ABSTRACT
BACKGROUND: Differentiating wide complex tachycardias (WCTs) into ventricular tachycardia (VT) and supraventricular wide tachycardia via 12-lead ECG interpretation is a crucial but difficult task. Automated algorithms show promise as alternatives to manual ECG interpretation, but direct comparison of their diagnostic performance has not been undertaken. METHODS: Two electrophysiologists applied 3 manual WCT differentiation approaches (ie, Brugada, Vereckei aVR, and VT score). Simultaneously, computerized data from paired WCT and baseline ECGs were processed by 5 automated WCT differentiation algorithms (WCT Formula, WCT Formula II, VT Prediction Model, Solo Model, and Paired Model). The diagnostic performance of automated algorithms was compared with manual ECG interpretation approaches. RESULTS: A total of 212 WCTs (111 VT and 101 supraventricular wide tachycardia) from 104 patients were analyzed. WCT Formula demonstrated superior accuracy (85.8%) and specificity (87.1%) compared with Brugada (75.2% and 57.4%, respectively) and Vereckei aVR (65.3% and 36.4%, respectively). WCT Formula II achieved higher accuracy (89.6%) and specificity (85.1%) against Brugada and Vereckei aVR. Performance metrics of the WCT Formula (accuracy 85.8%, sensitivity 84.7%, and specificity 87.1%) and WCT Formula II (accuracy 89.8%, sensitivity 89.6%, and specificity 85.1%) were similar to the VT score (accuracy 84.4%, sensitivity 93.8%, and specificity 74.2%). Paired Model was superior to Brugada in accuracy (89.6% versus 75.2%), specificity (97.0% versus 57.4%), and F1 score (0.89 versus 0.80). Paired Model surpassed Vereckei aVR in accuracy (89.6% versus 65.3%), specificity (97.0% versus 75.2%), and F1 score (0.89 versus 0.74). Paired Model demonstrated similar accuracy (89.6% versus 84.4%), inferior sensitivity (79.3% versus 93.8%), but superior specificity (97.0% versus 74.2%) to the VT score. Solo Model and VT Prediction Model accuracy (82.5% and 77.4%, respectively) was superior to the Vereckei aVR (65.3%) but similar to Brugada (75.2%) and the VT score (84.4%). CONCLUSIONS: Automated WCT differentiation algorithms demonstrated favorable diagnostic performance compared with traditional manual ECG interpretation approaches.
Subject(s)
Algorithms , Electrocardiography , Tachycardia, Supraventricular , Tachycardia, Ventricular , Humans , Electrocardiography/methods , Tachycardia, Ventricular/diagnosis , Tachycardia, Ventricular/physiopathology , Female , Middle Aged , Male , Tachycardia, Supraventricular/diagnosis , Tachycardia, Supraventricular/physiopathology , Diagnosis, Differential , Predictive Value of Tests , Adult , Reproducibility of Results , Aged , Signal Processing, Computer-Assisted , AutomationABSTRACT
BACKGROUND: Accurate automated wide QRS complex tachycardia (WCT) differentiation into ventricular tachycardia (VT) and supraventricular wide complex tachycardia (SWCT) can be accomplished using calculations derived from computerized electrocardiogram (ECG) data of paired WCT and baseline ECGs. OBJECTIVE: Develop and trial novel WCT differentiation approaches for patients with and without a corresponding baseline ECG. METHODS: We developed and trialed WCT differentiation models comprised of novel and previously described parameters derived from WCT and baseline ECG data. In Part 1, a derivation cohort was used to evaluate five different classification models: logistic regression (LR), artificial neural network (ANN), Random Forests [RF], support vector machine (SVM), and ensemble learning (EL). In Part 2, a separate validation cohort was used to prospectively evaluate the performance of two LR models using parameters generated from the WCT ECG alone (Solo Model) and paired WCT and baseline ECGs (Paired Model). RESULTS: Of the 421 patients of the derivation cohort (Part 1), a favorable area under the receiver operating characteristic curve (AUC) by all modeling subtypes: LR (0.96), ANN (0.96), RF (0.96), SVM (0.96), and EL (0.97). Of the 235 patients of the validation cohort (Part 2), the Solo Model and Paired Model achieved a favorable AUC for 103 patients with (Solo Model 0.87; Paired Model 0.95) and 132 patients without (Solo Model 0.84; Paired Model 0.95) a corroborating electrophysiology procedure or intracardiac device recording. CONCLUSION: Accurate WCT differentiation may be accomplished using computerized data of (i) the WCT ECG alone and (ii) paired WCT and baseline ECGs.
Subject(s)
Tachycardia, Paroxysmal , Tachycardia, Supraventricular , Tachycardia, Ventricular , Humans , Electrocardiography/methods , Diagnosis, Differential , Tachycardia, Ventricular/diagnosisABSTRACT
BACKGROUND: Automated wide complex tachycardia (WCT) differentiation into ventricular tachycardia (VT) and supraventricular wide complex tachycardia (SWCT) may be accomplished using novel calculations that quantify the extent of mean electrical vector changes between the WCT and baseline electrocardiogram (ECG). At present, it is unknown whether quantifying mean electrical vector changes within three orthogonal vectorcardiogram (VCG) leads (X, Y, and Z leads) can improve automated VT and SWCT classification. METHODS: A derivation cohort of paired WCT and baseline ECGs was used to derive five logistic regression models: (i) one novel WCT differentiation model (i.e., VCG Model), (ii) three previously developed WCT differentiation models (i.e., WCT Formula, VT Prediction Model, and WCT Formula II), and (iii) one "all-inclusive" model (i.e., Hybrid Model). A separate validation cohort of paired WCT and baseline ECGs was used to trial and compare each model's performance. RESULTS: The VCG Model, composed of WCT QRS duration, baseline QRS duration, absolute change in QRS duration, X-lead QRS amplitude change, Y-lead QRS amplitude change, and Z-lead QRS amplitude change, demonstrated effective WCT differentiation (area under the curve [AUC] 0.94) for the derivation cohort. For the validation cohort, the diagnostic performance of the VCG Model (AUC 0.94) was similar to that achieved by the WCT Formula (AUC 0.95), VT Prediction Model (AUC 0.91), WCT Formula II (AUC 0.94), and Hybrid Model (AUC 0.95). CONCLUSION: Custom calculations derived from mathematically synthesized VCG signals may be used to formulate an effective means to differentiate WCTs automatically.
Subject(s)
Tachycardia, Supraventricular , Tachycardia, Ventricular , Diagnosis, Differential , Electrocardiography , Humans , Logistic Models , Tachycardia, Supraventricular/diagnosis , Tachycardia, Ventricular/diagnosisABSTRACT
Arrhythmias are the most common cardiovascular complication of pregnancy in women with and without structural heart disease. Appropriate maternal diagnosis and management is of utmost importance to optimize maternal and fetal outcomes. A multidisciplinary care approach with cardiology, maternal fetal medicine, anesthesia, and pediatrics is important for preconceptional, pregnancy, and delivery planning.
Subject(s)
Arrhythmias, Cardiac , Pregnancy Complications, Cardiovascular , Arrhythmias, Cardiac/diagnosis , Arrhythmias, Cardiac/therapy , Female , Humans , Patient Care Team/organization & administration , Pregnancy , Pregnancy Complications, Cardiovascular/diagnosis , Pregnancy Complications, Cardiovascular/therapy , Pregnancy Outcome , Risk Adjustment/methodsABSTRACT
BACKGROUND: Studies comparing manual catheter navigation (MCN) to remote magnetic navigation (RMN) for atrial fibrillation (AF) ablation showed variable results. OBJECTIVE: The aim of this meta-analysis is to compare the safety and clinical outcomes of AF radiofrequency (RF) ablation using MCN versus RMN with irrigated tip catheters. METHODS: Medline and the Cochrane Central Register of Controlled Trials (CENTRAL) were queried from inception through January 2019. Studies comparing safety and clinical outcomes of AF ablation with RF using MCN versus RMN with irrigated tip catheters were included. Random effects meta-analysis was used to pool outcomes across studies. Study endpoints included freedom of AF at the end of the study, procedure total time, fluoroscopy time, and complications. RESULTS: A total of 14 studies (3 controlled non-randomized trials, 1 prospective observational, and 10 retrospective observational studies) involving 3375 patients (1871 in MCN and 1504 in RMN) were included in this meta-analysis. There was no significant difference between the two groups in terms of freedom of AF (OR 1.08, 95% CI 0.82-1.42, p = 0.52). The MCN group was associated with shorter procedure time (mean difference in minutes - 50.39, 95% CI - 67.99 to - 32.79, p < 0.01), longer fluoroscopy time (mean difference in minutes 18.01, 95% CI 10.73-25.29, p < 0.01), and higher complication rate (OR 2.18, 95% CI 1.24-3.82, p < 0.01). CONCLUSIONS: AF ablation utilizing MCN was associated with similar efficacy to RMN but with higher complication rates. Although the procedure time was shorter with MCN, the fluoroscopy time was more prolonged. Randomized clinical studies are needed to further verify these results.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Atrial Fibrillation/diagnostic imaging , Atrial Fibrillation/surgery , Catheters , Humans , Magnetic Phenomena , Treatment OutcomeABSTRACT
Lack of availability of commercial antibodies against whole-cell antigen or an antigenic epitope of Avibacterium paragallinarum (Av. paragallinarum) has hindered the development of novel immunoassays for the diagnose infectious coryza (IC). In this study, we raised polyclonal antisera against Av. paragallinarum and evaluated its antigenic-specificity using enzyme linked immunosorbent assay (ELISA). We standardized antigen coating concentration(s), antibody detection limit, and optimal range of dilutions of primary antisera and secondary conjugated antibody. Our results show the development of antigen-specific antibody response in rabbits following repeated antigenic exposure with 0.5% formalinized antigen over a period of four weeks. Further, we showed its possible applicability in detection of pathogens in tissues by immunohistochemistry for confirmatory disease diagnosis and disease pathogenetic study.
ABSTRACT
PURPOSE OF REVIEW: This study aims to summarize the literature on the role of electrocardiography (ECG) in (i) patient selection for cardiac resynchronization therapy (CRT), (ii) predicting clinical response after CRT system is implanted, and (iii) optimizing CRT programming. RECENT FINDINGS: Progress has been made in interpreting ECG beyond QRS duration and left bundle branch (LBBB) morphology to select patients for CRT. We now understand a higher chance of response to CRT in patients with atypical right bundle branch block and lower response rates in subgroups with atypical LBBB. QRS area has emerged as a novel marker to quantify baseline electrical dyssynchrony to improve patient selection. After CRT, the resultant QRS narrowing remains the most validated predictor of long-term favorable outcome. There is increasing awareness of prolonged left ventricular pacing latency hindering the desired response to CRT. There is active interest in using ECG beyond minimizing QRS duration to optimize CRT programming for maximal resynchronization. Novel strategies include fusion of paced and/or conducted wavefronts and minimization of paced QRS area. ECG remains the ubiquitous method for ventricular electrical mapping in context of CRT. The role of ECG in elucidating baseline electrical dyssynchrony to aptly select patients for this treatment continues to evolve, and ECG is increasingly being evaluated as a reliable endpoint for optimal CRT programming.
ABSTRACT
INTRODUCTION: Point-by-point 3-dimensional (3D) electroanatomic mapping (EAM) is used to guide catheter ablation of premature ventricular complexes (PVCs). Due to the differences in the spatial excursion of the cardiac chambers during cardiac cycles in PVCs vs sinus rhythm, the 3D location registration during PVCs is shifted relative to sinus rhythm. In this study, we describe our strategy to adjust for this displacement in real-time during PVC mapping. METHODS AND RESULTS: We report 21 patients who underwent catheter ablation of 23 unique PVCs using Carto 3. After mapping the earliest site for each PVC, we reregistered its 3D location to a sinus rhythm beat in real-time, and used this to guide ablation lesion delivery. The PVC earliest location was spatially displaced from the successful ablation lesion in sinus rhythm by average 6.7 (range 3.3-13.0) mm. Offline, we subsequently analyzed 25 unique chamber maps and 606 PVC points. For each point, we reregistered the 3D location to a preceding sinus beat. The PVC points were displaced from sinus rhythm location by average 4.4 (0.3-13.7) mm. The maximally displaced point for each chamber was 7.7 (4.7-13.7) mm. The general direction of shift during PVC was leftward and inferior relative to sinus rhythm. CONCLUSIONS: During electroanatomic mapping of PVCs using the Carto 3 system, points mapped during PVCs are spatially displaced relative to their location in sinus rhythm. Electrophysiologists should recognize this phenomenon and account for the shift to guide accurate delivery of ablation lesions.
Subject(s)
Action Potentials , Catheter Ablation , Electrophysiologic Techniques, Cardiac , Heart Rate , Ventricular Premature Complexes/surgery , Adult , Aged , Catheter Ablation/adverse effects , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Time Factors , Treatment Outcome , Ventricular Premature Complexes/diagnosis , Ventricular Premature Complexes/physiopathologyABSTRACT
Depression in adults with congenital heart disease is highly prevalent and strongly associated with adverse prognosis. Better management of risk factors for depression may improve clinical outcomes in this population. We conducted a single-site, cross-sectional study of 78 adults with congenital heart disease followed at Washington University School of Medicine. Data considered in the analyses included retrospectively obtained clinical information and patients' self-assessed psychosocial functioning and health status. To identify the clinical and psychosocial variables associated with depression, we built a stepwise multivariate model to measure the relative contribution of these variables to depression status. The prevalence of depression in our sample was 26%. Our model accounted for approximately 67% of the variability in depression scores. The final model consisted of the Cardiac Denial of Impact Scale, expectations domain of Barriers to Care, and the energy and social domains of the Rand 36-Item Short Form Health Survey. Clinical variables did not predict variability in depression scores. In conclusion, greater cardiac denial and negative expectations of the healthcare team were associated with increased depression symptoms in ACHD.
Subject(s)
Denial, Psychological , Depressive Disorder/epidemiology , Heart Defects, Congenital/psychology , Adult , Cross-Sectional Studies , Female , Health Status , Humans , Male , Middle Aged , Motivation , Prevalence , Retrospective Studies , Surveys and QuestionnairesABSTRACT
Infectious coryza (IC) is often a curse for poultry farmers when it occurs concurrently with several pathogens causing swollen head syndrome. The disease is caused by Avibacterium paragallinarum, which inflicts initial damage to the nasal and respiratory epithelium. This facilitates the progression of disease pathology across the nasal cavity, thereby providing a platform for multiplication of opportunistic microbes. In this study, we attempted to investigate the early entrance and migration pattern of A. paragallinarum in chicken and Japanese quail following experimental infection, by employing an in-house developed polyclonal antiserum against this pathogen. Antigenic-specificity of the raised antiserum was subsequently evaluated through immune-dot blot techniques and counter-current immunoelectrophoresis (CIE). The resultant antiserum characterized the antigen localization within formalin-fixed and partially decalcified nasal tissue sections though immunohistochemistry (IHC). Japanese quail showed prominent localization of the bacterial antigen at 12â h post-infection in anterior turbinates. However, the chicken exhibited a higher level of the bacterial pathogen with intense immuno-reactivity at 24 and 48â h post-inoculation. The decline in immunostaining intensity in the nasal tissue of chicken as well as Japanese quail by 72â h post-infection signifies either an attempt to resolve the infection by the resident immune cells across the nasal passage of the host, or its dissipation by certain inherent innate immune factors present across the nasal passage that are still unknown to us. In the present study, we used a moderately virulent pathogen (A. paragallinarum) that inflicted a mild to moderate degree of damage to histo-architecture of the nasal passage and provided a discernible migratory pattern with fewer alterations, along with provision toward unravelling basics of the immuno-pathogenetic mechanism. This knowledge will support efforts towards the development of a future mucosal nasal vaccine in birds affected with IC.
Subject(s)
Chickens , Coturnix , Pasteurellaceae Infections/veterinary , Pasteurellaceae/immunology , Poultry Diseases/microbiology , Animals , Female , Immunohistochemistry/veterinary , Male , Nasal Cavity/microbiology , Nasal Cavity/pathology , Pasteurellaceae/physiology , Pasteurellaceae Infections/microbiology , Pasteurellaceae Infections/pathology , Poultry Diseases/pathology , Rabbits , Random Allocation , Turbinates/microbiology , Turbinates/pathologyABSTRACT
OBJECTIVE: Growth in the adults with congenital heart disease (ACHD) population represents a challenge to the health care infrastructure. As patients with chronic disease are increasingly held accountable for their own care, contributors to disease-specific health knowledge, which are known to correlate with patients' participation in care, merit investigation to design patient-focused interventions. DESIGN: We conducted a single-site, cross-sectional study of ACHD patients. Investigators retrospectively gathered clinical data as well as psychometric and health status assessments completed at the time of enrollment. OUTCOME MEASURES: We investigated the impact of clinical and psychological variables on Leuven Knowledge Questionnaire for Congenital Heart Diseases health knowledge composite scores (HKCS). Variables with significant associations were considered in a stepwise multivariable regression model to determine which combination of variables jointly explained variability in HKCS. RESULTS: Overall HKCS was associated with the number of prior cardiac surgeries (r = 0.273; 95% CI: 0.050-0.467; P = .016), perceived stress (r = 0.260; 95% CI: 0.033-0.458; P = .024), SF-36 emotional well-being (r = -0.251; 95% CI: -0.451, -0.024; P = .030), history of noncardiac surgery (P = .037), cirrhosis (P = .048), and presence of implantable cardioverter-defibrillator (P = .028). On multivariable modeling, only the number of cardiac surgeries was found to correlate with HKCS. CONCLUSIONS: While univariate correlations were found between HCKS and several other clinical and psychological variables, only number of prior cardiac surgeries independently correlated with disease-specific health knowledge in ACHD patients. These results suggest that clinical and psychological variables are not impediments to disease-specific health knowledge.
Subject(s)
Delivery of Health Care/standards , Health Knowledge, Attitudes, Practice , Health Status , Heart Defects, Congenital/psychology , Adult , Cardiac Surgical Procedures , Cross-Sectional Studies , Female , Heart Defects, Congenital/epidemiology , Heart Defects, Congenital/surgery , Humans , Incidence , Male , Middle Aged , Missouri/epidemiology , Retrospective Studies , Surveys and QuestionnairesABSTRACT
Ventricular dysfunction is common among patients with repaired cyanotic congenital heart disease. To date, no pharmacologic intervention has been demonstrated to be beneficial in this setting. To begin addressing this knowledge gap, we conducted a single-center prospective, randomized, open-label pilot study to investigate the effects of eplerenone on serologic markers of collagen turnover and inflammation, 6-minute walk distance, and quality of life in patients with tetralogy of Fallot (TOF) or transposition of the great arteries with a systemic right ventricle (transposition of the great arteries [TGA]). Patients were randomized to a 3-month drug-free period at the beginning of the treatment period or at the end. All patients received 12 months of eplerenone therapy during the treatment period. Twenty-six patients were enrolled in the trial; 17 completed the study protocol: 8 with TOF and 9 with TGV. Eplerenone had no effect on serum levels of procollagen 1 N-terminal peptide (PINP), procollagen 3 N-terminal peptide (PIIINP), or galectin-3 (G3). Similarly, eplerenone had no effect on 6-minute walk distance or quality of life. In conclusion, PINP and PIIINP levels are as high as or higher in patients with TOF and TGA than in patients with normal cardiac anatomy and heart failure, whereas G3 levels are lower. Eplerenone is well tolerated by adults born with congenital heart disease.
ABSTRACT
The factors having the greatest impact on self-reported health status in adults with congenital heart disease (ACHD) remain incompletely studied. We conducted a single-site, cross-sectional study of ACHD patients followed at the Center for ACHD at Washington University School of Medicine, including retrospectively gathered clinical data and psychometric and health status assessments completed at the time of enrollment. To identify primary drivers of perceived health status, we investigated the impact of the demographic, clinical, and psychological variables on self-reported health status as assessed using the Rand 36-Item Short Form Health Survey. Variables with significant associations within each domain were considered jointly in multivariable models constructed via stepwise selection. There was domain-specific heterogeneity in the variables having the greatest effect on self-reported health status. Depression was responsible for the greatest amount of variability in health status in all domains except physical functioning. In the physical functioning domain, depression remained responsible for 5% of total variability, the third most significant variable in the model. In every domain, depression more strongly influenced health status than did any cardiac-specific variable. In conclusion, depression was responsible for a significant amount of heterogeneity in all domains of self-perceived health status. Psychological variables were better predictors of health status than clinical variables.
Subject(s)
Health Status Indicators , Heart Defects, Congenital/physiopathology , Heart Defects, Congenital/psychology , Adult , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , Missouri , Psychometrics , Retrospective Studies , Surveys and QuestionnairesABSTRACT
The current study examined cardiac denial and psychological predictors (i.e., depression, anxiety) of health outcomes including medical nonadherence and physical health in a sample of 80 adults with congenital heart disease (ACHD). Results indicated that denial of impact was elevated in this patient group compared with reference groups, and denial was negatively associated with depression and anxiety at ps < .01. Results indicated that depression, anxiety, and denial predicted unique variance in medical nonadherence, and gender moderated the relationships between these psychological factors and nonadherence. For depression, men and women showed similar relationships between depression and nonadherence at high levels of depression; however, at low levels of depression (i.e., a more normal mood state), men were less adherent compared with women. For anxiety, men and women did not differ in adherence at low levels of anxiety; however, men experiencing high anxiety were less adherent compared with women experiencing high anxiety. Implications of this study are discussed including the role of gender and denial and the impact of denial functioning to reduce negative affect. Depression was the only significant predictor of physical functioning. Results of this study suggest that psychological interventions aimed at depression and anxiety may function differently across gender to improve patient medical adherence and improve physical functioning in ACHD.
Subject(s)
Heart Defects, Congenital/psychology , Patient Compliance/psychology , Adult , Anxiety/psychology , Anxiety Disorders/psychology , Depression/psychology , Depressive Disorder/psychology , Female , Heart Defects, Congenital/therapy , Humans , Male , Middle Aged , Psychological Tests , Stress, Psychological/psychology , Surveys and QuestionnairesABSTRACT
Transposition of the great arteries encompasses a set of structural congenital cardiac lesions that has in common ventriculoarterial discordance. Primarily because of advances in medical and surgical care, an increasing number of children born with this anomaly are surviving into adulthood. Depending upon the subtype of lesion or the particular corrective surgery that the patient might have undergone, this group of adult congenital heart disease patients constitutes a relatively new population with unique medical sequelae. Among the more common and difficult to manage are cardiac arrhythmias and other sequelae that can lead to sudden cardiac death. To date, the question of whether implantable cardioverter-defibrillators should be placed in this cohort as a preventive measure to abort sudden death has largely gone unanswered. Therefore, we review the available literature surrounding this issue.
Subject(s)
Death, Sudden, Cardiac/prevention & control , Defibrillators, Implantable , Electric Countershock/instrumentation , Primary Prevention/instrumentation , Transposition of Great Vessels/therapy , Death, Sudden, Cardiac/etiology , Electric Countershock/adverse effects , Electric Countershock/mortality , Humans , Patient Selection , Prosthesis Design , Risk Assessment , Risk Factors , Transposition of Great Vessels/complications , Transposition of Great Vessels/diagnosis , Transposition of Great Vessels/mortality , Treatment OutcomeABSTRACT
Racial disparities exist in the treatment of many cardiovascular diseases. Aortic valve replacement (AVR) is the only treatment for aortic stenosis (AS) that improves patient symptoms and survival. To date, no studies have compared the rate of AVR among different races. The records of patients with an aortic valve area <1 cm(2) by echocardiography diagnosed between January 2004 and May 2010 at Barnes-Jewish Hospital were reviewed retrospectively. Patients were stratified by race. Of the 880 patients analyzed, 10% were African American (AA), and 90% were European American (EA). AA more frequently had hypertension (82% vs 67%, p <0.01), diabetes mellitus (45% vs 32%, p = 0.02), chronic kidney disease (28% vs 17%, p = 0.01), and end stage renal disease (18% vs 2%, p <0.001). AA underwent AVR less frequently than EA (39% vs 53%, p = 0.02) and refused intervention more often (33% vs 20%, p = 0.04). When treated, AA and EA had similar 3-year survival (49% [38 to 60] vs 50% [45 to 54], p = 0.31). Identification of the factors associated with treatment refusal would further our ability to counsel patients on the decision to pursue AVR.