Effects of Punica granatum L. peel extract supplementation on body weight, cardiac function, and haematological and biochemical parameters in an animal model of metabolic syndrome.

Introduction: Metabolic syndrome (MetS) is a cluster of pathological conditions well described in humans but still investigated insufficiently in animals. A novel approach in its management is the utilisation of nutrients from natural sources. Recent studies suggested that phenolic compounds from pomegranate peel could be a promising dietary intervention for MetS. This study evaluated the potency of polyphenol-rich pomegranate peel extract (EPP) in mitigating some MetS components in an animal model. Material and Methods: Zucker diabetic fatty rats (with an fa/fa missense mutation in the Lepr leptin receptor gene) and their healthy counterparts (fa/+) as controls were fed a high-calorie diet to induce MetS and supplemented with EPP at two doses: 100 mg/kg body weight (b.w.) and 200 mg/kg b.w. The extract was administered for eight weeks. The rats' body weights were monitored twice per week, and blood samples were taken before EPP administration after four weeks and eight weeks of study. Echocardiography measurement was performed at the beginning and at the end of the study. Results: The extract restrained the dynamic of weight gain. A cardioprotective effect of the highest dose of EPP supplementation was manifested in a relative decrease in heart rate and improved mid-fractional shortening, representing myocardial contractility. No improvement in fasting blood glucose or lipid profile was observed. Conclusion: Pomegranate peel extract possesses beneficial health properties that could be useful in dietary intervention in MetS. However, its bioavailability still requires further investigation in clinical trials in humans and animals suffering from endocrine and metabolic disorders.

Outcomes of left bundle branch area pacing compared to His bundle pacing as a primary pacing strategy: Systematic review and meta-analysis.

BACKGROUND: Novel pacing technologies, such as His bundle pacing (HBP) and left bundle branch area pacing (LBBaP), have emerged to maintain physiological ventricular activation. We investigated the outcomes of LBBP with HBP for patients requiring a de novo permanent pacing. METHODS AND RESULTS: Systematic review of randomized clinical trials and observational studies comparing LBBaP with HBP until March 01, 2023 was performed. Random and fixed effects meta-analyses of the effect of pacing technology on outcomes were performed. Study outcomes included pacing metrics, QRS duration, lead revision, procedure parameters, all-cause mortality and heart failure hospitalization (HFH). Overall, 10 studies with 1596 patients were included. Implant success rate was higher in LBBaP compared with HBP (RR 1.24, 95% CI: 1.08 to 1.42, p = .002). LBBaP was associated with lower capture threshold at implantation (mean difference (MD) -0.62 V, 95% CI: -0.74 to -0.51 V, p < .0001) and at follow-up (MD -0.74 V, 95% CI: -0.96 to -0.53, p < .0001), shorter procedure duration (MD -14.66 min, 95% CI: -23.54 to -5.78, p = .001) and shorter fluoroscopy time (MD -4.2 min, 95% CI: -8.4 to -0.0, p = .05). Compared with HBP, LBBaP was associated with a decreased risk of all-cause mortality (RR: 0.50, 95% CI: 0.33 to 0.77, p = .002) and HFH (RR: 0.57, 95% CI: 0.33 to 1.00, p = .05). No statistical differences were found in lead revisions and QRS duration before and after pacing. CONCLUSION: This meta-analysis found that LBBaP was superior to HBP regarding pacing metrics and implant success rate as an initial pacing strategy, although absence of head-to-head randomized comparison warrants caution in interpretation of the results.

The usefulness of echo-based hemodynamic parameters in cardiac resynchronization therapy with conduction system pacing for optimal device programing.

BACKGROUND: His bundle pacing (HBP) has proved to be a valuable alternative enabling the physiological activation of cardiac contraction in cardiac resynchronization therapy (CRT). At present, however, little is known about the optimal method of programming of the His bundle-paced CRT systems in terms of achieving the best cardiac output. AIM: The aim of this study was to evaluate the impact of cardiac resynchronization therapy with conduction system pacing (CRT+CSP) on echo-based hemodynamic parameters in the early post-operative measurements. METHODS: The study enrollment criteria included: permanent atrial fibrillation, heart failure and bundle branch block. All patients underwent implantation of CRT + HBP. During the post-operative phase, we aimed to optimize HOT-CRT settings in order to achieve the greatest cardiac output assessed by complex echocardiographic measurements. RESULTS: The study included 21 patients, mean age 71.2 (6.3) years, predominantly men (71.4%) with non-ischemic cardiomyopathy 62%. All patients had heart failure with NYHA functional class III and IV (81%). Mean left ventricular ejection fraction was 27.5 (9.7%). The mean duration of the QRS complex was 148.8 ms. The effects of resynchronization pacing: HBP alone, HBP with left ventricular pacing, HBP with biventricular pacing (BiV) and BiV without HBP ​​were analyzed consecutively. HBP combined with left ventricular pacing demonstrated the best hemodynamic response. CONCLUSION: His bundle pacing coupled with LV pacing proved to be the most advantageous pacing program setting with regard to cardiac output. Moreover, it performed better than biventricular pacing and significantly better than RV pacing.

HOT CRT-The Effective Combination of Conventional Cardiac Resynchronization and His Bundle Pacing.

Background and Objectives: Cardiac Resynchronization Therapy (CRT) has, besides its benefits, various limitations. For instance, atrial fibrillation (AF) has a huge impact on the therapy efficacy. It usually reduces the overall BiV pacing percentage and leads, inevitably, to lack of fusion beats. In many patients with heart failure that could benefit from resynchronization, the QRS morphology is often IVCD and atypical, or non-LBBB, which further diminishes the CRT response. In those cases, we established His pacing combined with LV pacing as a feasible option to reduce the impact of AF on the CRT response and regain partially physiological ventricular activation to improve the electromechanical sequence. Materials and Methods: We implanted two patients with AF, HF, EF < 35%, NYHA II-III and QRS > 150 ms with CRT-D systems modified to HOT-CRT and observed their clinical, ECG and echocardiographic improvements over a follow-up period of three months. Results: In both patients we observed improvements of the initial parameters. We were able to shorten the QRS duration to approx. 120 ms, improve NYHA functional class, increase the EF by approximately 12% and distinctly reduce mitral regurgitation. Conclusion: Since the conventional CRT reaches its limits within this specific patient group, we need to consider alternative pacing sites and the effective combination of them. Our results and respectively other studies that are also mentioned in the current guidelines, support the feasibility of HOT-CRT in the above mentioned patient group.

Biological Potential of Polyphenols in the Context of Metabolic Syndrome: An Analysis of Studies on Animal Models.

Metabolic syndrome (MetS) is a disease that has a complex etiology. It is defined as the co-occurrence of several pathophysiological disorders, including obesity, hyperglycemia, hypertension, and dyslipidemia. MetS is currently a severe problem in the public health care system. As its prevalence increases every year, it is now considered a global problem among adults and young populations. The treatment of choice comprises lifestyle changes based mainly on diet and physical activity. Therefore, researchers have been attempting to discover new substances that could help reduce or even reverse the symptoms when added to food. These attempts have resulted in numerous studies. Many of them have investigated the bioactive potential of polyphenols as a "possible remedy", stemming from their antioxidative and anti-inflammatory effects and properties normalizing carbohydrate and lipid metabolism. Polyphenols may be supportive in preventing or delaying the onset of MetS or its complications. Additionally, the consumption of food rich in polyphenols should be considered as a supplement for antidiabetic drugs. To ensure the relevance of the studies on polyphenols' properties, mechanisms of action, and potential human health benefits, researchers have used laboratory animals displaying pathophysiological changes specific to MetS. Polyphenols or their plant extracts were chosen according to the most advantageous mitigation of pathological changes in animal models best reflecting the components of MetS. The present paper comprises an overview of animal models of MetS, and promising polyphenolic compounds whose bioactive potential, effect on metabolic pathways, and supplementation-related benefits were analyzed based on in vivo animal models.

ST-segment depression in atrioventricular nodal reentrant tachycardia: Important finding or just an artifact?

BACKGROUND: The ST segment is component of the QRS-T complex located between the QRS and the T wave. ST segment changes during tachycardia with narrow QRS mainly takes the form of ST segment depression. This phenomenon is often observed in young healthy people for whom an ischemic background is unlikely. MATERIALS AND METHODS: The study included 104 patients (71 women and 33 men) with paroxysmal narrow QRS complex tachycardia. In all patients electrophysiological study was performed and the diagnosis of atrioventricular nodal reentrant tachycardia was established. The arrhythmogenic substrate was then eliminated successfully by subsequent ablation using radiofrequency energy which confirmed the diagnosis, all patients had measured QRS components - QR, RS and RJ during the tachycardia and during the sinusrhythm. All of the measurements were done in lead V5. RESULTS: The difference RJ-QR during tachycardia and sinus rhythm correlated negatively with tachycardia cycle length (R = 0.356, P = .001), first slowly, then rapidly reaching the cycle value of about 300 ms, then it decreases, stabilizing at the cycle level of about 270. By separating the RJ-QR in tachycardia and in the sinus rhythm from the tachycardia cycle, we can see that the correlation described in this point is largely due to the correlation between the heart rate and RJ-QR length in tachycardia. CONCLUSIONS: In patients with atrioventricular nodal reentrant tachycardia, there is a significant ST-segment depression during tachycardia episodes and the degree of this change is related to tachycardia cycle length. The most probable explanation of the ST-segment depression is the overlap of the QRS complex on the preceded T wave. This phenomenon is also influenced by some intrinsic properties of the individual electrocardiogram. It is possible to rule out ischemic origin of the presented ST segment change.

The clinical utility of direct His-bundle pacing in patients with heart failure and permanent atrial fibrillation.

In patients with significantly impaired left ventricle function permanent atrial fibrillation (AF) often coexists with symptoms of heart failure. Based on various studies, it is assumed that in patients with heart failure in functional class III and IV AF occurs in 40-50% of patients. AF adversely affects cardiac hemodynamics, and its harmfulness increases particularly in the failing heart. The lack of mechanical function of the left atrium, the usually fast ventricular rate and the irregular sequence of ventricular contraction constitute the spectrum of harmful effects of this arrhythmia. Therefore, the only way to address the underlying problem of AF, which is irregular ventricular rhythm, is to pace the ventricles and to slow or block the AV conduction. Classic, right ventricular pacing is contraindicated in this population as it promotes the abovementioned disorders by initiating additional dyssynchrony of left ventricular contraction with reduction of its contractility and aggravation of AF-related mitral regurgitation. The possibility of direct His bundle pacing (DHBP) significantly extended the clinical armamentarium of cardiac pacing. The restoration of the physiological electrical activation could significantly contribute to echocardiographic and clinical improvement. With time and the development of dedicated tools for direct His bundle pacing the success rate of implantations became more than 90% and the acceptable pacing thresholds under 2.0 V (1 ms) could be achieved in most patients. This contributed to the broader clinical application of DHBP in different patient' groups with various pacing indications. The authors of the paper discuss different electrocardiographic and clinical indications for DHBP.

ST-segment depression in atrioventricular nodal reentrant tachycardia: Preliminary results.

BACKGROUND: The ST-segment is part of the electrocardiogram and physiologically, it forms an isoelectric line. The ST-segment depression is often observed in young, healthy people with paroxysmal tachycardia with narrow QRS complexes. In this group of patients, the 'mysterious tachycardia-induced ST-segment depression', 'subendocardial myocardial ischemia' and other not fully understood terms are used to explain this phenomenon. OBJECTIVES: To assess the presence and possible mechanisms of ST-segment depression during atrioventricular nodal reentrant tachycardia (AVNRT) in patients undergoing radiofrequency (RF) ablation of the underlying arrhythmia. MATERIAL AND METHODS: The study included 50 patients (35 women and 15 men) aged about 49 years with clinically relevant paroxysmal narrow QRS complex tachycardia. During electrophysiological study (EPS), all patients had measured QRS components - QR, RS and RJ during the tachycardia and during the sinus rhythm. All of the measurements were done in lead V5. RESULTS: There was a statistically significant difference in cycle length during sinus rhythm and tachycardia (707.0 ±137.8 ms compared to 327.5 ±29.1 ms, p = 0.000), the RJ component (0.819 ±0.381 mV compared to 0.878 ±0.376 mV, p = 0.003) and the difference RJ-QR (0.081 ±0.083 mV compared to 0.163 ±0.108 mV, p = 0.000). The differences in RS and QR components during sinus rhythm and tachycardia did not reach the statistical significance. The difference RJ-QR during tachycardia correlated negatively with tachycardia cycle length (R = -0.39, p = 0.0049). The tachycardia cycle length correlated positively with the age of the studied patients (R = 0.28, p = 0.043). CONCLUSION: In patients with AVNRT, there is a ST-segment depression during the episodes of tachycardia and the degree of this change is related to tachycardia cycle length. The most probable explanation of the ST-segment depression is the overlap of the QRS complex on the preceded T wave. Some intrinsic properties of individual electrocardiogram (ECG) also influence this phenomenon. The ischemic origin of the presented ST-segment change can be excluded.

The P wave dispersion-one pixel, one millisecond.

The electrophysiological activity of the heart is recorded and presented in form of electrocardiogram (ECG). In 1998 the concept of P wave dispersion as the risk factor for atrial fibrillation (AF) recurrence was introduced. It was calculated as the difference between the longest and the shortest P wave. The aim of our study is to prove that the P wave dispersion is an artifact of low accuracy in P wave measurement. The study included 186 patients (78M 108F) aged 59.7 ± 12.9 years, undergoing various electrophysiological procedures. The P wave was measured twice: first, at the paper speed of 50 mm/s, enhancement 8× (standard - imprecise) and the second time at 200 mm/s, 64-256× (precise). The imprecise measurement method resulted in different duration of all P wave parameters in comparison with precise measurement. The difference between Δ P max and Δ P min indicated a higher value for the latter parameter. It was indicated that the imprecise P wave dispersion value correlated most significantly with the maximal P wave duration, which was measured in a similar way. In contrast with the imprecise measurement method, the minimal and maximal durations of the P waves, being measured accurately, were almost identical. Using precise methodology, the P wave dispersion reaches negligible values and tends to zero. The measurements of the P wave have to be precise to assure the highest scientific and medical sincerity. The highest clinical value is related to the P wave duration.

Patient with sick sinus syndrome and implanted dual-chamber pacemaker with reduced P-wave duration following low interatrial septal pacing: Case report.

INTRODUCTION: A dual-chamber pacemaker (DDD/R) for a sinus node disease is sometimes referred to as a physiological pacemaker as it maintains atrioventricular synchrony, however several clinical trials have proved its inferiority to a nonphysiological single-chamber ventricular back-up pacing. PATIENT CONCERNS: A subject of the study is a 74-year-old woman with a sick sinus syndrome (SSS) and a previously implanted physiological DDD/R pacemaker. The SSS was diagnosed because of patient's very slow sinus rhythm of about 36 bpm, and due to several episodes of dizziness. After the DDD/R implantation the percentage of atrial pacing approached 100%, with almost none ventricular pacing. DIAGNOSES: Sick sinus syndrome, complete Bachmann's bundle block, atrial fibrillation, atrial flutter. INTERVENTIONS: The patient was previously implanted with a physiological DDD/R pacemaker. Several years after the implantation, the atrial fibrillation was diagnosed and the pulmonary vein isolation was then performed by cryoablation. During the follow-up after pulmonary vein isolation, the improvement of mitral filling parameters was assessed using echocardiography. Shortly thereafter the patient developed the persistent paroxysm of a typical atrial flutter which was successfully terminated using a radiofrequency ablation. No recurrence thereof has been observed ever since (24 months). OUTCOMES: The atrial electrode of the pacing system was implanted within the low interatrial septal region that resulted in a reduced P-wave duration compared to native sinus rhythm P-waves. The said morphology was deformed because of the complete Bachmann bundle block. That approach, despite a nonphysiological direction of an atrial activation, yielded relatively short P-waves (paced P-wave: 179 ms vs intrinsic sinus P-wave: 237 ms). It also contributed to a significantly shorter PR interval (paced PR: 204 ms vs sinus rhythm PR: 254 ms). CONCLUSIONS: The authors took into consideration different aspects of alternative right atrial pacing sites. This report has shown that in some patients with a sinus node disease, low interatrial septal pacing can reduce the P-wave duration but does not prevent from the development of atrial arrhythmias.

P wave duration in paroxysmal and persistent atrial fibrillation.

BACKGROUND: Functional and structural changes in the atrial muscle constitute a substrate for atrial fibrillation (AF). The pathological changes in the left atrium decrease the conduction velocity and result in prolongation of the P wave duration. OBJECTIVES: To assess the duration of the P wave in patients with AF in different clinical presentations of arrhythmia. MATERIAL AND METHODS: The study group consisted of 119 patients diagnosed with AF: 57 women and 62 men, aged 65.3 ±9.4 years. There were 65 patients with paroxysmal AF and 54 with persistent AF. In this group, electrical cardioversion was performed. The P wave duration was measured using an electrophysiological system in all leads at a paper speed of 200 mm/s. RESULTS: The patients did not differ in terms of age, gender or comorbidities. The patients with persistent AF had longer P wave duration (159.9 ±22.3 ms compared to 144.6 ±17.2 ms; p < 0.001) and higher glucose concentration (119.4 ±33.4 mg/dL compared to 108.0 ±24.6 mg/dL; p = 0.015). These results were not influenced by the anti-arrhythmic treatment. CONCLUSIONS: Persistent AF shows a longer P wave duration than the paroxysmal AF, independent of age, gender and anti-arrhythmic medication. The prolongation of the P wave related to persistent arrhythmia should force physicians to restore the sinus rhythm earlier in order to more successfully maintain it in the long term.

The Role of Sleep Disturbance, Depression and Anxiety in Frail Patients with AF-Gender Differences.

The aim of the study was to assess the link between anxiety and depression and frailty syndrome (FS) in patients with atrial fibrillation (AF) with regard to gender differences. MATERIAL AND METHODS: The study was conducted on 158 patients with AF (mean age 70.4 ± 7.6). The study used the hospital anxiety and depression scale (HADS-M), the Athens insomnia scale (AIS) and the Edmonton frailty scale to assess and compare anxiety, depression, and sleep disturbance between frail and non-frail patients with AF. RESULTS: FS was diagnosed in 53.2% of patients. A comparative analysis showed a statistically significantly higher severity level of anxiety (12.0 ± 2.6 vs. 8.4 ± 2.5, p < 0.001) and depression (12.5 ± 2.5 vs. 7.2 ± 3.3, p < 0.001) in frail patients compared to non-frail patients. The analysis of the level of anxiety, depression and FS did not show any significant differences between the studied women and men. However, statistically, significant differences were observed when FS occurred, regardless of gender. Anxiety disorders were observed in 75.5% of patients with FS and in 16.7% without frailty, whereas depressive disorders were observed in 73.6% of frail patients and in 4.2% without frailty. In an analysis of the impact of cumulative variables on the level of frailty, the risk of FS in patients with anxiety/depression and sleep disturbance is almost 500 times higher compared to patients without anxiety/depression and sleep disturbance. The risk of frailty in patients with sleep disturbance only is thirteen times higher than in the reference group, i.e., in patients without depression/anxiety and sleep disturbances. CONCLUSIONS: Patients with AF and FS show deeper anxiety, depression and sleep disturbances. Gender does not influence the risk of frailty in AF patients. Frailty in patients with AF is associated with a higher risk of depression, sleep disturbances and anxiety.

The true nature of P wave dispersion.

BACKGROUND: The electrophysiological activity of the heart is recorded and presented in form of electrocardiography (ECG). In 1998, the concept of P wave dispersion as the risk factor for atrial fibrillation (AF) recurrence was introduced. It was calculated as the difference between the longest and the shortest P wave. OBJECTIVES: To prove that the P wave dispersion is an artifact of low accuracy in P wave measurement. MATERIAL AND METHODS: The study included 104 patients (48 women, 56 men), aged 63 ±14 years, undergoing various electrophysiological procedures. The P wave was measured twice - firstly at the paper speed of 50 mm/s, enhancement ×8 (standard - imprecise), and secondly at 200 mm/s, ×64-256 (precise). RESULTS: The imprecise measurement method resulted in different duration of all P wave parameters in comparison with precise measurement. The longest P wave duration (Pmax) measured imprecisely was 105.1 ±22.1, the Pmax measured precisely was 134.0 ±21.3 (p < 0.001). The P dispersion measured imprecisely was 44.1 ±16.8 and the P dispersion measured precisely was 2.8 ±3.4 (p < 0.0001). The correlation between imprecise Pmax and imprecise Pmin was r = 0.664 (p < 0.05). The correlation between imprecise Pmax and imprecise P wave dispersion was r = 0.612 (p < 0.05). The correlation between precise Pmax and Pmin was almost 1.0 (r = 0.987, p < 0.05). CONCLUSIONS: The P wave dispersion does not exist. The measurements of the P wave have to be precise to assure the highest scientific and medical sincerity. The highest clinical value is related to the P wave duration.

Transvenous extraction of 3-year-old Seldinger guide wire lost in venous system and causing superior vena cava syndrome - rare complication of implantable cardioverter-defibrillator implantation.

A CASE REPORT: A 65-year-old male patient underwent left-sided placement of implantable cardioverter-defibrillator. At three years after implantation he emerged complaining on left upper limb and left-sided neck edema. Left brachicephalic vein thrombosis due to device leads was recognized. The attending cardiologist referred the patient to university radiology department for venous angioplasty but the patient was admitted to cardiology department. Coronary angiography was performed due to suspicion of ischemic heart disease. However, it showed the presence of foreign body in cardiovascular system - completely intravascular round-tipped guide wire used in Seldinger technique for insertion of the endocardial lead abandoned in left subclavian vein and reaching to superior vena cava. Patient was transferred to third-degree reference lead extraction center. The procedure was performed under general anesthesia in hybrid operating room. Via femoral vein access we introduced Needle's Eye Snare and grasped the guide wire. Then, using polytetrafluoroethylene sheath the tissue adhesions were dissected and the complete guide wire was retrieved.

Cardiac resynchronization therapy with His bundle pacing.

AIMS: A novel therapy offering cardiac resynchronization therapy (CRT) with an additional lead placed in His bundle has been reported in a few case reports and case series as improving the hemodynamical and clinical condition of patients with permanent atrial fibrillation (AF) in whom other therapeutic methods have not been successful. METHODS: Fourteen consecutive patients with permanent AF, heart failure (HF), bundle branch block (BBB) with QRS complex width >130 ms, and impaired left ventricular ejection fraction (LVEF) underwent implantation of implantable cardioverter defibrillator (ICD)/CRT systems with His bundle pacing (HBP). During the follow-up, we assessed the efficacy of ICD/CRT systems with HBP in HF treatment. RESULTS: The study cohort consisted of 14 patients with the mean age of 67.35 ± 10 years. The mean duration of QRS was 159.2 ± 28.6 ms, mean LVEF was 24.36 ± 10.7%, and mean follow-up duration was 14.4 months. One patient died due to HF aggravation during the follow-up. In the remaining 13 patients, the mean LVEF significantly improved from 24% to 38%, P = 0.0015. The left ventricular end-diastolic dimension decreased from 72 mm to 59 mm, P < 0.001; left ventricular end-systolic dimension decreased from 59 mm to 47 mm, P = 0.0026. The mean QRS duration shortened from 159 ms to 128 ms, P = 0.016. The mean percentage of HBP reached 97%. As a result, 92.3% of patients demonstrated significant improvement in the New York Heart Association functional class, P < 0.001. CONCLUSION: The use of atrial channel for HBP, choice of optimal ICD/CRT pacing configuration, and optimization of pharmacological therapy resulted in a substantial narrowing of QRS width and clinical improvement in left ventricular mechanical function during the follow-up.