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Background: The association between Body Mass Index (BMI) and clinical outcomes following sepsis continues to be debated. We aimed to investigate the relationship between BMI and in-hospital clinical course and mortality in patients hospitalized with bacteremic sepsis using real-world data. Methods: A sampled cohort of patients hospitalized with bacteremic sepsis between October 2015 and December 2016 was identified in the National Inpatient Sample (NIS) database. In-hospital mortality and length of stay were defined as the relevant outcomes. Patients were divided into 6 BMI (kg/m2) subgroups; (1) underweight ≤ 19, (2) normal-weight 20–25, (3) over-weight 26–30, (4) obese I 31–35, (5) obese II 36–39, and (6) obese stage III ≥ 40. A multivariable logistic regression model was used to find predictors of mortality, and a linear regression model was used to find predictors of an extended length of stay (LOS). Results: An estimated total of 90,760 hospitalizations for bacteremic sepsis across the U.S. were analyzed. The data showed a reverse-J-shaped relationship between BMI and study population outcomes, with the underweight patients (BMI ≤ 19 kg/m2) suffering from higher mortality and longer LOS as did the normal-weight patients (BMI 20–25 kg/m2) when compared to the higher BMI groups. The seemingly protective effect of a higher BMI diminished in the highest BMI group (BMI ≥ 40 kg/m2). In the multivariable regression model, BMI subgroups of ≤19 kg/m2 and ≥40 kg/m2 were found to be independent predictors of mortality. Conclusions: A reverse-J-shaped relationship between BMI and mortality was documented, confirming the “obesity paradox” in the real-world setting in patients hospitalized for sepsis and bacteremia.

While obesity has been shown to be associated with elevated risk for Sudden Cardiac Death (SCD), studies examining its effect on outcomes in SCD victims have shown conflicting results. We aimed to describe the body mass index (BMI) distribution in a nationwide cohort of patients admitted for an out of hospital SCD (OHSCD), and the relationship between BMI and in‐hospital mortality. We drew data from the U.S. National Inpatient Sample (NIS), to identify cases of OHSCD. Patients were divided into six groups based on their BMI (underweight, normal weight, overweight, obese I, obese II, extremely obese). Socio‐demographic and clinical data were collected, mortality and length of stay were analyzed. Multivariate analysis was performed to identify predictors of mortality. Among a weighted total of 2330 hospitalizations for OHSCD in patients with documented BMI, the mean age was 62.3 ± 29 years, 52.4% were male and 62% were white. The overall rate of in‐hospital mortality was 69.3%. A U‐shaped relationship between the BMI and mortality was documented, as patients with 25

BACKGROUND Catheter ablation (CA) for ventricular arrhythmias (VAs) is increasingly utilized in recent years. We aimed to investigate the nationwide trends in utilization and procedural complications of CA for VAs in patients with mechanical valve (MV) prosthesis. METHODS We drew data from the US National Inpatient Sample database to identify cases of VA ablations, including premature ventricular contraction and ventricular tachycardia, in patients with MVs, between 2003 and 2015. Sociodemographic and clinical data were collected and the incidence of catheter ablation complications, mortality, and length of stay were analyzed. We compared the outcomes to a propensity-matched cohort of patients without prior valve surgery. RESULTS The study population included a weighted total of 647 CA cases in patients with prior MVs. The annual number of ablations almost doubled, from 34 ablations on average during the "early years" (2003-2008) to 64 on average during the "late years" (2009-2015) of the study (p = .001). Length of stay at the hospital did not differ significantly between patients with MVs and 649 matched patients without prior MVs (5.4 ± 0.4, 4.7 ± 0.3 days, respectively, p = .12). The data revealed a trend toward a higher incidence of complications (12.6% vs. 7.5% respectively, p = .14) and mortality (3.7% vs. 0.7%, respectively, p = .087) among patients with MVs compared to the matched control group, not reaching statistical significance. CONCLUSION The data show increased utilization of VA ablations in patients with MVs and a trend toward a higher incidence of in-hospital mortality and complications compared to the propensity-matched control group without MVs.

Background Evidence of diastolic dysfunction (DD) required for the diagnosis of heart failure with preserved ejection fraction (HFpEF) is elusive in atrial fibrillation (AF). Left ventricular (LV) and left atrial (LA) speckle-tracking echocardiography (STE) may provide rhythm independent indications of DD. We aimed to find common LV/LA myocardial mechanics parameters to demonstrate DD, using STE in patients with AF. Methods 176 echocardiographic assessments of patients were studied retrospectively by STE. 109 patients with history of AF were divided in three groups: sinus with normal diastolic function (n = 32, ND), sinus with DD (n = 35, DD) and patients with AF during echocardiography (n = 42). These assessments were compared to 67 normal controls. Demographic, clinical, echocardiographic and myocardial mechanic characteristics were obtained. Results The patients with DD in sinus rhythm and patients with AF were similar in age, mostly women, and had cardiovascular risk factors as well as higher dyspnea prevalence compared to either controls or patients with ND. In the AF group, LV ejection fraction (LVEF) (p = 0.008), global longitudinal strain and LA emptying were lower (p p Conclusions Vmin-I may be used to identify DD and assist in the diagnosis of HFpEF in patients with AF.

Background: Obesity has been associated with increased incidence and severity of various cardiovascular risk factors and increased risk for stroke. However, the evidence of its effect on outcomes in stroke victims have been equivocal. We aimed to investigate the distribution of BMI in a nation-wide cohort of individuals, admitted for a stroke, and the relationship between BMI and in-hospital mortality. Methods: Data from the U.S. National Inpatient Sample (NIS) was collected, to identify hospitalizations for stroke, between October 2015 and December 2016. The patients were sub-divided into six groups based on their BMI: underweight, normal weight, overweight, obese I, obese II and extremely obese groups. Various sociodemographic and clinical parameters were gathered, and incidence of mortality and the length of hospital stay were analyzed. Multivariable analysis was performed to identify independent predictors of in-hospital mortality. Results: A weighted total of 84,185 hospitalizations for stroke were included in the analysis. The approximate mean patients aged was 65.5 ± 31 years, the majority being female (55.3%) and white (63.1%). The overall in-hospital mortality during the study period was 3.6%. A reverse J-shaped relationship between the body mass index and in-hospital mortality was documented, while patients with elevated BMI showed significantly lower in-hospital mortality compared to the underweight and normal weight study participants, 2.8% vs. 7.4%, respectively, p < 0.001. Age and several comorbidities, as well as the Deyo Comorbidity Index, were found to predict mortality in a multivariable analysis. Conclusion: A reverse J-shaped relationship between body mass index and in-hospital mortality was documented in patients admitted for a stroke in the U.S. during the study period. The above findings support the existence of an “obesity paradox” in patients hospitalized following a stroke, similar to that described in other cardiovascular conditions.

Catheter ablation (CA) for atrial fibrillation (AF) is increasingly utilized in recent years, with promising results. We aimed to investigate the nationwide trends in utilization and procedural complications of CA for AF in patients with mechanical prosthetic valves (MPVs).We drew data from the US National Inpatient Sample (NIS) database to identify cases of AF ablations in patients with MPVs, between 2003 and 2015. Sociodemographic and clinical data were collected, and incidence of procedural complications, mortality, and length of stay were analyzed. We compared the outcomes to a propensity-matched cohort of patients without MPVs. The study included a weighted total of 1898 CA for AF cases in patients with MPVs. The median age of the study population was 67 (61-75) years and 53% were males. Despite the increasing age and significant uptrend in the prevalence of individual comorbidities and Deyo-Charlson Comorbidity Index (CCI) over the years, the risk of peri-procedural complications and mortality in the study group did not change between the early (2003-2008) and late (2009-2015) study years. The peri-procedural complication rate (8.4% vs. 10.4%, p = .33) and in-hospital mortality (0.2% vs. 0.2%, p = .9) did not differ significantly between patients with MPVs and 1901 matched patients without MPVs. Length of stay was higher among patients with prior MPVs compared to the controls (4.0 ± 0.2 vs. 3.3 ± 0.2 days, p = .011).This nationwide analysis shows that AF ablation in patients with mechanical valve prothesis bares a similar risk of periprocedural complications and mortality as in patients without prosthetic valves.

We aimed to describe the epidemiology of sudden cardiac death (SCD) in the obese, elaborating on the potential pathophysiological mechanisms linking obesity, SCD, and the outcomes in SCD survivors, as well as looking into the intriguing "obesity paradox" in these patients.Several studies show increased mortality in patients with BMI 30 kg/m

Purpose We have recently reported a method for measuring rest-stress myocardial blood flow (MBF) using a single, relatively short, PET scan session. The method requires two IV tracer injections, one to initiate rest imaging and one at peak stress. We previously validated absolute flow quantitation in ml/min/cc for standard bull's eye, segmental analysis. In this work, we extend the method for fast computation of rest-stress MBF parametric images. Methods We provide an analytic solution to the single-scan rest-stress flow model which is then solved using a two-dimensional table lookup method (LM). Simulations were performed to compare the accuracy and precision of the lookup method with the original non-linear method (NLM). Then the method was applied to 16 single scan rest/stress measurements made in 12 pigs: 7 studied after infarction of the left anterior descending artery (LAD) territory, and 9 imaged in the native state. Parametric maps of rest and stress MBF as well as maps of left (fLV) and right (fRV) ventricular spill-over fractions were generated. Regions of interest (ROIs) for 17 myocardial segments were defined in bull's eye fashion on the parametric maps. The mean of each ROI was then compared to the rest (K1r) and stress (K1s) MBF estimates obtained from fitting the 17 regional TACs with the NLM. Results In simulation, the LM performed as well as the NLM in terms of precision and accuracy. The simulation did not show that bias was introduced by the use of a predefined two-dimensional lookup table. In experimental data, parametric maps demonstrated good statistical quality and the LM was computationally much more efficient than the original NLM. Very good agreement was obtained between the mean MBF calculated on the parametric maps for each of the 17 ROIs and the regional MBF values estimated by the NLM (K1map LM=1.019 x K1ROI NLM + 0.019, R2=0.986; mean difference= 0.034 ± 0.036 mL/min/cc). Conclusions: We developed a table lookup method for fast computation of parametric imaging of rest and stress MBF. Our results show the feasibility of obtaining good quality MBF maps using modest computational ressources, thus demonstrating that the method can be applied in a clinical environment to obtain full quantitative MBF information. This article is protected by copyright. All rights reserved.

Aims Cardiac resynchronization therapy (CRT) device implantation has been shown to reduce morbidity and mortality in selected patients with heart failure. We sought to investigate the utilization and in-hospital complications of cardiac resynchronization therapy defibrillator (CRT-D) and pacemaker (CRT-P) implantations in the United States from 2003 to 2013. Methods and results Patients receiving CRT-D or CRT-P were identified in the National Inpatient Sample database (NIS), using the International Classification of Diseases-Ninth Revision-Clinical Modification procedure codes. Annual implantation rates, patient demographics, co-morbidities, in-hospital complications, and length of stay were analysed. From 2003 to 2013, an estimated total of 439 010 (95% CI: 406 723–471 296) inpatient CRT implantations were performed in the U.S. The median age of patients was 72 and 71% were male. Overall, 6.1% had at least one complication. During the study period, comorbidity index and overall complication rate increased (P = 0.002 and P = 0.01, respectively). Mortality and length of stay showed no significant trend. Predictors of complications included: age 65 and older, female sex (OR: 1.19; 95% CI: 1.12–1.27), Deyo–Charlson Comorbidity Index, and elective admission (OR: 0.61; 95% CI: 0.57–0.66). Conclusion From 2003 to 2013, the severity of comorbid conditions increased and a rising trend was observed in the rate of periprocedural complications among patients undergoing CRT in the United States. In-hospital mortality and length of stay showed no uniform trend.

A Novel Annotation Technique During Mapping to Facilitate the Termination of ATIntroduction The treatment of atrial tachycardia (AT) occurring after ablation for atrial fibrillation (AF) is challenging. The most common ablation strategy relies on entrainment, and electroanatomic activation mapping (EAM) using a conventional window of interest (WOI), centered on the easily detectable atrial signal on the coronary sinus catheter. We describe a novel EAM annotation technique that uses a WOI starting 40 milliseconds prior to the P wave in order to detect the reentrant AT exit site. This WOI timing is based on the similarity between scar-related reentrant AT and scar-related ventricular tachycardia. Methods Patients with AT after prior ablation for AF were included. The EAM of the AT was performed using the novel mapping annotation technique. The ablation was considered successful if the AT terminated during ablation at the site identified by this strategy. Results Twenty-eight patients with 36 ATs were included. The ATs were classified as follows: mitral annulus (13/36), roof (11/36), anterior/posterior/lateral left atrial wall (10/36), and RA (2/36). A complete EAM using the novel annotation technique was achieved in 34 of 36 AT's, encompassing 94 ± 6.5% of the cycle length. Low amplitude pre-P fractionated electrograms were found in 34 of 36 (94%) ATs and these occurred at a mean distance of 1.8 ± 1.2 mm from the “early-meets-late” line. Ablation at these areas resulted in termination of 34 of 36 ATs (94%). Conclusion The novel EAM annotation allows the accurate detection of the critical isthmus of post-AF ablation AT. Ablation of these isthmuses results in termination of the AT in the vast majority of patients.

Cardiac resynchronization therapy (CRT) has a symptomatic and survival benefit for patients with heart failure (HF), but the percentage of nonresponders remains relatively high. The aims of this study were to assess the clinical significance of baseline tricuspid regurgitation (TR) or worsening TR after implantation of a CRT device on the response to therapy. This is a multicenter retrospective analysis of prospectively collected databases that includes 689 consecutive patients who underwent implantation of CRT. The patients were divided into groups according to baseline TR grade and according to worsening TR within 15 months after device implantation. Outcome was assessed by clinical and echocardiographic response within 15 months and by estimated survival for a median interquartile range follow-up time of 3.3 years (1.6, 4.6). TR worsening after CRT implantation was documented in 104 patients (15%). These patients had worse clinical and echocardiographic response to CRT, but worsening of TR was not a significant predictor of mortality (p = 0.17). According to baseline echocardiogram, 620 patients (90%) had some degree of TR before CRT implant. Baseline TR was an independent predictor of worse survival (p0.001), although these patients had significantly better clinical and echocardiographic response compared with patients without TR. In conclusion, worsening of TR after CRT implantation is a predictor of worse clinical and echocardiographic response but was not significantly associated with increased mortality. Baseline TR is associated with reduced survival despite better clinical and echocardiographic response after CRT implantation.

Cardiac resynchronization therapy (CRT) has been shown to improve heart failure (HF) symptoms and survival. We hypothesized that a greater improvement in left-ventricular ejection fraction (LVEF) after CRT is associated with greater survival benefit.In 693 patients across 2 international centers, the improvement in LVEF after CRT was determined. Patients were grouped as non-/modest-, moderate-, or super-responders to CRT, defined as an absolute change in LVEF of ≤5%, 6-15%, and15%, respectively. Changes in New York Heart Association (NYHA) functional class and left ventricular end-diastolic dimension (LVEDD) were assessed for each group. There were 395 non-/modest-, 186 moderate-, and 112 super-responders. Super-responders were more likely to be female and to have nonischemic cardiomyopathy, lower creatinine, and lower pulmonary artery systolic pressure than non-/modest- and moderate-responders. Super-responders were also more likely to have lower LVEF than non-/modest-responders. There was no difference in NYHA functional class, mitral regurgitation grade, or tricuspid regurgitation grade between groups. Improvement in NYHA functional class (-0.9 ± 0.9 vs -0.4 ± 0.8 [P .001] and -0.6 ± 0.8 [P = .02]) and LVEDD (-8.7 ± 9.9 mm vs -0.5 ± 5.0 and -2.4 ± 5.8 mm [P .001 for both]) was greatest in super-responders. Kaplan-Meier survival analysis revealed that super-responders achieved better survival compared with non-/modest- (P .001) and moderate-responders (P = .049).Improvement in HF symptoms and survival after CRT is proportionate to the degree of improvement in LV systolic function. Super-response is more likely in women, those with nonischemic substrate, and those with lower pulmonary artery systolic pressure.

Background: Contemporary implantable cardiac defibrillators (ICD) enable storage of multiple, preepisode R-R recordings in patients who suffered from ventricular tachyarrhythmia (VTA). Timely prediction of VTA, using heart rate variability (HRV) analysis techniques, may facilitate the implementation of preventive and therapeutic strategies. Aim: To evaluate the novel multipole method of the HRV analysis in prediction of imminent VTAs in ICD patients. Methods: We screened patients from the Biotronik HAWAI Registry (Heart Rate Analysis with Automated ICDs). A total of 28 patients from the HAWAI registries (phase I and II), having medical records, who had experienced documented, verified VTA during the 2-year follow-up, were included in our analysis. HRV during preepisode recordings of 4,500 R-R intervals were analyzed using the Dyx parameter and compared to HRV of similar length recordings from the same patients that were not followed by arrhythmia. Results: Our study population consisted mainly of men 25 of 28 (89%), average age of 64.8 ± 9.4 years, 92% with coronary artery disease. HRV during 64 preevent recordings (2.3 events per patient on average) was analyzed and compared with 60 control recordings. The multipole method of HRV analysis showed 50% sensitivity and 91.6% specificity for prediction of ventricular tachycardia/ventricular fibrillation in the study population, with 84.5% positive predictive value. No statistically significant correlation was found between various clinical parameters and the sensitivity of imminent VTA predetection in our patients. Conclusion: The multipole method of HRV analysis emerges as a highly specific, possible predictor of imminent VTA, providing an early warning allowing to prepare for an arrhythmic episode. (PACE 2013; 36:1342‐1347)

The treatment of atrial tachycardia (AT) occurring after ablation for atrial fibrillation (AF) is challenging. The most common ablation strategy relies on entrainment, and electroanatomic activation mapping (EAM) using a conventional window of interest (WOI), centered on the easily detectable atrial signal on the coronary sinus catheter. We describe a novel EAM annotation technique that uses a WOI starting 40 milliseconds prior to the P wave in order to detect the reentrant AT exit site. This WOI timing is based on the similarity between scar-related reentrant AT and scar-related ventricular tachycardia.Patients with AT after prior ablation for AF were included. The EAM of the AT was performed using the novel mapping annotation technique. The ablation was considered successful if the AT terminated during ablation at the site identified by this strategy.Twenty-eight patients with 36 ATs were included. The ATs were classified as follows: mitral annulus (13/36), roof (11/36), anterior/posterior/lateral left atrial wall (10/36), and RA (2/36). A complete EAM using the novel annotation technique was achieved in 34 of 36 AT's, encompassing 94 ± 6.5% of the cycle length. Low amplitude pre-P fractionated electrograms were found in 34 of 36 (94%) ATs and these occurred at a mean distance of 1.8 ± 1.2 mm from the "early-meets-late" line. Ablation at these areas resulted in termination of 34 of 36 ATs (94%).The novel EAM annotation allows the accurate detection of the critical isthmus of post-AF ablation AT. Ablation of these isthmuses results in termination of the AT in the vast majority of patients.

Contemporary implantable cardiac defibrillators (ICD) enable storage of multiple, preepisode R-R recordings in patients who suffered from ventricular tachyarrhythmia (VTA). Timely prediction of VTA, using heart rate variability (HRV) analysis techniques, may facilitate the implementation of preventive and therapeutic strategies.To evaluate the novel multipole method of the HRV analysis in prediction of imminent VTAs in ICD patients.We screened patients from the Biotronik HAWAI Registry (Heart Rate Analysis with Automated ICDs). A total of 28 patients from the HAWAI registries (phase I and II), having medical records, who had experienced documented, verified VTA during the 2-year follow-up, were included in our analysis. HRV during preepisode recordings of 4,500 R-R intervals were analyzed using the Dyx parameter and compared to HRV of similar length recordings from the same patients that were not followed by arrhythmia.Our study population consisted mainly of men 25 of 28 (89%), average age of 64.8 ± 9.4 years, 92% with coronary artery disease. HRV during 64 preevent recordings (2.3 events per patient on average) was analyzed and compared with 60 control recordings. The multipole method of HRV analysis showed 50% sensitivity and 91.6% specificity for prediction of ventricular tachycardia/ventricular fibrillation in the study population, with 84.5% positive predictive value. No statistically significant correlation was found between various clinical parameters and the sensitivity of imminent VTA predetection in our patients.The multipole method of HRV analysis emerges as a highly specific, possible predictor of imminent VTA, providing an early warning allowing to prepare for an arrhythmic episode.

The ability to achieve transmural, durable ablation lesions is a significant challenge of a pulmonary veins isolation (PVI) procedure resulting in their reconnection. We aim to assess the effect of utilization of a force-sense irrigated tip catheters in conjunction with a novel automated ablation