Ultrasound Doppler technique for the diagnosis of focal nodular hyperplasia - case series and systematic review.

With the Superb Micro-Vascular Imaging (SMI), the established Doppler technology has been extended by another mode. With this technique, microvascular structures with slow blood flow can now also be displayed in real time. As with the introduction of Doppler ultrasound, this new technique opens further diagnostic fields for the examiner, which were previously reserved for magnetic resonance imaging (MRI), computed tomography (CT) or contrast ultrasound (CEUS). Focal nodular hyperplasia (FNH) of the liver is characterized by a typical spoke-wheel vascular malformation (spoke-wheel sign, SWS) anda good example using SMI for the diagnostic profit of our patients. The aim of this report is to describe the use of SMI as a new non-invasive, quick, and probably cost-effective diagnostic imaging tool.

Minimally invasive thoracoscopic surgery is an effective approach for treating inappropriate sinus tachycardia.

INTRODUCTION: Inappropriate sinus tachycardia (IST) is characterized by increased heart rate out of proportion to normal physiologic demand. IST ablation is challenging for the electrophysiology community due to the epicardial location of the sinus node and the risk of phrenic nerve (PN) injury during catheter ablation. In this study, we investigated the safety and efficacy of a minimally invasive thoracoscopic surgery for elimination of IST. METHODS: Patients with IST who failed medical therapy or endocardial ablation underwent minimally invasive thoracoscopic epicardial ablation. Epicardial activation mapping was performed to identify the earliest activation site and any possible migration of earliest activation along the lateral right atrium. The PN in each patient was protected by a pericardial retraction suture. RESULTS: From 1 January 2000 to 15 June 2018, 10 patients (eight females and two males) underwent minimally invasive thoracoscopic IST ablation. Mean age of the patients was 36.7 ± 12.5 years. Mean baseline sinus rate was 113.8 ± 21.8 beats per minute. After surgery, the mean heart rate significantly decreased to 79.8 ± 8.2 at postoperative day 1 and to 75.8 ± 8.1 at day 30 (both P < .001). No in-hospital death, stroke, or PN injury occurred. One patient required reintubation, one patient developed postoperative pericarditis, and another patient had a pulmonary embolus. Median follow-up was 6 months (range, 1-50). Freedom from reintervention was 88% at 6 months. CONCLUSION: Minimally invasive thoracoscopic ablation for IST is a safe and effective approach that preserves the phrenic nerve. Due to the possibility of IST activation site migration, continued follow-up after surgery is required.

Iatrogenic Ventricular Fibrillation after Direct-Current Cardioversion of Preexcited Atrial Fibrillation Caused by Inadvertent T-Wave Synchronization.

Direct-current cardioversion is an important means of managing arrhythmias. During treatment, carefully synchronizing energy delivery to the QRS complex is necessary to avoid ventricular fibrillation caused by a shock during the vulnerable period of ventricular repolarization, that is, a shock on the T wave. The presence of an accessory pathway and ventricular preexcitation can lead to difficulty in distinguishing the QRS complex from the T wave because of bizarre, wide, irregular QRS complexes and prominent repolarization. We present the cases of 2 patients who had iatrogenic ventricular fibrillation from inappropriate T-wave synchronization during direct-current cardioversion of preexcited atrial fibrillation. Our experience shows that rapidly recognizing the iatrogenic cause of VF and immediate treatment with unsynchronized defibrillation can prevent adverse clinical outcomes.

Postgraduate Education in Quality Improvement Methods: Initial Results of the Fellows' Applied Quality Training (FAQT) Curriculum.

OBJECTIVE: Training in quality improvement (QI) is a pillar of the next accreditation system of the Accreditation Committee on Graduate Medical Education and a growing expectation of physicians for maintenance of certification. Despite this, many postgraduate medical trainees are not receiving training in QI methods. We created the Fellows Applied Quality Training (FAQT) curriculum for cardiology fellows using both didactic and applied components with the goal of increasing confidence to participate in future QI projects. METHODS AND RESULTS: Fellows completed didactic training from the Institute for Healthcare Improvement's Open School and then designed and completed a project to improve quality of care or patient safety. Self-assessments were completed by the fellows before, during, and after the first year of the curriculum. The primary outcome for our curriculum was the median score reported by the fellows regarding their self-confidence to complete QI activities. Self-assessments were completed by 23 fellows. The majority of fellows (15 of 23, 65.2%) reported no prior formal QI training. Median score on baseline self-assessment was 3.0 (range, 1.85-4), which was significantly increased to 3.27 (range, 2.23-4; P = 0.004) on the final assessment. The distribution of scores reported by the fellows indicates that 30% were slightly confident at conducting QI activities on their own, which was reduced to 5% after completing the FAQT curriculum. An interim assessment was conducted after the fellows completed didactic training only; median scores were not different from the baseline (mean, 3.0; P = 0.51). CONCLUSION: After completion of the FAQT, cardiology fellows reported higher self-confidence to complete QI activities. The increase in self-confidence seemed to be limited to the applied component of the curriculum, with no significant change after the didactic component.

Transient, high-grade atrioventricular block from high-dose cyclophosphamide.

Cyclophosphamide, an alkylation agent, is widely used in stem cell transplantation for its antineoplastic and myeloablative properties. Congestive heart failure, pericarditis, and arrhythmias are well-known cardiac sequelae of high-dose cyclophosphamide therapy; however, high-grade atrioventricular block has rarely been reported. We present the case of a 71-year-old man who developed a high degree of atrioventricular block several hours after therapy with high-dose cyclophosphamide. After treatment with a temporary pacemaker and cessation of cyclophosphamide, the patient experienced no more events. Before administering cyclophosphamide, evaluating patients for underlying conduction abnormalities is advisable. Agents other than cyclophosphamide are available.

Cardiac arrhythmias during pregnancy.

OPINION STATEMENT: This article reviews the appropriate evaluation and management of cardiac arrhythmias in the pregnant patient. Any treatment strategy in this patient population has the inherent potential to adversely affect the health of the unborn child. As such, there is no room for empiric therapy in these patients. Adequate arrhythmia documentation is paramount, preferably by noninvasive means. The decision to treat should be based on symptom severity and the risk to both mother and fetus posed by potentially recurring arrhythmia episodes throughout the pregnancy. Minimal symptoms in the setting of a structurally normal heart call for a conservative approach. Less is better. If pharmacologic therapy is justified, drugs with historically demonstrated safety profiles in pregnancy should be tried first. The safety profiles of virtually all drugs used to treat cardiac arrhythmias during human pregnancy are based solely on an accumulation of past clinical experience. Newer antiarrhythmics therefore carry a largely unknown risk. Most inherent rhythm disorders manifest long before a woman reaches childbearing age. Women with previously diagnosed arrhythmias frequently experience a recurrence or worsening of their arrhythmia during the pregnancy. Counseling of these individuals and perhaps preemptive treatment by means such as arrhythmia ablation prior to a planned pregnancy would seem optimal.

Detection of a retention wire fracture in an asymptomatic patient 18 years after implantation.

An asymptomatic patient with a Teletronics Accufix atrial lead (Teletronics, Englewood, CO, USA) presented for an annual fluoroscopic examination. The examination revealed a retention wire fracture, which occurred 18 years after the initial implantation. Annual fluoroscopic examination of these leads should still be performed.

Appropriate evaluation and treatment of heart failure patients after implantable cardioverter-defibrillator discharge: time to go beyond the initial shock.

Multiple clinical trials support the use of implantable cardioverter-defibrillators (ICDs) for prevention of sudden cardiac death in patients with heart failure (HF). Unfortunately, several complicating issues have arisen from the universal use of ICDs in HF patients. An estimated 20% to 35% of HF patients who receive an ICD for primary prevention will experience an appropriate shock within 1 to 3 years of implant, and one-third of patients will experience an inappropriate shock. An ICD shock is associated with a 2- to 5-fold increase in mortality, with the most common cause being progressive HF. The median time from initial ICD shock to death ranges from 168 to 294 days depending on HF etiology and the appropriateness of the ICD therapy. Despite this prognosis, current guidelines do not provide a clear stepwise approach to managing these high-risk patients. An ICD shock increases HF event risk and should trigger a thorough evaluation to determine the etiology of the shock and guide subsequent therapeutic interventions. Several combinations of pharmacologic and device-based interventions such as adding amiodarone to baseline beta-blocker therapy, adjusting ICD sensitivity, and employing antitachycardia pacing may reduce future appropriate and inappropriate shocks. Aggressive HF surveillance and management is required after an ICD shock, as the risk of sudden cardiac death is transformed to an increased HF event risk.

Contribution of frequency-augmented inward Ca2+ current to myocardial contractility.

The sarcoplasmic reticular Ca2+ pump (SERCA) is thought to be the primary determinant of heart rate-dependent increases in myocardial contractile [Ca2+]i and force (force-frequency relationship (FFR)), an important mechanism to increase cardiac output. This report demonstrates a rate-dependent role for inward Ca2+ current (ICa) in the human and rat FFR. Human action potential plateau height increased linearly with contractility when heart rate increased in vivo, as measured by monophasic action potential catheter and echocardiography. Rat rate-dependent developed force and cytosolic [Ca2+]i transients were quantified in isolated left ventricular papillary muscles, and ICa and action potential duration in cardiomyocytes. ICa and SERCA measurements better reflected [Ca2+]i and force transients than SERCA activity alone. These data support a direct and (or) indirect contribution to myocardial contractility by ICa at heart rates from approximately 1 to 3-4 Hz (60 to 180-240 bpm) in tandem with SERCA to sustain the typical 'bell shape' of the FFR across species.

Benefit of cardiac resynchronization in elderly patients: results from the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) and Multicenter InSync ICD Randomized Clinical Evaluation (MIRACLE-ICD) trials.

PURPOSE: Heart failure (HF) affects five million patients each year with both prevalence and incidence increasing with age. At least 20% of hospital admissions in patients > age 65 are due to HF. Cardiac resynchronization therapy (CRT) has been shown to improve HF symptoms and decrease mortality. However, little data are available which specifically address the effects of CRT in the elderly (>65). METHODS: We performed an analysis of the NYHA III/IV 839 patients randomized in the MIRACLE (n = 470) and MIRACLE-ICD (n = 369) trials. Both included patients with moderate to severe HF, ejection fraction (EF) or=130 msec. Patients were grouped by age <65, 65-75, and >75 years. For each group, patients with CRT activated (ON) were compared with patients with CRT inactivated (OFF) for end points at 6 months, including New York Heart Association (NYHA) functional class and EF. RESULTS: Of the 839 patients, 368 were <65, 297 were 65-75, and 174 were >75 years old. Compared with controls, patients from all three age groups, whose CRT was activated, had statistically significant improvements in NYHA class (-0.84 for age <65, -0.78 for age 65-75, and -0.78 for age >75). All age groups with CRT ON also had statistically significant improvements in left ventricular EF (5.23%, 2.98%, and 4.03% respectively). There were no between group differences by age in LVEF improvement. CONCLUSIONS: In elderly patients enrolled in the MIRACLE and MIRACLE-ICD trials, CRT resulted in significant improvements in NYHA class and LVEF, regardless of age. These data suggest that the full age range of patients with appropriate indications for implantation can benefit from CRT.

Patient evaluation of ICD recall communication strategies: a vignette study.

INTRODUCTION: Communication about the unprecedented number of implantable cardioverter defibrillator (ICD) recalls has proved challenging. While initial studies have explored the psychological impact of recalls on patients, the optimal way to communicate recalls is not currently known. This study investigated the way communication of a recall can affect patients' responses. METHODS: Sixty-six ICD patients read one of six vignettes that detailed a hypothetical device recall. Vignette variables included the source of recall dissemination (physician vs. media vs. device manufacturer) and the personal relevance (own brand is recalled vs. different brand is recalled). Subsequently, patients rated their agreement to 12 statements concerning their response to the recall on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree). RESULTS: Patients were significantly more confident in the accuracy of recall information from both their physician and their manufacturer compared with the media, F (2, 63) = 36.10, P < 0.01, eta(2)= 0.53. Interestingly, patients were concerned about the recall regardless of whether their brand of ICD was recalled. Survey results indicated that 78.6% of patients reported learning about recalls from the media. In stark contrast, 77.0% of patients asserted preferring to learn about recalls from their physician. CONCLUSIONS: ICD patients report increased confidence in the accuracy of the recall information from physicians and manufacturers compared with the media in reporting recalls. Because it seems that most ICD patients learn about recalls from the media, these results demonstrate a disconnect between the initial source of recall information and the patients' desired sources.

Successful termination of atrial flutter by ibutilide during pregnancy.

Sustained atrial fibrillation and atrial flutter during pregnancy are uncommon arrhythmias that can significantly complicate normal prenatal care. Direct current external cardioversion is the current method of terminating these arrhythmias. In practice, however, this technique is sometimes considered undesirable by both physician and patients due to the need for deep sedation or anesthesia. In the present study, we describe the use of ibutilide to safely terminate symptomatic persistent atrial flutter in a patient during her 24th week of pregnancy.

Rapid achievement of therapeutic anticoagulation positively affects outcome in patients undergoing cardioversion for persistent atrial fibrillation.

BACKGROUND: Current guidelines recommend anticoagulation with warfarin with documentation of an International Normalized Ratio (INR) of 2-3 for 3 weeks prior to cardioversion of persistent atrial fibrillation (AF). Achievement of adequate anticoagulation often takes longer than 3 weeks, increasing the time to cardioversion. HYPOTHESIS: The goal of the study was to quantify the total time elapsed for adequate anticoagulation and to identify differences in time to cardioversion between patients managed by primary care physicians (PCP) compared with those enrolled in a structured anticoagulation clinic (AC). Finally, we assessed the effect on treatment outcome between groups. METHODS: A retrospective chart review identified those patients undergoing elective cardioversion who were started on warfarin at our medical center since 1997. The venue of anticoagulation management, time for adequate maintenance of INR, and total time to cardioversion were recorded. A comparison was made between the two groups to identify the effect on treatment outcome. Multivariate analysis was performed to evaluate any effect comorbidities may have played on maintenance of normal sinus rhythm (NSR) within the treatment groups. RESULTS: Of 83 patients, 48 had warfarin therapy monitored at their PCP and 35 were managed at our AC. Average time to therapeutic INR at AC and PCP was 29.1 +/- 9.3 and 50.7 +/- 6.8 days, respectively (p = 0.026). Average time to cardioversion at AC and PCP was 60.6 +/- 11.2 and 88.7 +/- 18.5 days (p = 0.041). At 12 months post cardioversion, 30 of 83 patients maintained NSR. Nineteen of 35 patients (54.3%) managed at AC maintained NSR compared with 11 of 48 patients (22.9%) managed at PCP (RR 0.61, 95% confidence interval 0.45-0.84) (p = 0.015). CONCLUSION: Therapeutic anticoagulation is more quickly achieved in a specialty anticoagulation clinic than at a PCP and positively affects therapy outcome.

Use of adenosine as a diagnostic tool for dual atrioventricular nodal pathways: response of control patients to incremental doses of adenosine.

BACKGROUND: Adenosine at low doses preferentially blocks fast over slow pathway conduction in patients with dual atrioventricular (AV) nodal physiology and typical AV nodal reentrant tachycardia (AVNRT). During atrial pacing, this effect is manifested as an abrupt increase in the AH interval with low doses of adenosine. This demonstration of dual AV nodal physiology may be useful as a diagnostic tool during electrophysiologic studies in patients with supraventricular tachycardia who are not easily inducible, as clear demonstration of dual AV nodal pathways may indicate that AVNRT is a likely diagnosis and that further attempts at arrhythmia induction should be tailored in that direction. However, to be a useful test, adenosine should not cause an abrupt increase in AH interval in patients without dual AV nodal physiology. HYPOTHESIS: This study was designed to investigate the prevalence of dual AV nodal pathways with administration of adenosine in patients with no history suggestive of AVNRT. METHODS: Thirty-seven patients who had no prior history of AVNRT and were undergoing electrophysiologic study for standard indications were enrolled. Baseline Wenckebach cycle length (WCL) and AV nodal effective refractory periods were measured at atrial pacing cycle lengths of 400 and 600 ms. The atrium was then paced at WCL + 50 ms, and WCL + 100 ms, while incrementally larger doses of intravenous adenosine were administered until AV nodal block occurred. RESULTS: The mean (+/- standard deviation) doses of adenosine required to cause AV nodal block while pacing at WCL + 50 ms and WCL + 100 ms were 7.1 +/- 3.9 and 7.4 +/- 4.5 mg, respectively. In 1 of 37 patients (2.7%, 95% confidence interval 0-8%), an abrupt prolongation of the AH interval was seen with the administration of adenosine during atrial pacing as well as during the atrial refractory period determination. In all other patients, no dual AV nodal physiology was demonstrated during the refractory period determination, and there were only gradual changes in the AH interval with atrial pacing during administration of adenosine. CONCLUSION: Among patients with no history suggestive of AV nodal reentrant tachycardia, only 2.7% have clinically silent dual AV nodal pathways using this method. Incremental adenosine infusion during electrophysiologic study can be used as a highly specific diagnostic tool for patients with dual AV nodal pathways.