Ability to remotely monitor atrial high-rate episodes using a single-chamber implantable cardioverter-defibrillator with a floating atrial sensing dipole.

AIMS: To allow timely initiation of anticoagulation therapy for the prevention of stroke, the European guidelines on atrial fibrillation (AF) recommend remote monitoring (RM) of device-detected atrial high-rate episodes (AHREs) and progression of arrhythmia duration along pre-specified strata (6 min…<1 h, 1 h…<24 h, ≥ 24 h). We used the MATRIX registry data to assess the capability of a single-lead implantable cardioverter-defibrillator (ICD) with atrial sensing dipole (DX ICD system) to follow this recommendation in patients with standard indication for single-chamber ICD. METHODS AND RESULTS: In 1841 DX ICD patients with daily automatic RM transmissions, electrograms of first device-detected AHREs per patient in each duration stratum were adjudicated, and the corresponding positive predictive values (PPVs) for the detections to be true atrial arrhythmia were calculated. Moreover, the incidence and progression of new-onset AF was assessed in 1451 patients with no AF history. A total of 610 AHREs ≥6 min were adjudicated. The PPV was 95.1% (271 of 285) for episodes 6min…<1 h, 99.6% (253/254) for episodes 1 h…<24 h, 100% (71/71) for episodes ≥24 h, or 97.5% for all episodes (595/610). The incidence of new-onset AF was 8.2% (119/1451), and in 31.1% of them (37/119), new-onset AF progressed to a higher duration stratum. Nearly 80% of new-onset AF patients had high CHA2DS2-VASc stroke risk, and 70% were not on anticoagulation therapy. Age was the only significant predictor of new-onset AF. CONCLUSION: A 99.7% detection accuracy for AHRE ≥1 h in patients with DX ICD systems in combination with daily RM allows a reliable guideline-recommended screening for subclinical AF and monitoring of AF-duration progression.

[Wartosc prognostyczna wskazników elektrokardiograficznych zawalu prawej komory w ocenie wewnatrzszpitalnego przebiegu klinicznego u chorych z rozpoznanym zawalem sciany dolnej leczonych interwencyjnie]. / Wartosc prognostyczna wskazników elektrokardiograficznych zawalu prawej komory w ocenie wewnatrzszpitalnego przebiegu klinicznego u chorych z rozpoznanym zawalem sciany dolnej leczonych interwencyjnie.

Myocardial infarction (MI) of the right ventricle (RV) coexists in 20- 60% of patients with inferior MI. There are electrocardiographic indicators which are connected with RV MI, which may also predict unfavorable clinical outcome of in-hospital follow-up. AIM: The aim of the study was determination a value of seven electrocardiographic predictors of RV MI in prognosis of in-hospital complications in patients with inferior MI. MATERIALS AND METHODS: The analysis of hospital files of patients admitted with diagnosis of inferior MI with persistent ST elevation (STEMI) was retrospectively performed. A set of seven RV MI predictors (RVMIP) was assessed from the electrocardiographic tracings (ECG). Finally in group of 167 patients relation between each RVMIP and in-hospital complications was statistically evaluated. RESULTS: The most often RVMIP was an elevation of ST higher in III lead then in II and aVF (RVMIP-2; recorded in 61,7% patients). In total any RVMIP was found in ECG of 142 patients (85%). Patients who had more RVMIP were more prone for combined adverse cardiac event (CACE, which included artificial respirotherapy, lungs edema and cardiogenic shock) (p=0,012); ventricular arrhythmias (p<0,001) and second/third grade atrioventricular blocks (p=0,028). Advanced atrioventricular blocks were more often observed in patient with ST elevation in V1 and ST depression in aVL (OR=4,91, p=0,005; OR=4,67, p=0,006; respectively). On the other hand second/third grade atrioventricular blocks were also related to higher incidence of CACE, ventricular arrhythmias and atrial fibrillation (AF), respectively: OR=8,1, p<0,001; OR=7,19, p=0,001; OR=5,75, p=0,001). CONCLUSIONS: The more RVMIPs the higher risk of in-hospital complication in patients with inferior MI. The second/third grade atrioventricular blocks were recorded more often in patients with ST elevation in V1 and ST depression in aVL. Advanced atrioventricular conduction blocks were related to worse outcome of in-hospital followup. A detailed ECG analysis in admission still adds important contribution in determination of in-hospital risk of complications.

Systemic Brucellosis with Arrhythmogenic Cardiac Inflammatory Pseudotumor.

BACKGROUND Cardiac inflammatory pseudotumors are rarely observed. Their etiology might include immunologic abnormalities, fibrogenetic disorders, specific reactions to infections or abnormalities related to trauma, necrosis, or neoplasm. Life-threatening ventricular tachycardia and cases of sudden death related to cardiac tumors have been reported. The present report describes and discusses diagnostic and therapeutic solutions for the treatment of nonsarcoid multiorgan pseudotumors with cardiac involvement. CASE REPORT A 38-year-old woman presented to the clinic with symptomatic ventricular tachycardia. As coronary artery disease, cardiomyopathy, and channelopathy were ruled out, and electrocardiograms were not typical of idiopathic arrhythmia, the patient underwent detailed diagnostics which included targeted endomyocardial biopsy, which revealed a cardiac inflammatory pseudotumor. Laborious testing (and eventually, antibiotic therapy) led to ex juvantibus diagnosis of multiorgan disseminated brucellosis with cardiac involvement. Treatment with ceftriaxone, doxycycline, and rifampicin resulted in a complete resolution of all lesions after 3 months, and sustained recovery was observed during a 5-year follow-up. As the risk of ventricular tachycardia could not be reliably predicted, the patient had a subcutaneous implantable cardioverter-defibrillator implanted. CONCLUSIONS A vast diagnostic armamentarium of modern medicine allowed us to diagnose an unsuspected and rare cardiac inflammatory pseudotumor. In the case of travelers, the possibility of regionally specific illnesses, especially infections, must be taken into consideration as possible causes of arrhythmias. Cardiac magnetic resonance imaging may be useful in patients with 'idiopathic ventricular tachycardias' to detect non-apparent myocardial lesions which may result from the underlying cause of the arrhythmia.

Clinical valuation of ST changes in a group of patients with ventricular arrhythmias: The inSighT Study.

BACKGROUND: The inSighT study was designed to determine the prevalence of ischemic changes as recorded by implantable cardioverter-defibrillator (ICD) ST deviations in intracardiac electrocardiograms (EGM) over the 24 h preceding malignant ventricular arrhythmias (VT/VF). METHODS: The study enrolled patients with known coronary artery disease (CAD) or high risk of future development of CAD implanted with an ICD equipped with an ST monitoring feature (Ellipse™/Fortify Assura™, St. Jude Medical). Device session records were collected at each in-clinic follow-up. EGM ST levels of the beats over the 15 minutes prior to VT/VF events were compared using a t test with those from a baseline period of 23-24 h prior to the VT/VF event. All events with p < .05 were visually inspected to confirm they were evaluable; additional criteria for exclusion from further analysis included inappropriate therapy, aberrant conduction, and occurrence of VT/VF within 24h prior to the current event. RESULTS: The study enrolled 481 ICD patients (64 ± 11 years, 83% male) in 14 countries and followed them for 15±5 months. A total of 165 confirmed VT/VF episodes were observed, of which 71 events (in 56 patients, 34% of all patients with VT/VF) were preceded by significant (p < .05) ST-segment changes unrelated to known non-ischemic causes. None of the analyzed demographic and clinical factors proved to be associated with greater odds of presenting with ST-segment changes prior to VT/VF episode. CONCLUSION: In this exploratory study, characteristic ST-segment changes, likely representative of ischemic events, were observed in 34% of all patients with VT/VF episodes.

Percutaneous Occlusion of the Left Atrial Appendage with Thrombus Irresponsive to Antithrombotic Therapy.

We analyzed clinical experience with percutaneous closure of instances of left atrial appendage with thrombus (LAAT) irresponsive to antithrombotic therapy in patients treated in three high-volume cardiology centers. Clinical and procedural data regarding consecutive patients who underwent percutaneous left atrial appendage closure (PLAAC) due to LAAT were retrospectively analyzed. The study population consisted of 17 patients (11 men; 68 ± 14 years; CHA2DS2VASC 4.7 ± 1.9; HASBLED 3 (0-5)) with LAAT confirmed by transesophageal echocardiography, and included 5 patients with mechanical heart valves. Most of the patients (94.1%) received anticoagulation therapy before PLAAC. All LAATs were located in distal portions of the appendage and occupied less than 30% of its volume. Occluding-device implantation was successful in 17 patients; in one, a residual leak was disclosed. Appropriate positioning of occluders required more than 1 attempt in 6 individuals (35.3%); in 3 others (17.6%), the subjects' devices had contact with thrombi. No procedural complications were noted. Midterm follow-up (median: 10 months) revealed no procedure-related complications or clinically diagnosed thromboembolism. Transesophageal echocardiography (TEE) performed after six months revealed device-related thrombus in one patient. We concluded that LAAT irresponsive to antithrombotic therapy might be effectively treated with PLAAC, even in patients with mechanical-valve prostheses.

Dietary habits and myocardial infarction in occupationally active men.

OBJECTIVES: Only a few studies have been undertaken to analyze the dietary habits of people with cardiovascular diseases. The aim of this study was to evaluate the dietary behaviors of working people who were hospitalized due to experiencing the first acute cardiovascular incident. MATERIAL AND METHODS: In the study, the Functional Activity Questionnaire was used. The study was conducted in 2 groups. The first group included all the men hospitalized during 1 year (January-December 2009) in 2 clinics of cardiology, who were professionally active until the first myocardial infarction (MI). It comprised 243 men aged 26-70 years. The reference group consisted of 403 men, blue- and white-collar workers, aged 35-65 years. RESULTS: The body mass index of the MI patients was significantly higher (p = 0.006). The frequency of consumption of particular products in the MI group and in the reference group differed significantly for 11 of 21 products. The MI patients significantly less frequently reported the daily consumption of fruit, raw vegetables, cheese, vegetable oils and fish. In this group, the consumption of salty (p = 0.0226) or fatty (p < 0.0001) foods was significantly higher. It was shown that, after adjusting for age, education and the type of work, the daily consumption of fish, salads and cooked vegetables, as well as fruit and vegetable oils, significantly reduced the risk of myocardial infarction. An increased MI risk was, in turn, associated with obesity and preference for fatty foods. CONCLUSIONS: The authors found that diet significantly modified the MI risk in the examined workers. This indicates that an important aspect of prevention activities among working people should involve education about proper dietary habits. Int J Occup Med Environ Health. 2019;32(6):853-63.

Straight and crosier­shaped catheter techniques for phrenic nerve stimulation during cryoballoon pulmonary vein isolation for the treatment of atrial fibrillation.

BACKGROUND: Cryoablation is an effective and safe method of pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). However, monitoring of phrenic nerve function during cryoballoon PVI remains an important issue. AIMS: We aimed to compare 2 techniques of phrenic nerve stimulation (PNS) with the use of either a straight or a crosier­shaped decapolar deflectable catheter. METHODS: The study included 218 patients (mean [SD] age, 61.8 [10.9] years; 87 women) referred for cryoballoon PVI for AF. Patients were randomly assigned to PNS with either a straight or a crosier­shaped catheter. RESULTS: The groups did not differ in demographic characteristics or PVI effectiveness. The current threshold during PNS was lower in the group in which the crosier­shaped catheter was applied (mean [SD], 6.7 [4.9] mA vs 4.8 [3.7] mA; P <0.01). In this group, the procedure time was shorter (mean [SD], 72.6 [22.8] min vs 64.4 [14.8] min; P <0.01), fewer repositioning maneuvers were required (31.8% vs 19.4%; P <0.05), and atrial capture during PNS was observed more frequently (11.5% vs 29.6%; P <0.01). CONCLUSIONS: Straight and crosier­shaped catheter techniques are equally effective in monitoring for phrenic nerve palsy. The crosier­shaped catheter maintains its position better, thus leading to fewer dislocations and requiring fewer correction maneuvers, which might correlate with shorter procedure time. Moreover, this technique provides lower pacing thresholds. Both techniques may be safely used in patients with AF, and if stable phrenic nerve capture cannot be achieved, switching to another technique seems reasonable.

Impact of admission glycaemia on the annual risk of major cardiovascular events and development of type 2 diabetes mellitus in patients with non-ST-elevation acute coronary syndrome undergoing percutaneous coronary intervention.

Elevated admission glycaemia (ABG) in a patient with or without type 2 diabetes (T2DM) is associated with adverse consequences. There is still a lack of accurate data on the adverse effects of ABG on the risk of major cardiovascular events and the development of T2DM in patients hospitalized for unstable angina (UA) or non-ST elevation myocardial infarction (NSTEMI) undergoing percutaneous coronary intervention. AIM: The main aim of this study was to evaluate the effect of ABG to the risk of major cardiovascular events and the development of T2DM during one year follow-up in patients with UA and NSTEMI. MATERIALS AND METHODS: 100 consecutive patients (68% men, mean age 64.2±10.5 years) hospitalized due to non-ST-elevation acute coronary syndrome (NSTE-ACS) were included in observational study. In each patient, medical history was taken and physical examination, standard diagnostics procedures, including venous glucose deterioration and coronarography were performed. Patients were assigned to two groups: UA or NSTEMI and observed during hospitalization and one year after discharge. RESULTS: 74 patients were diagnosed with NSTEMI and 26 with UA. 41 patients were treated for T2DM and 28 were diagnosed with impaired fasting glucose (IFG) prior to hospitalization. Both carbohydrate disorders occurred with a similar frequency in the compared groups of patients, and its incidence was comparable in both groups. During observation, T2DM was diagnosed only in 8 patients with IFG. Out of the 8 patients whose ABG was >250mg/dl, 7 died during one year, including three during hospitalization, and two during the first month after discharge. These patients were diagnosed with T2DM before hospitalization. CONCLUSIONS: Different degrees of impaired glucose homeostasis are present before or develop after occurrence NSTE-ACS. ABG >250mg/ dl in this group of patients is associated with the highest risk of death, regardless of the diagnosis of UA or NSTEMI.

Potential benefit of optimizing atrioventricular & interventricular delays in patients with cardiac resynchronization therapy.

BACKGROUND & OBJECTIVES: The clinical benefit of optimization (OPT) of atrioventricular delay (AVD) and interventricular delay (VVD) in cardiac resynchronization therapy (CRT) remains debatable. This study was aimed to determine the influence of AVD and VVD OPT on selected parameters in patients early after CRT implantation and at mid-term follow up (FU). METHODS: Fifty two patients (61±10 yr, 23 males) with left bundle branch block, left ventricular ejection fraction (LVEF) ≤35 per cent and heart failure were selected for CRT implantation. Early on the second day (2DFU) after CRT implantation, the patients were assigned to the OPT or the factory setting (FS) group. Haemodynamic and electrical parameters were evaluated at baseline, on 2DFU after CRT and mid-term FU [three-month FU (3MFU)]. Echocardiographic measures were assessed before implantation and at 3MFU. The AVD/VVD was deemed optimal for the highest cardiac output (CO) with impedance cardiography (ICG) monitoring. RESULTS: On 2DFU, the AVD was shorter in the OPT group, LV was paced earlier than in FS group and CO was insignificantly higher in OPT group. At 3MFU, improvement of CO was observed only in OPT patients, but the intergroup difference was not significant. At 3MFU in OPT group, reduction of LV in terms of LV end-diastolic diameter (LVeDD), LV end-systolic diameter, LV end-diastolic and systolic volume with the improvement in LVEF was observed. In FS group, only a reduction in LVeDD was present. In OPT group, the paced QRS duration was shorter than in FS group patients. INTERPRETATION & CONCLUSIONS: CRT OPT of AVD and VVD with ICG was associated with a higher CO and better reverse LV remodelling. CO monitoring with ICG is a simple, non-invasive tool to optimize CRT devices.

Risk score to assess mortality risk in patients undergoing transvenous lead extraction.

AIMS: The main aim of this study was to assess 1-year mortality and its predictors in a cohort of patients who underwent transvenous lead extraction (TLE) procedure. METHODS: Retrospective analysis of clinical characteristics and 1-year follow-up of patients referred for a TLE procedure in a single, high-volume center between June 2006 and October 2014 was performed. RESULTS: The studied population included 130 patients (82 males; mean age 64 ± 15 years) implanted with pacemakers (74%), implantable cardioverter defibrillators (15%), or cardiac resynchronization therapy defibrillator (11%). Indications for the extraction included infective endocarditis (40.5%), pocket infection (18.5%), and lead fault or failure (41%). Total radiological success rate was 90% while clinical success rate was 93.5%. The cumulative 1-year mortality was 28%. Mortality was higher in a group of older patients (94.4% vs 68%, P = 0.001) and those with chronic kidney disease (33.3% vs 4.3 %, P = 0.0002) as well as in patients after removal of high voltage lead (88.9% vs 26.3%, P = 0.01). Higher mortality was also related to infection as an indication for TLE (37.2% vs 13.5%, P = 0.002). Following these findings a new risk score model named IKAR (I = infective indications; K = kidney dysfunction; A = age ≥ 56; R = removal of high voltage lead) was constructed. Patients with IKAR score ≥3 points were characterized by 79% mortality as compared to 16% in those with a score 1-2 points. CONCLUSIONS: One-year mortality of patients undergoing TLE procedure can be predicted by using IKAR risk score.

[Technical options of electrotherapy in patients with vasovagal syncope]. / Techniczne mozliwosci elektroterapii u osób z omdleniami wazowagalnymi.

Syncope is a symptom of the disease with diverse etiology and can be evidence of both benign and very serious life-threatening conditions. Vasovagal syncope(VVS), with prevalence about 35% of the general population, is most frequent causes of transient loss of consciousness (T-LOC). Most cases of vasovagal syncope requires conservative treatment. Although cardioinhibitory type of VVS characterized by a significant bradycardia or pause of the heart rate and can be treated with continuous electrotherapy. This article discuss cardiac pacing and technical solutions for the treatment of VVS. Available cardiac pacing methods used to detect and break VVS such as Rate Drop Response (RDR), Closed Loop Stimulation (CLS) and rate response driven by variations of myocardial contractility like Peak Endocardial Acceleration (PEA), has been presented.

Relationship Between Changes in Pulse Pressure and Frequency Domain Components of Heart Rate Variability During Short-Term Left Ventricular Pacing in Patients with Cardiac Resynchronization Therapy.

BACKGROUND The aim of the study was to explore the relationship between changes in pulse pressure (PP) and frequency domain heart rate variability (HRV) components caused by left ventricular pacing in patients with implanted cardiac resynchronization therapy (CRT). MATERIAL AND METHODS Forty patients (mean age 63±8.5 years) with chronic heart failure (CHF) and implanted CRT were enrolled in the study. The simultaneous 5-minute recording of beat-to-beat arterial systolic and diastolic blood pressure (SBP and DBP) by Finometer and standard electrocardiogram with CRT switched off (CRT/0) and left ventricular pacing (CRT/LV) was performed. PP (PP=SBP-DBP) and low- and high-frequency (LF and HF) HRV components were calculated, and the relationship between these parameters was analyzed. RESULTS Short-term CRT/LV in comparison to CRT/0 caused a statistically significant increase in the values of PP (P<0.05), LF (P<0.05), and HF (P<0.05). A statistically significant correlation between ΔPP and ΔHF (R=0.7384, P<0.05) was observed. The ΔHF of 6 ms2 during short-term CRT/LV predicted a PP increase of ≥10% with 84.21% sensitivity and 85.71% specificity. CONCLUSIONS During short-term left ventricular pacing in patients with CRT, a significant correlation between ΔPP and ΔHF was observed. ΔHF ≥6 ms2 may serve as a tool in the selection of a suitable site for placement of a left ventricular lead.

[Clinical procedure in amiodarone-induced thyroid dysfunction]. / Postepowanie kliniczne w poamiodaronowych zaburzeniach czynnosci gruczolu tarczowego.

Amiodarone is an antiarrhythmic drug frequently used in everyday clinical practice. Its mechanism of action involves the interaction with many receptors, including those in the cardiac conduction system. Amiodarone usefulness is protect in the treatment of a variety of tachyarrhythmias, both benign and life-threatening. In contrast to other antiarrhythmic drugs, amiodarone is characterized by high therapeutic efficacy, both in patients with normal and impaired left ventricular systolic function. A significant limitation of its is associated with side effects including thyroid gland dysfunction. Disturbances of this organ associated with amiodarone are an important diagnostic and therapeutic problem. They may contribute to the occurrence of both Amiodarone- Induced Thyrotoxicosis (AIT) and Amiodarone-Induced Hypothyroidism (AIH). The risk of such complications should be considered for each patient individually, taking into account thyroid function at the beginning of pharmacotherapy. Appropriate procedure, both before and after treatment allows a rapid diagnosis and treatment of thyroid disturbances. It seems that the best parameter used to assess the hormonal imbalance during amiodarone therapy is the concentration of the free triiodothyronine (fT3). The evaluation of thyroid function should be performed before starting pharmacotherapy, and then repeated every six months. In the case of a thyroid dysfunction, assessment must be performed immediately according to standard diagnostic and therapeutic regimens. Despite abnormal thyroid function, high efficiency of amiodarone and relatively small risk of thyroid damage allows continuation therapy. Amiodarone therapy requires a care from both cardiologist and endocrinologist. The aim of this paper is to present the state of art of evaluation of the thyroid function and procedures implemented in care of thyroid dysfunction before and during treatment with amiodarone.

[Atrial fibrillation in patients with heart failure].

The most common arrhythmia is atrial fibrillation, which is very often associated with heart failure. Treatment of both clinical entries are difficult and became a clinical, social and economic challenge in last decades. The authors present clinical aspects connected with a coexistence of HF and AF. They discuss systematic review of research studies regarding medical therapy and invasive electrotherapy.