The impact of chronic Trimethylamine N-oxide administration on liver oxidative stress, inflammation, and fibrosis.

TMAO, a gut microbiota derived byproduct, has been associated with various cardiometabolic diseases by promoting oxidative stress and inflammation. The liver is the main organ for TMAO production and chronic exposure to high doses of TMAO could alter its function. In this study, we evaluated the effect of chronic exposure of high TMAO doses on liver oxidative stress, inflammation, and fibrosis. TMAO was administered daily via gastric gavage to laboratory rats for 3 months. Blood was drawn for the quantification of TMAO, and liver tissues were harvested for the assessment of oxidative stress (MDA, GSH, GSSG, GPx, CAT, and 8-oxo-dG) and inflammation by quantification of IL-1α, TNF-α, IL-10, TGF-ß, NOS and COX-2 expression. The evaluation of fibrosis was made by Western blot analysis of α-SMA and Collagen-3 protein expression. Histological investigation and immunohistochemical staining of iNOS were performed in order to assess the liver damage. After 3 months of TMAO exposure, TMAO serum levels enhanced in parallel with increases in MDA and GSSG levels in liver tissue and lower values of GSH and GSH/GSSG ratio as well as a decrease in GPx and CAT activities. Inflammation was also highlighted, with enhanced iNOS, COX-2, and IL-10 expression, without structural changes and without induction of liver fibrosis.

Acute mitral isthmus block during catheter ablation with vein of Marshall ethanol infusion: Angiographic considerations.

BACKGROUND: Achieving bidirectional mitral isthmus block is still challenging. Conventional ablation methods involve radiofrequency applications on the endocardial aspect of the lateral mitral isthmus, and often epicardial applications inside the coronary sinus. AIM: To evaluate the impact of the systematic use of ethanol infusion in the vein of Marshall on the achievement of acute mitral isthmus block of additional epicardial component lesion. METHODS: We evaluated patients referred to two centres for long-standing persistent atrial fibrillation ablation or recurrent peri-mitral flutter. All patients had pulmonary vein isolation and mitral isthmus line using ethanol infusion in the vein of Marshall for the first procedure and additional radiofrequency ablation lesion if necessary. For redo procedures, additional ablations (atrial lines and complex fractionated atrial electrogram ablations, if needed) were also performed. RESULTS: We included 149 patients, and ethanol infusion in the vein of Marshall was not performed in 27 patients (18%). Among 122 patients, 115 had long-standing persistent atrial fibrillation (94.2%) and seven had peri-mitral flutter (5.8%). The mean duration of continuous atrial fibrillation was 53 months before ablation. Acute bidirectional mitral isthmus block was obtained in 115 (94.2%) of the 122 patients who received ethanol infusion in the vein of Marshall (77% when considering the total population). The mean radiofrequency delivery time to obtain mitral isthmus block was 2.6minutes for the endocardial mitral isthmus radiofrequency ablation and 2.6minutes for the epicardial mitral isthmus radiofrequency ablation. Failure to obtain mitral isthmus block was associated with increased mitral isthmus length and left atrial dilation. No major complications related to ethanol infusion in the vein of Marshall were observed. CONCLUSION: Ethanol infusion in the vein of Marshall, when feasible (82%), was a safe approach to obtaining a high success rate (94%) of acute bidirectional endocardial and epicardial mitral isthmus block.

Galectin-3, Inflammation, and the Risk of Atrial High-Rate Episodes in Patients with Dual Chamber Pacemakers.

Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias that are exclusively detected by cardiac implantable electronic devices (CIEDs) with an atrial lead. The objective of this study was to investigate the incidence and predictive factors for AHREs, and to evaluate the ability of inflammation biomarkers to predict the occurrence of AHREs. 102 patients undergoing CIED procedure who received a dual chamber pacemaker were included. CIED interrogation was performed 1 year after the implantation procedure. Patients were divided into groups according to the occurrence of AHREs, which was the primary endpoint of the study. The mean age of the patients was of 73 ± 8.6 years and 48% were male. The incidence of AHREs was 67% at 1 year follow-up. Patients with AHREs were older, had higher left atrial indexed volume (LAVi), higher baseline galectin-3 levels (1007.5 ± 447.3 vs. 790 ± 411.7 pg/mL) and received betablockers more often, along with amiodarone and anticoagulants. Interestingly, the CHADSVASC score did not differ significantly between the two groups. A cut-off value of galectin > 990 pg/mL predicted AHREs with moderate accuracy (AUC of 0.63, 95% CI 0.52 to 0.73, p = 0.04), and this association was confirmed in the univariate regression analysis (OR 1.0012, 95% CI 1.0001 to 1.0023, p = 0.0328). However, based on the multivariate regression analysis, galectin lost its prognostic significance under the effect of LAVi, which remained the only independent predictor of AHREs (OR 1.0883, 95% CI 1.0351 to 1.1441, p = 0.0009). AHREs are common in CIEDs patients. Galectin-3 may bring additional data in the prediction of AHREs.

The Acute Effect of Trimethylamine-N-Oxide on Vascular Function, Oxidative Stress, and Inflammation in Rat Aortic Rings.

A growing body of evidence suggests that the gut microbiota affects the cardiovascular system directly and indirectly via biologically active molecules. TMAO, a key metabolite produced by gut bacteria is implicated in atherosclerosis and chronic endothelial dysfunction, but with an unclear effect on vascular tone, oxidative stress, and inflammation. Our study aimed to evaluate the acute effects of TMAO on vascular contractility in relation with oxidative stress markers and inflammation. Aortic rings were harvested from laboratory rats and placed in a tissue bath system containing TMAO in concentrations of 300, 100, 10 µM, and control. Vascular tone under the influence of vasoconstrictor phenylephrine and non-endothelial-dependent vasodilator sodium nitroprusside was assessed using force transducers connected to a computer-based acquisition system. Oxidative stress and inflammation were quantified by vascular assessment of the activity of NF-κB, NRF2, SOD1, and iNOS by western-blotting and MDA by spectrofluorimetry. After the incubation of the aortic rings in TMAO solutions for 1 h, there was no difference in vasoconstrictor and non-endothelial vasodilator response between the studied doses. TMAO acutely induced oxidative stress and inflammation, significantly increasing levels of MDA and the expression of NF-κB, NRF2, SOD1, and iNOS, mostly in a dose-dependent manner. Our study showed the lack of a short-term effect of studied TMAO doses on vascular contractility, but demonstrated an acute prooxidative effect and activation of major inflammatory pathways, which can partially explain the detrimental effects of TMAO in cardiovascular disease.

Predictors for the Development of Major Adverse Limb Events after Percutaneous Revascularization-Gender-Related Characteristics.

Background and Objectives: Revascularization has been proven to be superior to medication for symptom improvement in patients with peripheral arterial disease (PAD). There are well known gender differences in therapeutic strategies for PAD. The influence of gender on post-angioplasty prognosis is not fully understood though. The present study aims to identify potential peculiarities between men and women undergoing peripheral angioplasty, as well as factors responsible for those differences. Material and methods: 104 consecutive subjects (50 women and 54 men) who underwent percutaneous angioplasty (PTA) between January and October 2019 for symptomatic PAD were included. Demographics, PAD history, cardiovascular risk factors, comorbidities, the associated coronary or cerebrovascular diseases, biological parameters, drug-treatment and PTA type and technique were taken into account. The follow-up period was 2 years, during which major adverse limb events (MALE) were documented. Results: The mean age was 67 ± 10 years. Women were 4 years older than the men (69 ± 10 years vs. 65 ± 9.2 years-p = 0.04). Smoking was more prevalent in men (p = 0.0004), while other cardiovascular risk factors did not differ significantly. The mean follow-up of the two groups was 21 ± 2.4 months. Women had infra-inguinal involvement more frequently (78%), while men exhibited mixed disease, with supra + infra-inguinal (37%) or solely supra-inguinal (20.3%) involvement (p = 0.0012). Rates of MALE were similar in the two groups (p = 0.914). Gender did not influence the incidence of PAD-related adverse events. The only parameter that proved to have a significant influence on the occurrence of MALE was the ankle-brachial index (ABI). A value below 0.5 was found to be an independent predictor for MALE (p = 0.001). Conclusions: There was no significant difference in the incidence rates of MALE between the two genders over a 2-year follow-up period post-PTA. Regardless of sex, an ankle-brachial index value below 0.5 was the sole independent predictor for limb-related adverse events.

Body size influences heart rate in children aged 6 to 18 years old.

Previous research established age-related normal limits for children's heart rates (HRs). However, children of the same age can have significantly different HRs, depending on whether they are overweight or underweight, tall or short. Studies on children HR have failed to find a clear correlation between HR and body size. The goal of our study was to create Z scores for HR based on weight (W), height (H), body mass index (BMI), and body surface area (BSA) and compare them to normal age-related HR limits. Electrocardiograms were recorded from a total of 22,460 healthy children ranging in age from 6 to 18 years old using BTL machines. A comparison was made between different age groups, in function of W, H, BMI, and BSA, based on the HR that was automatically detected by using the digitally stored electrocardiogram. Z scores were computed for each of the categories that were mentioned. Incremental Z score values between -2.5 and 2.5 were calculated to establish upper and lower limits of HR. The BSA's estimation of HR is the most accurate of the available methods and can be utilized with accuracy in clinical practice. Z scores for HR in children differ in function of the age, W, H, BMI and BSA. The best estimation is based on BSA. The novelty of our study is that we developed Z scores for HR in relation to body size, age and sex, producing a standardized, consistent, and reproducible result without requiring practitioners to learn and remember cutoff values for a wide range of variables across age groups and sexes. Z scores minimize observer and institutional bias, hence generating uniform and reproducible standards.

Low Atrial Rhythm in a Large Cohort of Children from Transylvania, Romania.

Low atrial rhythm (LAR) is an ectopic rhythm originating in the lower part of the right or left atrium. Prior observational studies attempted to quantify the prevalence of low atrial rhythm in the pediatric population, but the observed prevalence was highly variable with relatively small sample sizes. We aimed to characterize low atrial rhythm and determine its prevalence in a large population of 24,316 asymptomatic children from northwestern Transylvania. We found a prevalence of 0.6% (145 children) for low atrial rhythm. Children with LAR had a significantly lower heart rate (mean 78.6 ± 8.3 bpm), than the control sinus rhythm group (85.02 ± 4.5 bpm). Furthermore, a shorter PR interval was seen in children with LAR (132.7 ± 12.7 ms) than in the children from the control group (141.7 ± 5.4; p = 0.0001).There was no significant association between gender and the presence of left LAR (LLAR) or right LAR (RLAR) (p = 0.5876). The heart rate of children with LLAR was significantly higher (81.7 ± 11.6 bpm) than that of the children with LRAR (77.6 ± 11.1 bpm) (p = 0.037). Pediatric cardiologists should recognize low atrial rhythm and be aware that asymptomatic, healthy children can exhibit this pattern, which does not require therapeutic intervention.

Particularities of Catheter Ablation in Women with Atrial Fibrillation and Associated Ischemic Heart Disease.

BACKGROUND: Atrial fibrillation is more common in men, but in the presence of ischemic heart disease, this arrhythmia is more frequent in women. However, like in coronary heart disease, women with atrial fibrillation are suboptimally treated. METHODS: To identify particularities of ablation, in women with atrial fibrillation and ischemic heart disease. RESULTS: 29 women and 26 men, with documented ischemic heart disease and atrial fibrillation, who underwent catheter ablation, were admitted in the study. No significant differences were registered regarding the heart rate control treatment. Electrical cardioversion was significantly higher in men, while pharmacological cardioversion was predominantly recommended in women. The ablation was performed later in women, after 2.55 ± 1.84 years versus 1.80 ± 1.05 in men (p = 0.05). The time elapsed until the ablation was performed was statistically correlated with atypical symptomatology and with the number of antiarrhythmics used prior to the ablation. There were no significant differences for the relapse of atrial fibrillation at 3 months. Quality of life at 3 months after ablation was increased in both groups. CONCLUSION: Catheter ablation is performed much later in women, and the causes responsible for this delay would be more atypical symptoms and a greater number of antiarrhythmics tried before the ablation.

Anatomical-MRI Correlations in Adults and Children with Hypertrophic Cardiomyopathy.

Hypertrophic Cardiomyopathy (HCM) is the most frequent hereditary cardiovascular disease and the leading cause of sudden cardiac death in young individuals. Advancements in CMR imaging have allowed for earlier identification and more accurate prognosis of HCM. Interventions aimed at slowing or stopping the disease's natural course may be developed in the future. CMR has been validated as a technique with high sensitivity and specificity, very few contraindications, a low risk of side effects, and is overall a good tool to be employed in the management of HCM patients. The goal of this review is to evaluate the magnetic resonance features of HCM, starting with distinct phenotypic variants of the disease and progressing to differential diagnoses of athlete's heart, hypertension, and infiltrative cardiomyopathies. HCM in children has its own section in this review, with possible risk factors that are distinct from those in adults; delayed enhancement in children may play a role in risk stratification in HCM. Finally, a number of teaching points for general cardiologists who recommend CMR for patients with HCM will be presented.

Formula to estimate left atrial volume using antero-posterior diameter in patients with catheter ablation of atrial fibrillation.

ABSTRACT: In patients undergoing atrial fibrillation (AF) ablation, an enlarged left atrium (LA) is a predictor of procedural failure as well as AF recurrence on long term. The most used method to assess LA size is echocardiography-measured diameter, but the most accurate remains computed tomography (CT).The aim of our study was to determine whether there is an association between left atrial diameters measured in echocardiography and the left atrial volume determined by CT in patients who underwent AF ablation.The study included 93 patients, of whom 60 (64.5%) were men and 64 (68.8%) had paroxysmal AF, who underwent AF catheter ablation between January 2018 and June 2019. Left atrial diameters in echocardiography were measured from the long axis parasternal view and the LA volume in CT was measured on reconstructed three-dimensional images.The LA in echocardiography had an antero-posterior (AP) diameter of 45.0 ±â€Š6 mm (median 45; Inter Quartile Range [IQR] 41-49, range 25-73 mm), longitudinal diameter of 67.5 ±â€Š9.4 (median 66; IQR 56-88, range 52-100 mm), and transversal diameter of 42 ±â€Š8.9 mm (IQR 30-59, range 23-64.5 mm). The volume in CT was 123 ±â€Š29.4 mL (median 118; IQR 103-160; range 86-194 mL). We found a significant correlation (r = 0.702; P < .05) between the AP diameter and the LA volume. The formula according to which the AP diameter of the LA can predict the volume was: LA volume = AP diam3 + 45 mL.There is a clear association between the left atrial AP diameter measured on echocardiography and the volume measured on CT. The AP diameter might be sufficient to determine the increase in the volume of the atrium and predict cardiovascular outcomes.

Pheno4D: A spatio-temporal dataset of maize and tomato plant point clouds for phenotyping and advanced plant analysis.

Understanding the growth and development of individual plants is of central importance in modern agriculture, crop breeding, and crop science. To this end, using 3D data for plant analysis has gained attention over the last years. High-resolution point clouds offer the potential to derive a variety of plant traits, such as plant height, biomass, as well as the number and size of relevant plant organs. Periodically scanning the plants even allows for performing spatio-temporal growth analysis. However, highly accurate 3D point clouds from plants recorded at different growth stages are rare, and acquiring this kind of data is costly. Besides, advanced plant analysis methods from machine learning require annotated training data and thus generate intense manual labor before being able to perform an analysis. To address these issues, we present with this dataset paper a multi-temporal dataset featuring high-resolution registered point clouds of maize and tomato plants, which we manually labeled for computer vision tasks, such as for instance segmentation and 3D reconstruction, providing approximately 260 million labeled 3D points. To highlight the usability of the data and to provide baselines for other researchers, we show a variety of applications ranging from point cloud segmentation to non-rigid registration and surface reconstruction. We believe that our dataset will help to develop new algorithms to advance the research for plant phenotyping, 3D reconstruction, non-rigid registration, and deep learning on raw point clouds. The dataset is freely accessible at https://www.ipb.uni-bonn.de/data/pheno4d/.

Validation of Normal P-Wave Parameters in a Large Unselected Pediatric Population of North-Western Romania: Results of the CARDIOPED Project.

AIMS: Reference values of the P-wave on 12 lead electrocardiograms are lacking for children and adolescents in Eastern Europe. Hence, the present study is aimed at determining the standard values of the P-wave in children and adolescents based on ECG data from the CARDIOPED project, a large-scale general population of children who participated in a screening program in Transylvania, Romania. METHODS AND RESULTS: A total of 22,411 ECGs of participants aged 6 to 18 years old from a school-based ECG screening were obtained between February 2015 and December 2015 in Transylvania, Romania. Three pediatric cardiologists manually reviewed each ECG. P-wave duration, voltage, axis, and correlation with gender and age were analyzed. The mean P-wave duration was 88 ± 10.7 ms, with a maximum duration of 128 ms. P-wave showed a positive correlation with age but did not differ between sexes. There was a positive correlation between the P-wave duration and the heart rate, but not with the body max index. The mean P-wave axis was 40.4 ± 31.1, and the mean P-wave amplitude was 0.12 ± 0.03 mV. CONCLUSION: In this study on many pediatric subjects, we have provided normal limits for the P-wave in Romanian children aged 6-18 years. Our findings are useful for creating interpretation guidelines for pediatric ECG.

Atrial high-rate episodes: a comprehensive review.

Cardiac electronic implantable devices (CIEDs) have the ability to monitor, store and interpret complex arrhythmias, which has generated a new arrhythmic entity: atrial high-rate episodes (AHRE). AHRE are atrial tachyarrhythmias, detected only by CIEDs. They are widely considered a precursor to atrial fibrillation (AF) but can also be represented by other kinds of supraventricular arrhythmias such as atrial flutter or atrial tachycardia. CIED-detected AHRE are associated with an increased risk of stroke, but the risk is significantly lower than the stroke risk of clinical AF. Moreover, there seems to be no temporal correlation between AHRE and thromboembolic events. Because of the current gaps in evidence, the appropriate management of this arrythmia can be challenging. In this review we take into account the epidemiology behind AHRE, predictive factors, clinical impact and management of this arrhythmia.

Global work index by non-invasive pressure-strain loops: a novel parameter to assess left ventricular performance in the early stages of heart failure with preserved or mid-range ejection fraction after acute myocardial infarction.

AIM: To determine the relationship between myocardial work (MW) indices derived from non-invasive pressure-strain loops (PSL) and established parameters of left ventricular (LV) performance in patients with acute myocardial infarction (AMI) and heart failure (HF) with preserved or mid-range ejection fraction (HFpEF/HFmrEF). MATERIAL AND METHODS: Speckle-tracking echocardiography (STE) was used to determine MW indices and global longitudinal strain (GLS) in the first 24-48 hours after admission in patients with AMI, HF symptoms, NT-proBNP >300 pg/mL and left ventricular ejection fraction (LVEF) >40%. MW was calculated by using PSL, which combine strain and non-invasive blood pressure measurement. Global MW index (GWI) was defined as the work inside the area of the PSL. RESULTS: Forty-nine patients (mean age 68±13 years) fulfilled the inclusion criteria. Both GWI (1057±338 mmHg%) and GLS (-10.4±3.3%) were reduced in the majority of the patients. However, a proportion of patients with abnormal GLS showed normal GWI. There was a strong inverse relationship between GWI and GLS (r=-0.81). GWI demonstrated a strong relationship with LVEF (r=0.69) and a moderate correlation to NT-proBNP (n=-0.29). NT-proBNP showed a tendency to higher values in patients with more reduced GWI (820 [590-2550] vs 707 [460-1335], p=0.17). Out of the diastolic dysfunction parameters, GWI showed moderate correlations to LA volume index (r-0.29), E/A (r=-0.23) and E/e' (r=-0.39), which were also significantly more impaired in patients with more reduced GWI. CONCLUSION: Non-invasive PSL might bring further information to LVEF and GLS in patients AMI at the early stages of HFpEF/HFmrEF, since LV performance depends on both contractile properties and variations in load in the ischemic segments.

Catheter ablation of a latent accessory pathway under continuous infusion of adenosine: A case report.

RATIONALE: In absence of conduction over the accessory pathway (AP) during the electrophysiological study, mapping and ablation is impossible. Various techniques can be used to activate absent conduction. In this presentation we describe the first case of latent AP ablation performed under continuous infusion of adenosine. PATIENT CONCERNS: A 65-year-old man, presented to emergency department with atrial fibrillation and antegrade conduction through a left lateral AP. He had palpitations and lightheadedness that occurred every 2 to 3 weeks. DIAGNOSIS: The electrophysiological study confirmed a latent left-side AP. INTERVENTIONS: Catheter ablation could not be performed because of absent conduction through AP. Therefore, a continuous infusion of adenosine was used to activate AP. Ablation was performed at the left lateral mitral ring. OUTCOMES: After catheter ablation and a new adenosine bolus there was no conduction through AP. LESSONS: In case of a latent AP when ablation is difficult to perform because of absent conduction at the time of electrophysiological study, adenosine can be used in doses of 1.5 mg/kg over 5 minutes continuous infusion.

Transesophageal and intracardiac ultrasound in arrhythmogenic right ventricular dysplasia/cardiomyopathy: Two case reports.

RATIONALE: Two-dimensional echocardiography (2D echo) is a major tool for the diagnosis of Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). However 2D echo can skip regional localized anomalies of the right ventricular wall. We aimed to determine whether transesophageal and intracardiac ultrasound can provide additional information, on the right ventricular abnormalities compared to 2D echo. PATIENT CONCERNS: Case 1 is a 30-year-old patient that presented in the Emergency Department with multiple episodes of fast monomorphic ventricular tachycardia (VT) manifested by palpitations and diziness. Case 2 is a 65-year-old patient that also presented with episodes of ventircular tachycardia associated with low blood pressure. DIAGNOSIS: Both patients had a clear diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy confirmed by cardiac magnetic resonance imaging. INTERVENTION: In both patients transesophageal and intracardiac ultrasound was performed, which brought more information on the diagnosis of ARVD/C compared to transthoracic echocardiograpy. OUTCOMES: The first patient was implanted with an internal cardiac defibrillator and treated with Sotalol for VT recurrences. He presented episodes of VT during follow-up, treated with antitachycardia pacing. The second patient was implanted with an internal cardiac defibrillator and treated with Sotalol without any VT recurrence at 18 month-follow-up. LESSONS: Transesophageal echocardiography and intracardiac echocardiography can provide additional information on small, focal structural abnormalities in patients with ARVD/C: bulges, saculations, aneurysms with or without associated thrombus, partial or complete loss of trabeculations and hypertrophy of the moderator band. These changes are particularly important in cases with "concealed" form of the disease in which no morphological abnormalities are evident in transthoracic echocardiograpy.

What is the optimal duration of the TILT after administration of 0.4 mg nitroglycerin spray?

Performing a head-up tilt test can be of great value for the diagnosis of vasovagal syncope. The European Society of Cardiology recommends a drug challenge phase duration of 15 to 20 minutes, with either Isoprenaline or Nitroglycerin administration.We sought to investigate the outcome of a ten-minute active phase with Nitroglycerin in patients suspected of vasovagal syncope and determine the percentage of loss in the positivity rate, using this short duration approach.We consecutively enrolled patients presenting with syncope undergoing the head-up tilt test (HUTT), with a clinical suspicion of vasovagal syncope between the years 2009 to 2019. The HUTT consisted of 2 successive phases: passive and active. During the passive phase, the patients were tilted at 70° for 20 minutes. If negative, the test was continued after administration of 0.4 mg sublingual Nitroglycerin. Applying the (VASIS) Vasovagal Syncope International Study classification of the vasovagal syncope international study and comparing for age and gender, positive responses were categorized into 3 types.A number of 306 patients (age = 43.5 +/-20.3; male = 140 [45.7%]) with suspected vasovagal syncope, undergoing HUTT, were enrolled in the years of 2009 to 2019. Of those, 245 (80.2%) presented a positive test, with 200 patients (82.0%) during the being positive during the active phase of the test. The results were as follows: 116 subjects (47.2%) presented with a mixed response (VASIS I), 52 (21.3%) showed a cardio inhibitory response (VASIS II), and 77 (31.5%) displayed a vasodepressor response (VASIS III). We found no relationship between the type of syncope with neither gender, nor age of the patient. Three minutes represented the median time to positivity, after Nitroglycerine administration. The time distribution showed a peak incidence appearing between minutes 3 and 5, ranging from 1 to 20 minutes. Only 3 patients tested positive after minute 10.Shortening the active phase to 10 minutes would result in a positivity rate loss of 1.5%.

Intracardiac echocardiography for transseptal puncture. A guide for cardiac electrophysiologists.

The key to a successful catheterization of the left heart chambers is the safe transseptal puncture. Intracardiac echocardiography (ICE) is an attractive tool used in cardiac catheterization and electrophysiology labs to provide detailed images thatcan facilitate transseptal puncture. ICE permits a direct visualization of the endocardium and precisely locates the needle and the sheath against the interatrial septum. Two different ICE catheters are available: a phased array and a mechanical transducer, both being currently used in clinical practice. This paper describes the technique used for guiding transseptal puncture with ICE. Due to its advantages, ICE has currently become an important tool used to maximize the safety of the transseptal puncture and increase efficacy of interventional cardiology procedures.

Catheter ablation of a right posterior accessory pathway in a patient with left ventricular noncompaction: A case report.

RTIONALE: Left ventricular noncompaction (LVNC) is a genetic cardiomyopathy characterized by the presence of a thin compacted layer of myocardium and a spongy subendocardial layer with trabeculations and recesses. LVNC associated Wolf-Parkinson-White syndrome is very rare. PATIENT CONCERNS: A 32-year-old male presented with short episodes of palpitations and a syncope 6 months before his hospitalization. DIAGNOSIS: His ECG revealed the presence of a right posterior accessory pathway. Echocardiography identified trabeculations of the septal, apical, and lateral wall of the left ventricle, consistent with left ventricular noncompaction. Cardiac MRI confirmed the diagnosis, as the ratio between the noncompacted and compacted myocardial layer was 2.3. INTERVENTIONS: The electrophysiological study revealed a malignant right posterior accessory pathway. Catheter ablation was successfully performed at the level of posterior tricuspid annulus. Programmed ventricular stimulation could not induce any arrhythmia at the end of the procedure. OUTCOMES: During 15 months of follow-up, the patient presented no more episodes of palpitations or syncope. LESSONS: Left ventricular noncompaction with right accessory pathway is a rare association with genetic basis and gives a higher risk of sudden cardiac death. Catheter ablation of the accessory pathway is a valuable way of treatment in this category of patients, lowering the risk of sudden cardiac death.

Recommendations for the use of electrophysiological study: Update 2018.

The field of cardiac electrophysiology has greatly developed during the past decades. Consequently, the use of electrophysiological studies (EPSs) in clinical practice has also significantly augmented, with a progressively increasing number of certified electrophysiology centers and specialists. Since Zipes et al published the Guidelines for Clinical Intracardiac Electrophysiology and Catheter Ablation Procedures in 1995, no official document summarizing current EPS indications has been published. The current paper focuses on summarizing all relevant data of the role of EPS in patients with different types of cardiac pathologies and provides up-to-date recommendations on this topic. For this purpose, the PubMed database was screened for relevant articles in English up to December 2018 and ESC and ACC/AHA Clinical Practice Guidelines, and EHRA/HRS/APHRS position statements related to the current topic were analyzed. Current recommendations for the use of EPS in clinical practice are discussed and presented in 17 distinct cardiac pathologies. A short rationale, evidence, and indications are provided for each cardiac disease/group of diseases. In conclusion, because of its capability to establish a diagnosis in patients with a variety of cardiac pathologies, the EPS remains a useful tool in the evaluation of patients with cardiac arrhythmias and conduction disorders and is capable of establishing indications for cardiac device implantation and guide catheter ablation procedures.