (QRSd) with morbidity and mortality is understudied in patients with atrial fibrillation (AF). We sought to assess any association of prolonged QRS with increased risk of death or hospitalization among patients with AF. METHODS AND RESULTS: QRS duration was retrieved from the baseline electrocardiograms of patients enroled in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study and divided into three categories: <90, 90-119, ≥120 ms. Cox models were applied relating the hazards of mortality and hospitalizations to QRSd. Among 3804 patients with AF, 593 died and 2305 were hospitalized. Compared with those with QRS < 90 ms, patients with QRS ≥ 120 ms, had an increased mortality [hazard ratio (HR) 1.61, 95% confidence interval (CI): 1.29-2.03, P < 0.001] and hospitalizations (HR 1.14, 95% CI: 1.07-1.34, P = 0.043) over an average follow-up of 3.5 years. Importantly, for patients with QRS 90-119 ms, mortality and hospitalization were also increased (HR 1.31, P = 0.005 and 1.11, P = 0.026, respectively). In subgroup analysis based on heart failure (HF) status (previously documented or ejection fraction <40%), mortality was increased for QRS ≥ 120 ms patients with (HR 1.87, P < 0.001) and without HF (HR 1.63, P = 0.02). In the QRS 90-119 ms group, mortality was increased (HR 1.38, P = 0.03) for those with HF, but not significantly among those without HF (HR 1.23, P = 0.14). CONCLUSION: Among patients with AF, QRSd ≥ 120 ms was associated with a substantially increased risk for mortality (all-cause, cardiovascular, and arrhythmic) and hospitalization. Interestingly, an increased mortality was also observed among those with QRS 90-119 ms and concomitant HF.

Increased mortality among patients taking digoxin--analysis from the AFFIRM study.

AIMS: Digoxin is frequently used for rate control of atrial fibrillation (AF). It has, however, been associated with increased mortality. It remains unclear whether digoxin itself is responsible for the increased mortality (toxic drug effect) or whether it is prescribed to sicker patients with inherently higher mortality due to comorbidities. The goal of our study was to determine the relationship between digoxin and mortality in patients with AF. METHODS AND RESULTS: The association between digoxin and mortality was assessed in patients enrolled in the AF Follow-Up Investigation of Rhythm Management (AFFIRM) trial using multivariate Cox proportional hazards models. Analyses were conducted in all patients and in subsets according to the presence or absence of heart failure (HF), as defined by a history of HF and/or an ejection fraction <40%. Digoxin was associated with an increase in all-cause mortality [estimated hazard ratio (EHR) 1.41, 95% confidence interval (CI) 1.19-1.67, P < 0.001], cardiovascular mortality (EHR 1.35, 95% CI 1.06-1.71, P = 0.016), and arrhythmic mortality (EHR 1.61, 95% CI 1.12-2.30, P = 0.009). The all-cause mortality was increased with digoxin in patients without or with HF (EHR 1.37, 95% CI 1.05-1.79, P = 0.019 and EHR 1.41, 95% CI 1.09-1.84, P = 0.010, respectively). There was no significant digoxin-gender interaction for all-cause (P = 0.70) or cardiovascular (P = 0.95) mortality. CONCLUSION: Digoxin was associated with a significant increase in all-cause mortality in patients with AF after correcting for clinical characteristics and comorbidities, regardless of gender or of the presence or absence of HF. These findings call into question the widespread use of digoxin in patients with AF.

Taylor Swift.

Two-dimensional transthoracic echocardiogram, short axis view of the main pulmonary artery (MPA, left) demonstrates a saddle pulmonary embolism (PE) with the highly correlative axial display from the contrast-enhanced computed tomography scan (right). Ao, aorta; PA, pulmonary artery (From Graphical Abstract, Saddle Pulmonary Embolism Detected by Transthoracic Echocardiography in a Patient With Suspected Myocardial Infarction, Eugene Yuriditsky, MD et al.)Graphical abstractTwo-dimensional transthoracic echocardiogram, short axis view of the main pulmonary artery (MPA, left) demonstrates a saddle pulmonary embolism (PE) with the highly correlative axial display from the contrast-enhanced computed tomography scan (right). Ao, aorta; PA, pulmonary artery (From Graphical Abstract, Saddle Pulmonary Embolism Detected by Transthoracic Echocardiography in a Patient With Suspected Myocardial Infarction, Eugene Yuriditsky, MD et al.).

The many faces of takotsubo syndrome: A review.

Takotsubo syndrome is a state of an acute heart failure featuring reversible left ventricular dysfunction. In recent years, the incidence of Takotsubo syndrome has risen 8-fold. In this case series and literature review, we present the rare presentations or complications of Takotsubo syndrome and highlight diagnostic or management strategies. We aim to raise the awareness on the pathologic spectrum of takotsubo syndrome for the clinicians encountering this challenging diagnosis.

Simplified echocardiographic assessment of regional left ventricular wall motion pattern in patients with takotsubo and acute coronary syndrome: The Randomized Blinded Two-chamber Apical Kinesis Observation (TAKO) Study.

BACKGROUND: Differentiating Takotsubo cardiomyopathy (TTC) from acute coronary syndrome involving the left anterior descending coronary artery (LAD-ACS) is difficult due to left ventricular apical wall motion abnormality pattern in both and typically requires an invasive coronary angiography (ICA) study for diagnostic confirmation. OBJECTIVES: To identify differences in the regional wall motion abnormality (RWMA) pattern using a comprehensive comparative analysis of the transthoracic echocardiographic (TTE) findings in patients with TTC versus LAD-ACS. METHODS: This was a retrospective, randomized, blinded comparison study including a derivation cohort of 105 patients with TTC (N=52) or LAD-ACS (N=53) with concomitant TTE and ICA identified from our institutional database. A comprehensive echocardiographic wall motion analysis was performed (unblinded) to search for subtle differences in RWMA patterns by marking the exact locations of the end-systolic hinge points (HP) - defined as the intersection between the normal and abnormal regional myocardial thickening - in all apical views. The HP location relative to mitral annulus in each apical view was compared for symmetry and the apical 2-chamber (A2C) view was identified as having the most consistent, quantitative difference between TTC and LAD-ACS. This A2C quantitative model was then prospectively studied in a randomized, blinded, validation cohort of 30 subjects with either TTC or LAD-ACS by eight echocardiographic readers with all levels of clinical experience. RESULTS: In the unblinded derivation cohort, the A2C view showed that the ratio (1.02) and the absolute distance between the anterior HP (3.57 cm) and the inferior HP (3.53 cm) in TTC was significantly different than the ratio (0.761) and the absolute differences between the AHP (4.5 cm) and the IHP (5.93 cm) in LAD-ACS. An AHP: IHP of 0.96 for men and 0.84 for women was able to correctly categorize 84.8% of male and 91.7% of female patients. When applied to the validation cohort, the model showed fairly accurate results with a 74% prediction rate in diagnosing TTC in female patients. CONCLUSION: We propose a relatively simple 2-D TTE diagnostic tool emphasizing subtle differences in the RWMA pattern in the A2C view alone as a semi-quantitative imaging parameter to help differentiate TTC from LAD-ACS.

Best Practices for Point of Care Ultrasound: An Interdisciplinary Expert Consensus.

Despite the growing use of point of care ultrasound (POCUS) in contemporary medical practice and the existence of clinical guidelines addressing its specific applications, there remains a lack of standardization and agreement on optimal practices for several areas of POCUS use. The Society of Point of Care Ultrasound (SPOCUS) formed a working group in 2022 to establish a set of recommended best practices for POCUS, applicable to clinicians regardless of their training, specialty, resource setting, or scope of practice. Using a three-round modified Delphi process, a multi-disciplinary panel of 22 POCUS experts based in the United States reached consensus on 57 statements in domains including: (1) The definition and clinical role of POCUS; (2) Training pathways; (3) Credentialing; (4) Cleaning and maintenance of POCUS devices; (5) Consent and education; (6) Security, storage, and sharing of POCUS studies; (7) Uploading, archiving, and reviewing POCUS studies; and (8) Documenting POCUS studies. The consensus statements are provided here. While not intended to establish a standard of care or supersede more targeted guidelines, this document may serve as a useful baseline to guide clinicians, leaders, and systems considering initiation or enhancement of POCUS programs.

What's So False about a False Chord?

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Recognized and Unrecognized Value of Echocardiography in Guideline and Consensus Documents Regarding Patients With Chest Pain.

Guideline and consensus documents have recently been published on the important topic of the noninvasive evaluation of patients presenting with chest pain (CP) or patients with known acute or chronic coronary syndromes. Authors for these documents have included members representing multispecialty imaging societies, yet the process of generating consensus and the need to produce concise written documents have led to a situation where the particular advantages of echocardiography are overlooked. Broad guidelines such as these can be helpful when it comes to "when to do" noninvasive cardiac testing, but they do not pretend to offer nuances on "how to do" noninvasive cardiac testing. This report details the particular value of echocardiography and potential explanations for its understated role in recent guidelines. This report is categorized into the following sections: (1) impact of the level of evidence on guideline creation; (2) versatility of echocardiography in the assessment of CP and the inimitable role for echo Doppler echocardiography in the assessment of dyspnea; (3) value of point-of-care ultrasound in assessing CP and dyspnea; and (4) the future role of echocardiography in ischemic heart disease.

Echocardiographic Evaluation of His Bundle Pacing in Patients with Prolonged PR Intervals.

Background: Patients with PR intervals >240ms have atrio-ventricular (AV) dyssynchrony, which can increase risk of atrial fibrillation and all-cause mortality. When requiring pacing, long AV delays (AVDs) have been programmed to avoid ventricular dyssychrony. His bundle pacing (HBP) may provide improved AV synchrony in patients with prolonged PR. Methods: 10 patients with sinus node dysfunction and prolonged PR who received HBP were studied. Real-time echocardiographic was performed with 3 pacemaker modes (RV septal, non-selective HBP, and selective HBP) using the following pacemaker settings: control (no ventricular pacing), pacing with AVD of 180ms, 150ms, 120ms, 100ms, and 70ms. Echocardiographic Doppler measurements: EA/RR, >40% = AV synchrony; E/e', <8 = normal left atrial pressure; pulmonic-to-aortic pre-ejection time difference, <40ms = interventricular synchrony; septal-to-lateral wall activation time difference, <56ms = intraventricular synchrony; and LVOT VTI. Unpaired T test was used to evaluate for significance. Exclusion criteria: persistent atrial fibrillation, second-degree AV block. Results: Compared to control programming, HBP showed a 31.5% increase in EA/RR time, a decrease in E/e' of 26.9%, and an increase in the LVOT VTI of 21.3%. Compared to RV septal pacing, there was a similar increase in LVOT VTI. These findings met statistical significance and were considered optimal based on Doppler echocardiography findings primarily at AVDs of 150ms and 120ms. Comparisons between selective and non-selective pacing were not significantly different. Conclusion: Compared to controls and RV septal pacing, physiologic His bundle pacing was shown to increase markers of AV synchrony and LV stroke volume while maintaining ventricular synchrony.

Three-dimensional echocardiography in the electrophysiology laboratory.

The use of three-dimensional echocardiography (3DE) during electrophysiology (EP) procedures is the end product of years of growth in two diverse cardiology subspecialties; namely, advanced cardiac imaging and the EP. During the past decade, progress in both fields has resulted in many important advances that have culminated in their union for a new area of growth and development. Imaging advances have provided the cardiovascular specialist with enhanced cardiac volume and function data, and more recently, 3DE capabilities with improved spatial and temporal resolution providing unprecedented spatial relationships. This latter development is valued by EP specialists in need of hitherto never required anatomic knowledge as they press forward with extraordinary expansion in their capabilities. It makes sense that by combining these two rapidly growing subspecialties, future capabilities in patient care may be achieved that would otherwise not be possible. This paper discusses the value of 3DE during EP procedures and offers the readers insight into this novel multispecialty hybrid arena. Using this model as a template, it is likely that the readers may identify other areas within their practices where periprocedural advanced imaging may afford significant dividends in patient outcomes.