Applying systems thinking to unravel the mechanisms underlying orthostatic hypotension related fall risk.

Orthostatic hypotension (OH) is an established and common cardiovascular risk factor for falls. An in-depth understanding of the various interacting pathophysiological pathways contributing to OH-related falls is essential to guide improvements in diagnostic and treatment opportunities. We applied systems thinking to multidisciplinary map out causal mechanisms and risk factors. For this, we used group model building (GMB) to develop a causal loop diagram (CLD). The GMB was based on the input of experts from multiple domains related to OH and falls and all proposed mechanisms were supported by scientific literature. Our CLD is a conceptual representation of factors involved in OH-related falls, and their interrelatedness. Network analysis and feedback loops were applied to analyze and interpret the CLD, and quantitatively summarize the function and relative importance of the variables. Our CLD contains 50 variables distributed over three intrinsic domains (cerebral, cardiovascular, and musculoskeletal), and an extrinsic domain (e.g., medications). Between the variables, 181 connections and 65 feedback loops were identified. Decreased cerebral blood flow, low blood pressure, impaired baroreflex activity, and physical inactivity were identified as key factors involved in OH-related falls, based on their high centralities. Our CLD reflects the multifactorial pathophysiology of OH-related falls. It enables us to identify key elements, suggesting their potential for new diagnostic and treatment approaches in fall prevention. The interactive online CLD renders it suitable for both research and educational purposes and this CLD is the first step in the development of a computational model for simulating the effects of risk factors on falls.

The Coax Dipole: A fully flexible coaxial cable dipole antenna with flattened current distribution for body imaging at 7 Tesla.

PURPOSE: The coax dipole antenna, a flexible antenna for body imaging at 7T is presented. Similar to the high impedance coil, this coaxial cable antenna is fed on the central conductor and through gaps in the shield, the current passes to the outside of the antenna to generate B1 field. This could achieve more favorable current distributions and better adaptation to the body curvature. METHODS: Finite difference time domain (FDTD) simulations are performed to optimize the positions of the gaps in the shield for a flat current profile. Lumped inductors are added to each end to reduce losses. The performance of a single antenna is compared to a fractionated dipole using B1 maps and MR thermometry. Finally, an array of eight coax dipoles is evaluated in simulations and used for in-vivo scanning. RESULTS: An optimal configuration is found with gaps located at 10 cm from the center and inductor values of 28 nH. In comparison to the fractionated dipole antenna, in single antenna phantom measurements the coax dipole achieves similar B1 amplitude with 18% lower peak temperature. In simulations, the eight-channel array of coax dipoles improved B1 homogeneity by 18%, along with small improvements in transmit efficiency and specific absorption rate (SAR). MRI measurements on three volunteers show more consistent performance for the coax dipoles. CONCLUSION: The coax dipole is a novel antenna design with a flattened current distribution resulting in beneficial properties. Also, the flexible design of the coax dipoles allows better adaptation to the body curvature and can potentially be used for a wide range of imaging targets.

A plug-and-play, lightweight, single-axis gradient insert design for increasing spatiotemporal resolution in echo planar imaging-based brain imaging.

The goal of this study was to introduce and evaluate the performance of a lightweight, high-performance, single-axis (z-axis) gradient insert design primarily intended for high-resolution functional magnetic resonance imaging, and aimed at providing both ease of use and a boost in spatiotemporal resolution. The optimal winding positions of the coil were obtained using a genetic algorithm with a cost function that balanced gradient performance (minimum 0.30 mT/m/A) and field linearity (≥16 cm linear region). These parameters were verified using field distribution measurements by B0 -mapping. The correction of geometrical distortions was performed using theoretical field distribution of the coil. Simulations and measurements were performed to investigate the echo planar imaging echo-spacing reduction due to the improved gradient performance. The resulting coil featured a 16-cm linear region, a weight of 45 kg, an installation time of 15 min, and a maximum gradient strength and slew rate of 200 mT/m and 1300 T/m/s, respectively, when paired with a commercially available gradient amplifier (940 V/630 A). The field distribution measurements matched the theoretically expected field. By utilizing the theoretical field distribution, geometrical distortions were corrected to within 6% of the whole-body gradient reference image in the target region. Compared with a whole-body gradient set, a maximum reduction in echo-spacing of a factor of 2.3 was found, translating to a 344 µs echo-spacing, for a field of view of 192 mm, a receiver bandwidth of 920 kHz and a gradient amplitude of 112 mT/m. We present a lightweight, single-axis gradient insert design that can provide high gradient performance and an increase in spatiotemporal resolution with correctable geometrical distortions while also offering a short installation time of less than 15 min and minimal system modifications.

Nationwide Longitudinal Follow-Up of Riata Leads Under Advisory at 3 Annual Screenings: Report From the Netherlands Heart Rhythm Association Device Advisory Committee.

OBJECTIVES: This study sought to determine prospectively the rate of conductor externalization (CE), and whether this was associated with electrical failure. BACKGROUND: The Riata family of defibrillator leads was placed under U.S. Food and Drug Administration advisory as of November 28, 2011 because of high rates of CE. METHODS: A nationwide cohort established in 2012 of 1,029 patients with recalled Riata leads with 147 CE were followed until death, lead discontinuation, or 3 annual screenings with fluoroscopy and device interrogation. RESULTS: Follow-up of 882 patients with normal baseline fluoroscopy revealed incident overt CE in 95 leads (11%) after median risk time of 2.9 years, yielding an incidence rate of 4.9 (95% confidence interval [CI]: 3.9 to 5.9) per 100 patient-years. The incidence rate was significantly higher in 8-F Riata leads than in 7-F Riata ST leads (7.0 vs. 3.2 per 100 patient-years; p < 0.001). Electrical follow-up demonstrated electrical abnormality in 77 leads, resulting in an incidence rate of 4.0 (95% CI: 3.2 to 5.0) per 100 patient-years. The incidence rate of electrical abnormalities was not different between leads without CE and those with CE (3.9 vs. 5.2 per 100 patient-years; p = 0.39). CONCLUSIONS: The development of CE is progressive in nature with an incidence rate of new CE of 4.9 per 100 patient-years, with a higher rate for 8-F Riata leads than for 7-F Riata ST leads. Despite the high rate of structural failure, no association between development of CE and electrical failure was observed.

Prediction of Acute Response to Cardiac Resynchronization Therapy by Means of the Misbalance in Regional Left Ventricular Myocardial Work.

BACKGROUND: Patients with left ventricular (LV) dyssynchrony have a marked misbalance in LV myocardial work distribution, with wasted work in the septum and increased work in the lateral wall. We hypothesized that a low septum-to-lateral wall (SL) myocardial work ratio at baseline predicts acute LV pump function improvement during cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Twenty patients (age 65 ± 10 y, 15 men) underwent cardiac magnetic resonance (CMR) tagging for regional LV circumferential strain assessment and invasive pressure-volume loop assessment at baseline and during biventricular pacing. Segmental work at baseline was calculated from regional strain rate and LV pressure. Subsequently, the SL work ratio was calculated and related to acute pump function (stroke work [SW]) improvement during CRT. During biventricular pacing, SW increased by 33% (P <.001). SL work ratio at baseline was found to be significantly related to SW improvement by means of CRT (R = -0.54; P = .015). Moreover, it proved to be the only marker that was significantly related to acute response to CRT, whereas QRS duration and other measures of dyssynchrony or dyscoordination were not. CONCLUSIONS: The contribution of the septum to LV work varies widely in CRT candidates with left bundle branch block. The lower the septal contribution to myocardial work at baseline, the higher the acute pump function improvement that can be achieved during CRT.

Bifocal left ventricular stimulation or the optimal left ventricular stimulation site in cardiac resynchronization therapy: a pressure-volume loop study.

AIMS: Several implantation strategies have been proposed to improve response to cardiac resynchronization therapy (CRT), including bifocal left ventricular (LV) stimulation and optimal single-LV lead placement. This study aimed to compare these two strategies during invasive pressure-volume (PV) loop measurements. METHODS AND RESULTS: Thirty-three patients eligible for CRT were included [21 (64%) men, 20 (61%) ischaemic aetiology, QRS 155 ± 23 ms], and underwent cardiac magnetic resonance (CMR) imaging and invasive PV loop measurements. Left ventricular pump function was characterized by stroke work (SW) and dP/dtmax (5.1 ± 3.4 L mmHg and 856 ± 190 mmHg/s, respectively). Haemodynamic response was assessed during stimulation at single-LV sites and during bifocal LV [anterolateral and posterolateral (PL)] stimulation. Response during bifocal LV stimulation was not significantly higher compared with standard PL pacing (SW; ß = 9.4 ± 5.4, P = 0.080; dP/dtmax, ß = 0.2 ± 1.9, P = 0.922). However, mean pump function improvement was significantly higher during stimulation at the optimal LV site compared with bifocal LV stimulation (SW; ß = 12.7 ± 5.1, P = 0.012; dP/dtmax, ß = 3.3 ± 1.2, P = 0.020). Myocardial tissue properties were assessed by CMR tissue tagging. Mechanical activation at the optimal LV site was significantly more delayed compared with the worst LV site (431 ± 93 ms vs. 326 ± 127 ms; P = 0.004). CONCLUSION: Stimulation at the optimal LV site showed a significantly higher pump function improvement compared with bifocal LV stimulation. Mechanical activation at the optimal LV site was significantly more delayed compared with the non-optimal LV site. In general, these results suggest that implantation of a second LV lead yields no additional benefit over implantation of one optimally placed LV lead. However, a bifocal approach might be beneficial in the individual patient.

Scar tissue-guided left ventricular lead placement for cardiac resynchronization therapy in patients with ischemic cardiomyopathy: an acute pressure-volume loop study.

BACKGROUND: Response to cardiac resynchronization therapy (CRT) is hampered by the extent and location of left ventricular (LV) scar tissue. It is commonly advised to avoid scar tissue while placing the LV lead. However, whether individual patients benefit from this strategy remains unclear. METHODS: Thirty-two CRT candidates with ischemic cardiomyopathy were enrolled from 2 successive clinical trials (TBS and E-pot study). Magnetic resonance imaging with late contrast enhancement was performed to assess location, degree and transmurality of LV scar tissue. Patients underwent invasive pressure-volume loop measurements to assess acute LV pump function changes during pacing at posterolateral (PL) and anterolateral LV sites. RESULTS: In the study population (26 [81%] men, ejection fraction [EF] 22% ± 8%, QRS 149 ± 20 milliseconds), baseline mean stroke work (SW) and dP/dtmax were 4.4 ± 2.2 L∙mmHg and 849 ± 212 mmHg/s, respectively. The extent of scar tissue was inversely related to the acute increase in SW during pacing (R = -0.53, P = .002). Stimulating PL scar tissue resulted in deterioration of pump function (∆SW -17% ± 17%, P = .018), whereas pacing PL viable tissue led to an increase in pump function (∆SW +62% ± 51%, P < .001). Switching from pacing at the location of scar tissue, irrespective of the scar location, to viable tissue showed a significant increase in SW (-8% ± 20% vs +20 ± 40, P = .004). CONCLUSIONS: The extent of LV scar tissue is inversely related to acute pump function improvement during CRT. Pacing at the location of (transmural) scar tissue at any site of the LV will generally deteriorate LV pump function. Placing the LV lead over viable myocardium significantly improves pump function as compared with pacing at the location of scar tissue in patients with ischemic cardiomyopathy.

Interference of electronic apex locators with implantable cardioverter defibrillators.

INTRODUCTION: The purpose of this in vitro study was to evaluate the potential electromagnetic interference of electronic apex locators (EALs) on implantable cardioverter defibrillators (ICDs). METHODS: Four different EALs were tested for their ability to interfere with the correct function of 3 different ICDs. Each ICD was placed in a plastic container with 1.5 L physiological saline, and the EAL unit was placed at a distance of 2.5 cm from the ICD. The file electrode and lip clip were placed directly against the ICD. The EAL was turned on for 30 seconds while continuously showing the "APEX" mark. As a negative control, the ICD was tested without EAL for 30 seconds. An electrosurgical unit served as a positive control. During each test, the ICD output was monitored continuously by real-time telemetry, and after completion of the experiment, intracardiac electrocardiograms were printed. The tests were repeated 3 times for each device. The electrocardiograms were examined for interference on ICD ventricular activity. RESULTS: All EALs tested and the negative control failed to produce electromagnetic interference in each of the ICDs tested. The electrosurgical unit induced interference in the ICDs, which were detected as episodes of ventricular tachycardia and led to the initiation of electrical shocks in all ICDs. CONCLUSIONS: The 4 EALs tested did not interfere with the correct functioning of ICDs in vitro.

Prediction of long-term outcome of cardiac resynchronization therapy by acute pressure-volume loop measurements.

AIMS: Invasive assessment of acute haemodynamic response to biventricular pacing has been proposed as a tool to determine individual response and to optimize the effects of CRT. However, the long-term results of this approach have been poorly studied. The present study relates acute haemodynamic effects of CRT to long-term outcome. METHODS AND RESULTS: Forty-one patients were analysed in the present study. During temporary biventricular pacing before implantation, acute changes in LV pump function were assessed by pressure-volume loop measurements and related to long-term response after CRT. In the study population [30 (71%) men, NYHA class 2.9 ± 0.4, EF 28 ± 7%, QRS 150 ± 25 ms], baseline mean stroke work (SW) and dP/dt(max) were 4.6 ± 2.6 L × mmHg and 874 ± 259 mmHg/s, respectively. During biventricular pacing, mean SW and dP/dt(max) increased significantly by 43 ± 39% (+ 2.2 ± 2.4 L × mmHg, P < 0.001) and 13 ± 18% (+ 96 ± 136 mmHg/s, P < 0.001), respectively. In long-term responders (n = 29, 71%) compared with non-responders (n = 12, 29%), the acute increase in SW was significantly higher (+57 ± 33% vs. + 10 ± 30%, P < 0.001), whereas the acute increase in dP/dt(max) was not significantly different between responders and non-responders (+ 15 ± 18% vs. 6 ± 15%, P = 0.139). Receiver operating characteristic (ROC) curve analysis indicated that SW was superior to dP/dt(max), QRS duration and LV dyssynchrony in prediction of response to CRT. A cut-off value for SW of 20% yielded a sensitivity of 90% and specificity of 75% to predict reverse remodelling at 6 months. CONCLUSION: Invasive assessment of acute haemodynamics is a reliable tool to determine individual response to CRT. An acute increase in SW predicts long-term response to CRT with a higher accuracy than an acute increase in dP/dt(max), baseline QRS duration, and degree of LV mechanical dyssynchrony.

Prevalence and presentation of externalized conductors and electrical abnormalities in Riata defibrillator leads after fluoroscopic screening: report from the Netherlands Heart Rhythm Association Device Advisory Committee.

BACKGROUND: The Riata family of implantable cardioverter-defibrillator (ICD) leads is prone to a specific insulation abrasion characterized by externalization of conductor cables. The objective of this study was to determine the prevalence of externalized conductors and electrical abnormalities in Riata ICD leads by fluoroscopic screening and standard ICD interrogation. METHODS AND RESULTS: All ICD implantation centers were contacted by the Netherlands Heart Rhythm Association Device Advisory Committee to identify all patients with an active Riata ICD lead and to perform fluoroscopic screening of the lead. In addition, the electrical integrity of the lead was assessed. As of March 1, 2012, data for 1029 active Riata leads were available; 47% of these were 8-F Riata and 53% were 7-F Riata ST. Externalized conductors were observed in 147 leads (14.3%). Proportion of externalized conductors was higher in 8-F Riata compared with 7-F Riata ST (21.4% vs 8.0%; P<0.001). Median time from implantation to detection of externalized conductors was 65.3 months. The estimated rates of externalized conductors were 6.9% and 36.6% at 5 and 8 years after implantation, respectively. Of the 147 leads with externalized conductors, 10.9% had abnormal electrical parameters vs 3.5% in nonexternalized leads (P<0.001). CONCLUSIONS: The prevalence of externalized conductors in Riata leads is significantly high (14.3%) using fluoroscopic screening. The majority of externalized conductors are not detectable with standard ICD interrogation. Screening with fluoroscopy is reasonable.

Implantable cardioverter-defibrillators have reduced the incidence of resuscitation for out-of-hospital cardiac arrest caused by lethal arrhythmias.

BACKGROUND: Over the last decades, a gradual decrease in ventricular fibrillation (VF) as initial recorded rhythm during resuscitation for out-of-hospital cardiac arrest (OHCA) has been noted. We sought to establish the contribution of implantable cardioverter-defibrillator (ICD) therapy to this decline. METHODS AND RESULTS: Using a prospective database of all OHCA resuscitation in the province North Holland in the Netherlands (Amsterdam Resuscitation Studies [ARREST]), we collected data on all patients in whom resuscitation for OHCA was attempted in 2005-2008. VF OHCA incidence (per 100 000 inhabitants per year) was compared with VF OHCA incidence data during 1995-1997, collected in a similar way. We also collected ICD interrogations of all ICD patients from North Holland and identified all appropriate ICD shocks in 2005-2008; we calculated the number of prevented VF OHCA episodes, considering that only part of the appropriate shocks would result in avoided resuscitation. VF OHCA incidence decreased from 21.1/100 000 in 1995-1997 to 17.4/100 000 in 2005-2008 (P<0.001). Non-VF OHCA increased from 12.2/100 000 to 19.4/100 000 (P<0.001). VF as presenting rhythm declined from 63% to 47%. In 2005-2008, 1972 ICD patients received 977 shocks. Of these shocks, 339 were caused by a life-threatening arrhythmia. We estimate that these 339 shocks have prevented 81 (minimum, 39; maximum, 152) cases of VF OHCA, corresponding with 33% (minimum, 16%; maximum, 63%) of the observed decline in VF OHCA incidence. CONCLUSIONS: The incidence of VF OHCA decreased over the last 10 years in North Holland. ICD therapy explained a decrease of 1.2/100 000 inhabitants per year, corresponding with 33% of the observed decline in VF OHCA.

Electrocardiographic changes in therapeutic hypothermia.

INTRODUCTION: During therapeutic hypothermia (TH), electrocardiographic (ECG) abnormalities such as Osborn waves and/or ST-segment elevation have been described. However, the incidence and prognostic value of these ECG changes are uncertain given the small-scale studies that have been carried out to date. The aim of this study is to further evaluate the electrocardiographic changes during TH. METHODS: During a period of 3 years, 81 patients (age 63 ± 14 years) were included retrospectively. All patients underwent TH after being resuscitated. ECG registrations before, during and after TH were collected and analyzed. Patients were divided into two groups based on the presence or absence of transmural ischemia ST elevation on the first representative ECG upon arrival at the hospital (ST-segment elevation myocardial infarction (STEMI) and non-STEMI). RESULTS: A total of 243 ECGs were analyzed. During TH 24 patients (30%) had Osborn waves, which disappeared in 22 patients (92%) after regaining normal body temperature. The presence of Osborn waves was not associated with age, gender, average pH, electrolytes, or lactate levels and was not associated with excess in-hospital mortality. In 10 patients (12%, six non-STEMI patients) new STEMI was observed during TH, which disappeared after TH discontinuation. The STEMI group (44 patients) had significantly more Osborn waves during TH than the non-STEMI group (38.6% vs. 15.2%, odds ratio = 3.508; 95% confidence interval = 1.281 to 9.610). CONCLUSIONS: Hypothermia-induced Osborn waves are relatively common and are not associated with an unfavorable short-term outcome. TH is associated with ECG changes that may mimic STEMI.

Incidence and predictors of short- and long-term complications in pacemaker therapy: the FOLLOWPACE study.

BACKGROUND: Today quantitative information about the type of complications and their incidence during long-term pacemaker (PM) follow-up is scarce. OBJECTIVE: To assess the incidence and determinants of short- and long-term complications after first pacemaker implantation for bradycardia. METHODS: A prospective multicenter cohort study (the FOLLOWPACE study) was conducted among 1517 patients receiving a PM between January 2003 and November 2007. The independent association of patient and implantation-procedure characteristics with the incidence of PM complications was analyzed using multivariable Cox regression analysis. RESULTS: A total of 1517 patients in 23 Dutch PM centers were followed for a mean of 5.8 years (SD 1.1), resulting in 8797 patient-years. Within 2 months, 188 (12.4%) patients developed PM complications. Male gender, age at implantation, body mass index, a history of cerebrovascular accident, congestive heart failure, use of anticoagulant drugs, and passive atrial lead fixation were independent predictors for complications within 2 months, yielding a C-index of 0.62 (95% confidence interval 0.57-0.66). Annual hospital implanting volume did not additionally contribute to the prediction of short-term complications. Thereafter, 140 (9.2%) patients experienced complications, mostly lead-related complications (n = 84). Independent predictors for long-term complications were age, body mass index, hypertension, and a dual-chamber device, yielding a C-index of 0.62 (95% confidence interval 0.57-0.67). The occurrence of a short-term PM complication was not predictive of future PM complications. CONCLUSIONS: Complication incidence in modern pacing therapy is still substantial. Most complications occur early after PM implantation. Although various patient- and procedure-related characteristics are independent predictors for early and late complications, their ability to identify the patient at high risk is rather poor. This relatively high incidence of PM complications and their poor prediction underscores the usefulness of current guidelines for regular follow-up of patients with PM.

Effects of QRS duration and pacing location on pressure-volume loop evaluation of cardiac resynchronization therapy in end-stage heart failure.

Cardiac resynchronization therapy (CRT) decreases the morbidity and mortality in patients with end-stage heart failure. However, patient selection remains challenging, because a considerable 30% to 50% do not respond. Controversy exists on the cutoff values for the QRS duration and the optimal lead location. The present study relates these parameters on an individual basis to acute pump function improvement using invasively obtained pressure-volume loops. Fifty-seven patients with symptomatic end-stage heart failure were included in our temporary biventricular stimulation study and were grouped according to the QRS duration (QRS <20 ms, QRS ≥120 ms but <150 ms, and QRS ≥150 ms). All patients underwent pressure-volume loop assessment of the response to biventricular pacing, comparing the baseline measurements to both right ventricular apex pacing combined with a left ventricular lead in the posterolateral and anterolateral region of the LV. Group analysis during conventional (posterolateral and right ventricular apex) CRT did not show improvement in stroke work and dP/dt(max) (-2%, p = NS; and -7%; p <0.001) in the narrow QRS group but a significant increase in the intermediate (+27%, p = 0.020, and +5%, p = 0.044) and wide (+48%, p = 0.002, and +18%, p <0.001) QRS groups. CRT using the anterolateral and right ventricular apex configuration evoked a consistently lower response compared to posterolateral and right ventricular apex, resulting in a significant hemodynamic deterioration in the narrow QRS group. However, analysis on an individual basis identified 25% of patients with narrow QRS duration showing possible hemodynamic benefit from CRT compared to 83% of patients with intermediate and wide QRS combined. In contrast, 15% of patients had deterioration by conventional (posterolateral right ventricular apex) CRT in the intermediate and wide QRS groups compared to 31% in the narrow QRS group; 19% of patients could be improved by lead placement in the anterolateral rather than the posterolateral region. In conclusion, the acute hemodynamic response to CRT is generally in line with the long-term results from large randomized trials; however, the individual variation is large. The temporary biventricular stimulation protocol might aid in individual patient selection and in research aiming at a reduction of nonresponders and improvement in lead positioning.

Effects of pacing rates on global and regional myocardial blood flow.

BACKGROUND: Information is scarce on the effects of right ventricular apical (RVA) pacing on regional and global myocardial blood flow (MBF). The purpose of this study was to assess the relationship between pacing rate and both regional and global MBF. METHODS: Four patients with exclusive atrial pacing and six patients with exclusive RVA pacing underwent three consecutive H(2) (15)O positron emission tomography scans at 60, 90, and 130 pulses per minute (ppm). For each pacing rate, regional and global MBF was determined. In all patients, the left ventricular (LV) function was normal. RESULTS: By varying the atrial pacing rate from 60 to 130 ppm, the mean global MBF increased from 0.94 to 1.40 mL/g/min, whereas the mean septal to lateral MBF ratio decreased from 1.09 to 0.83. In ventricular-paced patients at corresponding rates, the mean global MBF also increased from 1.07 to 1.52 mL/g/min but here the mean septal to lateral MBF ratio increased from 0.83 to 1.0. CONCLUSIONS: During both acute atrial and RVA pacing, regional and global MBF increases with higher pacing rates. However, the septal to lateral MBF ratio decreases with atrial pacing and increases with RVA pacing in patients with normal LV function. In RVA pacing, these different rate-dependent effects on regional MBF can be considered as a favorable factor that helps to understand why in some long-term paced patients, LV function is preserved.

Risk stratification for ventricular arrhythmias in ischaemic cardiomyopathy: the value of non-invasive imaging.

The introduction of the implantable cardioverter defibrillator (ICD) has had a major impact on survival and treatment of patients with ischaemic cardiomyopathy. However, only a third of patients receive appropriate ICD discharges during the first 3 years of follow-up, hence creating opportunities for improvement in patient care as well as for health care costs containment. Therefore, refinement of ICD implantation criteria is needed. Evaluation of pathophysiological substrates related to electrical instability with imaging modalities such as nuclear imaging, cardiac magnetic resonance imaging, and echocardiography might yield important prognostic information. This review discusses the currently available literature regarding the value of these imaging modalities for prediction of ventricular arrhythmias in patients with ischaemic cardiomyopathy.

Loss of opposite left ventricular basal and apical rotation predicts acute response to cardiac resynchronization therapy and is associated with long-term reversed remodeling.

BACKGROUND: Normal left ventricular (LV) torsion is caused by opposite basal and apical rotation. Opposite rotation can be lost in heart failure, but might be restored by pacing; therefore, the predictive value of the loss of opposite base-apex rotation in heart failure patients for the response to cardiac resynchronization therapy (CRT) was studied. METHODS AND RESULTS: In 34 CRT candidates and 12 controls, basal and apical LV rotations were calculated using magnetic resonance image tagging. Loss of opposite rotation was quantified by the correlation between both rotation curves: a negative correlation indicates normal, opposite rotation and a positive correlation indicates that base and apex rotate in the same direction. In patients, LV pressure was measured invasively during biventricular stimulation. Acute response to CRT was defined by >10% increase in dP/dt(max) relative to baseline. LV volume was determined at baseline and 8 months follow-up using echocardiography. The base-apex rotation correlation (BARC) was significantly higher in acute responders (n=22) than in nonresponders (n=12) and controls (0.64+/-0.51, -0.23+/-0.67, and -0.68+/-0.22, respectively; P=.001). The sensitivity and specificity for prediction of acute response were 82% and 83%, respectively, at a cutoff value of 0.5. At follow-up, volumes could be analyzed in 18 patients. In the group with BARC >0.5, end-diastolic volume decreased by 7% (NS), end-systolic volume by 16%, and ejection fraction increased by 28% (both P=.02), whereas in the group with BARC <0.5, no significant changes were observed. CONCLUSIONS: The loss of opposite base-apex rotation in patients eligible for CRT is an excellent predictor of acute response and is associated with LV reverse remodeling.