ECG characteristics of "true" left bundle branch block: Insights from transcatheter aortic valve-related LBBB and His-Purkinje conduction system pacing-correctable LBBB.

BACKGROUND: Left bundle branch block (LBBB) pattern on the electrocardiogram includes patients with both complete conduction block in the His-Purkinje system as well as nonspecific left ventricular conduction delay without discrete block. OBJECTIVE: The purpose of this study was to characterize electrocardiographic morphological features of LBBB patterns in patients with (1) LBBB after transcatheter aortic valve replacement (TAVR) and (2) LBBB correctable by conduction system pacing (CSP). METHODS: Consecutive patients with post-TAVR (n = 123) or CSP-correctable LBBB (n = 58) from 2 centers were included in this retrospective evaluation. QRS durations as well as detailed morphological features, including notching and slurring, of QRS complexes in leads I, aVL, V1, V2, V5, and V6 and in all 3 inferior leads were recorded. RESULTS: The mean age of the entire cohort was 78.3 ± 10.1 years, with 48% of the cohort being male (87/181). In the CSP-correctable group (n = 58), 14 (24.1%) underwent His-bundle pacing and 44 (75.9%) left bundle branch area pacing. A total of 17 of 181 (9.4%) of the combined cohort failed to completely meet the Strauss criteria. QRS morphology in lead V1/V2 was always either rS or QS, and there were no q/Q waves noted in lead V5/V6. Although dominant R waves were seen in leads I and aVL of 176 of 181 (97.2%), q/Q waves were present in only 21 of 181 (11.6%). Importantly, notched or slurred QRS complexes were identified in at least 1 lead of 4 leads I, aVL, V5, and V6 in 181 of 181 (100%). CONCLUSION: Strauss criteria and QRS notching are highly prevalent in LBBB after TAVR and in LBBB correctable by CSP.

A Combined Deep Learning and Anatomical Inch Measurement Approach to Robotic Acupuncture Points Positioning.

Acupuncture therapy is one of the cornerstones in traditional Chinese medicine. It requires rich experiences from Chinese medicine practitioner. However, repeatability among different practitioners are low. Meanwhile, there is a large variety of skin conditions in terms of color, diseases, size, etc. In recent year, deep neural network for acupuncture point detection is proposed. However, it is difficult to localize multiple acupuncture points. In this paper, a high repeatability robot with a new approach of acupuncture points positioning is proposed which can be adaptive to variety skin conditions and achieve multiple acupuncture points' localization.Clinical Relevance- This system can provide identical acupuncture therapy to different patients. Thus, the quality of the therapy can be practitioner independent. Furthermore, the machine operation is simple therefore manual error can be reduced significantly. As the result, the efficiency and accuracy of therapy can be increased.

Guillain-Barré Syndrome After Primary Cytomegalovirus Infection in a Patient With a Heart Transplant.

A 56-year-old man underwent cardiac transplantation in April 2018. His post-operative course was uncomplicated and he had normal allograft function. On December 2019 he was admitted for fever and diarrhea and was found to have cytomegalovirus infection. A few weeks later, he presented with Guillain-Barré Syndrome. (Level of Difficulty: Advanced.).

Cardiac Pressure Overload Decreases ETV1 Expression in the Left Atrium, Contributing to Atrial Electrical and Structural Remodeling.

BACKGROUND: Elevated intracardiac pressure attributable to heart failure induces electrical and structural remodeling in the left atrium (LA) that begets atrial myopathy and arrhythmias. The underlying molecular pathways that drive atrial remodeling during cardiac pressure overload are poorly defined. The purpose of this study is to characterize the response of the ETV1 (ETS translocation variant 1) signaling axis in the LA during cardiac pressure overload in humans and mouse models and explore the role of ETV1 in atrial electrical and structural remodeling. METHODS: We performed gene expression profiling in 265 left atrial samples from patients who underwent cardiac surgery. Comparative gene expression profiling was performed between 2 murine models of cardiac pressure overload, transverse aortic constriction banding and angiotensin II infusion, and a genetic model of Etv1 cardiomyocyte-selective knockout (Etv1f/fMlc2aCre/+). RESULTS: Using the Cleveland Clinic biobank of human LA specimens, we found that ETV1 expression is decreased in patients with reduced ejection fraction. Consistent with its role as an important mediator of the NRG1 (Neuregulin 1) signaling pathway and activator of rapid conduction gene programming, we identified a direct correlation between ETV1 expression level and NRG1, ERBB4, SCN5A, and GJA5 levels in human LA samples. In a similar fashion to patients with heart failure, we showed that left atrial ETV1 expression is downregulated at the RNA and protein levels in murine pressure overload models. Comparative analysis of LA RNA sequencing datasets from transverse aortic constriction and angiotensin II-treated mice showed a high Pearson correlation, reflecting a highly ordered process by which the LA undergoes electrical and structural remodeling. Cardiac pressure overload produced a consistent downregulation of ErbB4, Etv1, Scn5a, and Gja5 and upregulation of profibrotic gene programming, which includes Tgfbr1/2, Igf1, and numerous collagen genes. Etv1f/fMlc2aCre/+ mice displayed atrial conduction disease and arrhythmias. Correspondingly, the LA from Etv1f/fMlc2aCre/+ mice showed downregulation of rapid conduction genes and upregulation of profibrotic gene programming, whereas analysis of a gain-of-function ETV1 RNA sequencing dataset from neonatal rat ventricular myocytes transduced with Etv1 showed reciprocal changes. CONCLUSIONS: ETV1 is downregulated in the LA during cardiac pressure overload, contributing to both electrical and structural remodeling.

DOPE facilitates quaternized lipidoids (QLDs) for in vitro DNA delivery.

This paper describes the synthesis of a combinatorial library of quaternized lipidoids (QLDs) and an evaluation of their abilities to facilitate in vitro DNA delivery. The QLDs alone showed low efficiency for DNA delivery. By formulating liposomes with a neutral helper lipid, such as 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE), the capability of QLDs for gene transfection is significantly enhanced due to the fusogenic properties of DOPE which facilitate endosomal escape and cargo delivery. We further optimized the liposome composition and DNA dose for gene transfection and investigated the structure-activity relationships of the lipidoid library in DNA delivery. FROM THE CLINICAL EDITOR: This paper describes the synthesis and evaluation of a combinatorial library of quaternized lipidoids to facilitate in vitro DNA delivery, which occurs at a low level but can be enhanced with DOPE. The authors also further optimized the liposome composition and DNA dose for delivery and investigated the structure-activity relationships of the lipidoid library.

A drug-laden elastomer for surgical treatment of anal fistula.

Anal fistula is a common surgical problem with high incidence and causes suffering to patients. The management of high and complex anal fistula is challenging. The purpose of this work is to develop drug-laden elastomer not only to act as seton in the surgical management of anal fistula but also provide painkilling effect during the treatment. Elastic silicone bands were fabricated with different concentrations of lidocaine, with different in vitro drug release profiles. Muscle cutting experiment showed that the drug-laden elastic silicone bands were as effective as the surgical rubber bands in cutting function. Preliminary clinical trial indicated that the drug-laden silicone bands can be used as setons with analgesic effect in the treatment of anal fistula. The findings showed that the drug-laden elastic silicone bands are potentially useful as seton for surgical treatment of anal fistula.