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Aims: Fluctuations in left ventricular (LV) thresholds with cardiac resynchronization therapy (CRT) are unknown. The LV capture management (LVCM) algorithm automatically measures LV thresholds on a daily basis and offers the opportunity to analyse threshold fluctuations.Methods and Results: A total of 282 patients implanted with a Medtronic Concerto CRT-D device were prospectively studied. Device data were collected at periodic visits, including daily thresholds from the preceding 14 days and weekly threshold ranges since implantation, acquired by the LVCM algorithm up to 12 months' follow-up. Overall, LV thresholds remained relatively stable, with 189/208 (91%) patients having a maximum increase in threshold of < or = 1.0 V at any time between their 1 and 6 month visits and 127/135 (94%) between the 6 and 12 month visits. However, increase in threshold was significantly affected by LV threshold amplitude. Of the 170 patients with a 1 month threshold of < or = 2.0 V, 159 (94%) had increases of <1.0 V up to their 6 month visit, whereas 8/38 (21%) patients with >2.0 V threshold had increases of >1.0 V (P = 0.01). There were no significant changes in LV threshold amplitude and fluctuation over the 12 month follow-up.Conclusion: For patients with low (< or = 2.0 V) LV thresholds, a safety margin of 1.0 V is sufficient to ensure LV capture if phrenic nerve stimulation is an issue, and may be even lower in devices with auto-adaptive capture management algorithms. However, the margin should be greater in patients with higher thresholds because of larger fluctuations. Left ventricular capture management may be particularly useful in these patients to ensure LV capture without sacrificing device longevity. [ABSTRACT FROM AUTHOR]

Aim: This study compares different parameters of right atrial size evaluated by two-dimensional (2D) echocardiography with right atrial volume measured using three-dimensional echocardiography (3DE). Methods and Results: One hundred sixty-three consecutive patients with a history of atrial arrhythmias were studied by standard two-dimensional and by real time 3DE. Of these 142 (87%) recordings were of sufficient quality for interpretation of the right atrium by both imaging techniques. The following parameters of right atrial size were measured: apical four-chamber short-axis diameter (4CH short axis), apical four-chamber long axis diameter (4CH long axis), and apical four-chamber planimetry area. The 2D-derived right atrial volume was calculated by using the single plane area-length method (4CH area-length). The 2D parameters were then correlated with right atrial volume measured by real time 3DE. Linear regression analysis showed moderate correlation for four-chamber planimetry area (r = 0.72, P < 0.001) and 2D-derived volume calculation (r of 4CH single plane area-length RA volume = 0.70, P < 0.001). Diameters correlated clearly less well with 3DE volume (r of 4CH short axis = 0.61, 4CH long axis = 0.59, P < 0.001 respectively). Conclusion: Real time 3DE is highly feasible for right atrial volume determination. The results demonstrate that measurements of dimensions using 2D echocardiography may not accurately assess right atrial size. If 3DE is not available, apical 4CH planimetry area is a simple alternative that may be used for evaluating right atrial size in clinical practice. The 2D-derived right atrial volume by single plane area-length method was not better correlated with 3DE volume than four-chamber planimetry area. [ABSTRACT FROM AUTHOR]

Echocardiography is playing an increasing role in patient selection for cardiac resychronization therapy (CRT). The most frequently used techniques for evaluating inter- and intraventricular dyssynchrony are standard echocardiography and tissue Doppler imaging (TDI). Whether these techniques give concordant results is unknown. We studied 44 patients with a left ventricular ejection fraction of 20 ms. Parameters using Sm(p) were highly variable with poor reproducibility, making them unsuitable for evaluating dyssynchrony. In conclusion, our study indicates that there is poor agreement between standard echocardiography and TDI for diagnosing dyssynchrony. [ABSTRACT FROM AUTHOR]

Prediction of the individual risk of sudden cardiac arrest (SCA) remains the main challenge in Brugada syndrome. Several studies have shown that the surface electrocardiogram (ECG) can provide useful information that allows to estimate the risk of SCA. The T-wave amplitude is inversely correlated with the risk of ventricular fibrillation (VF) & SCA in several heart diseases. The purpose of this study was to evaluate the prognostic value of a low T/R ratio in patients with a spontaneous type-1 Brugada pattern (SBT1). In a multicenter study, we retrospectively reviewed 115 pts (105 males, 91.3%) with a SBT1. 45 had VF and/or SCA (38.7 ± 11.5 years old, all males), while 70 (49.3 ± 12.0 years, 10 women) remained free of ventricular arrhythmia. 6 ECG markers plus the lowest T/R ratio among leads V5 & II were studied. The lowest T/R ratio among leads II & V5 was significantly smaller in the VF/SCA group (0.26 ± 0.15 vs. 0.35 ± 0.16; P = 0.006). The optimized cut-off value was ≤ 0.17 by the receiver operating characteristic curve method. 44.4% of pts in the VF/SCA group had a lowest T/R ratio among leads II & V5 ≤ 0.17 compared to 11.4% in the non-VF/SCA group (P < 0.001). In multivariate analysis, a lowest T/R ratio among leads II & V5 ≤ 0.17 was independently associated with VF/SCA (OR 6.10, 95% CI 1.92-19.40; P = 0.002). Type-1 Brugada pattern in a peripheral lead (OR 10.78) and early repolarization (OR 3.60) were the other independent ECG markers of VF/SCA (Fig. 1). A low T/R ratio among leads II & V5 is independently and strongly related to the risk of VF/SCA in patients with a spontaneous type-1 Brugada pattern. [ABSTRACT FROM AUTHOR]

Introduction Abnormalities of myocardial repolarization may play a key role in the initiation of ventricular fibrillation (VF) in Brugada syndrome (BrS). Recent studies have shown that the height of the T-waves and the T/R ratio are inversely proportional to the sudden cardiac arrest (SCA) risk in early repolarization syndrome and hypertrophic cardiomyopathy. Objective To study the prognostic value of a low T/R ratio in patients (pts) with a spontaneous Brugada type 1 pattern (SBT1). Method In an international retrospective study, we reviewed 115 pts (mean age 45.1 ± 12.8 years, 91.3% males) with SBT1. Forty-five presented a documented VF and/or SCA at a mean age of 38.7 ± 11.5 years, 20 came from a review of published cases reports. Six ECG markers and the T/R ratio in leads V5 and II were studied. A low T/R ratio was defined by < 0.2. Results The T/R ratio was significantly lower in pts with VF/SCA (lead V5: 0.28 ± 0.15 vs. 0.36 ± 0.17, P = 0.008; lead II: 0.47 ± 0.33 vs. 0.61 ± 0.51, P = 0.04). A low T/R ratio in lead V5 or II was significantly associated with VF/SCA (respectively 44.4% vs. 14.3%, P < 0.001 and 22.2% vs. 7.1%, P = 0.02). In multivariate analysis by logistic regression, a low T/R ratio in lead V5 was an independent marker of a higher risk of VF/SCA with an OR of 4.11 (P = 0.02). Brugada type 1 pattern in peripheral leads, wide QRS in lead V2 and early repolarization were other independent risk markers (see Fig. 1). Conclusion A low T/R ratio in lead V5 is an independent marker for VF/SCA risk in patients with a SBT1. [ABSTRACT FROM AUTHOR]

Abstract Introduction We report a case of postural tachycardia syndrome occurring after the surgical correction of an aortic coarctation, and coexisting with upper airway resistance syndrome. Case presentation A 29-year-old Caucasian man complained of extreme fatigue, daytime sleepiness, shortness of breath on exertion, light-headedness and general weakness on standing. These symptoms began shortly after the surgical correction of an aortic coarctation and became progressively more debilitating, impairing any daily activity. An extensive work-up revealed postural tachycardia syndrome and a coexisting sleep-related breathing disorder, characterized as upper airway resistance syndrome. Conclusion This is the first reported case describing the occurrence of postural tachycardia syndrome after the surgical correction of an aortic coarctation. This case also provides evidence for the suggestion that this syndrome may coexist with upper airway resistance syndrome, although the exact nature of their relationship must still be better established.

Abstract Background Predicting response to cardiac resynchronization therapy (CRT) remains a challenge. We evaluated the role of baseline QRS pattern to predict response in terms of improvement in biventricular ejection fraction (EF). Methods Consecutive patients (pts) undergoing CRT implantation underwent radionuclide angiography at baseline and at mid-term follow-up. The relationship between baseline QRS pattern and mechanical dyssynchrony using phase analysis was evaluated. Changes in left and right ventricular EF (LVEF and RVEF) were analyzed with regard to baseline QRS pattern. Results We enrolled 56 pts, 32 with left bundle branch block (LBBB), 4 with right bundle branch block (RBBB) and 20 with non-specific intraventricular conduction disturbance (IVCD). A total of 48 pts completed follow-up. LBBB pts had significantly greater improvement in LVEF compared to RBBB or non-specific IVCD pts (+9.6 ± 10.9% vs. +2.6 ± 7.6%, p = 0.003). Response (defined as ≥ 5% increase in LVEF) was observed in 68% of LBBB vs. 24% of non-specific IVCD pts (p = 0.006). None of the RBBB pts were responders. RVEF was significantly improved in LBBB (+5.0 ± 9.0%, p = 0.007), but not in non-specific IVCD and RBBB pts (+0.4 ± 5.8%, p = 0.76). At multivariate analysis, LBBB was the only predictor of LVEF response (OR, 7.45; 95% CI 1.80-30.94; p = 0.006), but not QRS duration or extent of mechanical dyssynchrony. Conclusions Presence of a LBBB is a marker of a positive response to CRT in terms of biventricular improvement. Pts with non-LBBB pattern show significantly less benefit from CRT than those with LBBB.

Introduction: During implantation of biventricular devices, manipulation of the guiding sheath during localization of the coronary sinus (CS) ostium may result in injury to the right bundle and complete heart block. A preventive measure is to implant the right ventricular (RV) lead first, though this may interfere with manipulation of the guiding sheath and dislodge the permanent lead. We tested the feasibility of backup pacing with a 0.035' guidewire, advanced through the guiding sheath during CS localization. Methods: One hundred six consecutive patients (mean age = 70 ± 11 years, 81 men) undergoing biventricular device implantation were studied. A 0.035\'02\'02 guidewire with an uncoated tip was advanced into the right ventricle through the guiding sheath, and unipolar capture threshold, R-wave sensing amplitude, and pacing impedance were measured. Results: RV pacing was successful in all patients. The mean capture threshold was 3.8 ± 2.1 V/0.5 ms, R-wave amplitude 5.4 ± 4.3 mV, and pacing impedance 226 ± 78 omega. No arrhythmia was observed during the tests. Two patients developed complete heart block during the implant procedure and were successfully paced temporarily using the 0.035' guidewire. Conclusion: Temporary RV pacing, using a 0.035' guidewire within the guiding sheath, is a simple, reliable, and safemethod that allows backup pacing in case of traumatic complete heart block, developing during the implantation of biventricular devices. [ABSTRACT FROM AUTHOR]

Describes the case of a diagnostic pitfall in a patient with an implantable cardioverter-defibrillator. Admission of the patient to the hospital due to repeated shocks from his Guidant Ventak Prizm dual chamber implantable cardioverter-defibrillator.

Presents a case of a 41-year-old woman diagnosed with papillary fibroelastoma which causes cardioembolic stroke. Nuclear magnetic resonance imaging of the brain; Transesophageal echocardiography; Surgery for ablation of the mass with preservation of the aortic valve.

A 42-year-old woman was referred after the discovery of a 3/6 diastolic murmur maximal at the aortic region, with vigorous pulsation of the suprasternal notch. Echocardiography followed by magnetic resonance imaging revealed a fusiform aneyurism of the ascending aorta, without evidence of dissection, extending from the aortic root up to the brachiocephalic artery, associated with severe aortic regurgitation. Histological examination of the operative material showed a Erdheim-Gsell cystic medial necrosis of the aorta.

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Objectives: This meta-analysis compared amiodarone with placebo and class Ic drugs for the cardioversion of recent-onset atrial fibrillation (AF), defined as lasting less than seven days.Background: Despite the lack of trials that support its efficacy convincingly, amiodarone is widely used for conversion of recent-onset AF.Methods: We searched Medline and EMBASE databases, as well as the Cochrane Controlled Trials Register for randomized trials on recent-onset AF comparing amiodarone to placebo or class Ic drugs. Data were combined according to a fixed effect model. The primary end point was the rate of conversion at 24 h. To study time-dependency of the drugs, efficacy at 1 to 2 h, 3 to 5 h, 6 to 8 h, and at 24 h was analyzed.Results: We found six studies randomizing amiodarone versus placebo (595 patients) and seven studies versus class Ic drugs (579 patients). There was no significant difference between amiodarone and placebo at 1 to 2 h, but significant efficacy was found after 6 to 8 h (relative risk [RR] 1.23, p = 0.022) and at 24 h (RR 1.44, p < 0.001). Efficacy with amiodarone was inferior to class Ic drugs for up to 8 h (RR 0.67, p < 0.001) but no difference was seen at 24 h (RR 0.95, p = 0.50). There were no major adverse effects.Conclusions: Amiodarone is superior to placebo for cardioversion of AF, and even though the onset of conversion is delayed, its efficacy is similar at 24 h compared with class Ic drugs. These results favor amiodarone as a reasonable alternative for patients with recent AF in whom class Ic and other, more rapidly acting antiarrhythmic drugs cannot be used. [ABSTRACT FROM AUTHOR]

Introduction et but de l’étude L’impédancemétrie corporelle bioélectrique est une méthode recommandée pour mesurer la composition corporelle. L’évaluation nutritionnelle est essentielle chez les patients souffrants de maladies chroniques comme l’insuffisance cardiaque sévère à fraction d’éjection ventriculaire gauche réduite, souvent porteurs d’un défibrillateur cardioverteur implantable, car le risque de dénutrition est élevé. Les guidelines de l’ESPEN [1] déconseillent l’utilisation de l’impédancemétrie corporelle bioélectrique chez ces patients à cause des interférences électromagnétiques qui pourraient notamment provoquer des chocs inappropriés. Matériel et méthodes Durant 3 mois consécutifs, la composition corporelle a été mesurée par impédancemétrie corporelle bioélectrique utilisant un générateur/analyseur de courant (Nutriguard M, DataInput, Allemagne) à 800 mAmp et 3 fréquences (5, 50, 100 kHz) chez des patients ambulatoires venant contrôler leurs défibrillateur cardioverteur implantable. Les niveaux de sensibilités du défibrillateur cardioverteur implantable étaient réglés à leurs maximums pour maximiser le risque d’interférences électromagnétiques. Les thérapies du défibrillateur cardioverteur implantable étaient inactivées le temps de la mesure. L’électrogramme intracardiaque était surveillé en temps réel pour évaluer la présence d’interférences électromagnétiques durant la mesure par impédancemétrie corporelle bioélectrique. Résultats Ont été inclus 63 patients (54 hommes) porteurs de défibrillateur cardioverteur implantable (simple et double-chambre, biventriculaire) provenant des 5 fabricants principaux : Biotronik ( n = 11), Boston scientific ( n = 15), Medtronic ( n = 20), Sorin ( n = 4), et St-Jude ( n = 13). L’âge moyen était de 64,8 ± 14,6 ans, la fraction d’éjection ventriculaire gauche moyenne de 32,1 ± 16,5 %. Quarante-trois pour cent étaient classés > 2 pour la dyspnée selon la New York Heart Association. Le temps moyen depuis l’implantation du défibrillateur cardioverteur implantable était de 23,8 ± 21 mois. Aucune interférence électromagnétique n’a été détectée par le défibrillateur cardioverteur implantable chez ces patients, et aucun artéfact n’était visualisé sur les électrogrammes. Conclusion L’ impédancemétrie corporelle bioélectrique peut être effectuée en toute sécurité chez les patients porteurs d’un défibrillateur cardioverteur implantable. Cela est un message important afin d’améliorer le dépistage et la prise en charge de la dénutrition chez les patients atteints d’insuffisance cardiaque sévère, qui sont à haut risque nutritionnel. Les guidelines de l’ESPEN [1] concernant les modalités d’utilisation de l’impédancemétrie corporelle bioélectrique pourraient être mis à jour. [ABSTRACT FROM AUTHOR]