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Aims To evaluate the benefit of speckle tracking radial strain imaging (STRSI)-guided left ventricular (LV) lead (LVL) positioning in cardiac resynchronization therapy (CRT) in patients (pts) with ischaemic cardiomyopathy with CRT indication. Methods and results We conducted a prospective randomized controlled trial. Patients were enrolled in nine centres with 2:1 randomization into two groups (guided vs. control). Patients underwent STRSI to identify the optimal LV position from six LV segments at midventricular level. Implantation via STRSI was attempted for recommended segment in the guided group only. Follow-up included echocardiography (6 months) and clinical evaluation (6 and 12 months). The primary endpoint was comparison % reduction in LV end-systolic volume at 6 months with baseline. Secondary endpoints included hospitalizations for heart failure and death, and improvement in additional echocardiographic measurements and quality of life score. A total of 172 patients (115 guided vs. 57 control) were enrolled. In the guided group, 60% of the implanted LV leads were adjudicated to be successfully located at the recommended segment, whereas in the control group 44% reached the best STRSI determined segment. There was no difference between the groups in any of the primary or secondary endpoints at 6 and 12 months. Conclusion Our findings suggest that echo-guided implantation of an LV lead using STRSI does not improve the clinical or echocardiographic response compared with conventional implantation.

Epicardial and Pericardia fat have been hypothesized to exert local and systemic pathogenic effects on nearby cardiac structures. The present study aimed to evaluate the impact of epicardial and pericardial fat volumes on the outcome of patients that underwent a first pulmonary vein isolation (PVI) with cryoablation. We included 130 consecutive patients with atrial fibrillation (AF) that underwent contrast enhanced ECG-gated cardiac computed tomography (CCT) before a PVI. The control group included 50 patients in normal sinus rhythm that underwent ECG-gated CT to rule out coronary artery disease. Epicardial and pericardial fat volumes were quantified with CCT. Patients with AF compared to patients with normal sinus rhythm (control group) had significantly larger epicardial (140.3 ± 58.1 vs. 55.9 ± 17.7 ml; respectively, P

Objectives This study aimed to compare permanent pacemaker implantation (PPMI) rates among patients undergoing Trans-catheter Aortic Valve Implantation (TAVI) with first generation (G1) versus second generation (G2) valves and the impact of PPMI on long-term mortality. Background PPMI is a known adverse event after TAVI. Recently, two novel iterations of valve designs of both the balloon expandable valves (BEV) and self-expanding valves (SEV) were introduced as a second generation valves. Methods All patients included in the Israeli multicenter TAVI registry were grouped according to valve type (BEV vs. SEV) and generation (G1 vs. G2). A comparison was made for clinical and outcome indices of patients undergoing TAVI with G1 and G2 in each of the valve systems. Results A total of 1377 patients were included. The incidence of PPMI did not differ between G1-BEV versus G2-BEV (15.3% vs. 17.4%; p = 0.598) nor between G1-SEV versus G2-SEV (23.4% vs. 20.3%; p = 0.302). Depth of implantation and complete right bundle branch block were independently associated with PPMI post-TAVI in both valve systems. PPMI was not associated with an increased risk for 2-year mortality. Conclusions The incidence of PPMI remains a relevant adverse event post-TAVI even when the newer generation valves are used. Since the predictors for PPMI are well established, a standardized approach for the management of conduction disorders is much needed.

Cardiovascular implantable electronic device (CIED) replacement is increasingly common. It has been proposed that capsule removal at the time of CIED replacement may reduce infection rates. In this study, we aimed to assess how pocket capsule removal impacted infection rates in patients undergoing CIED replacement. We retrospectively reviewed the medical records of patients who underwent CIED replacement from 2006 to 2016 at a single centre. We retrieved patient data, procedure details, and clinical outcomes. To evaluate the relationship between capsule removal and CIED infection, we used the Cox proportional hazard model, with adjustment for multiple variables. During the study period, 773 patients underwent device replacement. Of these patients, 194 (25%) underwent capsule debridement during the replacement procedure. The mean patient age was 75 ± 15 years, and 281 (36.3%) were females. The replaced CIEDs included DDD pacemakers (32%), VDD pacemakers (15%), VVI/AAI pacemakers (13%), defibrillators (22%), and cardiac resynchronization therapy devices (CRT-D/P) (17%). During an average follow-up of 3.6 years, 42 (5%) patients experienced a CIED infection. Multivariate analysis revealed that patients who underwent capsule removal had a significantly lower risk of CIED infection, with a hazard ratio of 0.32 (95% confidence interval, 0.12–0.83; P = 0.019). Capsule debridement during CIED replacement was associated with a significant reduction of CIED infection risk. There is a need for randomized controlled studies to confirm these findings.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): BIOTRONIK SE & Co. KG OnBehalf BIO|STREAM.HF Background At the beginning of the Covid-19 pandemic in spring 2020, governments around the world issued curfews and other stay at home orders (‘lockdown’) to limit the spread of the SARS-CoV19 virus. This may have forced people to decrease their physical activity. Physical inactivity as well as social stress is known to be especially deleterious for heart failure (HF) patients. The BIO|STREAM.HF study enrolled such HF patients into a prospective registry with Home Monitoring. Purpose We aimed to evaluate the impact of the lockdown during the first Covid-19 pandemic wave on physical activity and arrhythmia burden of heart failure patients. Methods We analysed daily transmitted data of patients enrolled into a large international registry (BIO|STREAM.HF) being implanted with a cardiac resynchronization therapy (CRT) devices. Patients with NYHA ≥ II and LVEF ≤ 40% before CRT implantation were selected. Intra-individual weekly mean and median values were calculated for the following daily transmitted parameters: physical activity (measured as % of the day during which the patient moves), atrial arrhythmia burden, mean heart rate (at rest), PP variability, PVC burden, and rate of biventricular pacing. Values were calculated for 12 weeks before and 12 weeks after the country-specific effective date of most rigorous restrictions in spring 2020 to visualize the general trend of parameter changes. Moreover, values for intra-individual changes between three 28-days periods (before, during, and after the lockdown) were calculated. Results Of 444 patients, 76% were male. They had a mean age of 69 ± 10 years and LVEF of 28.2 ± 6.7%. HF was of ischemic etiology in 42% of cases and they were in NYHA class II (47.5%), III (50.0%) or IV (2.5%). On average, patients were active for 9% of the day (2 h 10 min). The physical activity decreased by approx. 10% with the onset of the lockdown (figure 1) and recovered within the following eight weeks. Comparison of the 28-days periods before, during and after the lockdown showed a statistically significant intra-individual decrease in physical activity (mean decrease 9 min per day) during the lockdown compared to pre- and post-lockdown values and a trend toward reduced mean heart rates. In parallel, a significant increase in device detected atrial arrhythmia burden (mean increase 17 min per day) was observed. All other parameters did not change significantly. Conclusion Our results show that patients reduced their physical activity during the Covid-19 related lockdown in spring 2020. This was associated with an increase in atrial arrhythmia burden and a reduction of the mean heart rate. Prognostic implications of these results will further be analysed. Abstract Figure.

Introduction: In patients with atrial fibrillation (AF) at risk for stroke, dabigatran 150 mg twice a day (DE150) is superior to warfarin for stroke prevention. However, there is paucity of data with respect to bleeding risk at this dose in elderly patients (≥75 years). We aimed to evaluate the safety of DE150 in comparison to warfarin in a real-world population with AF and low bleeding risk (HAS-BLED score ≤2). Methods: In this prospective observational study, 754 consecutive patients with AF and HAS-BLED score ≤2 were included. We compared outcome of elderly patients (age ≥75 tears) to younger patients (age Results: There were 230 (30%) elderly patients, 151 patients were treated with warfarin, and 79 were treated with DE150. Fifty-two patients experienced the primary endpoint during the 1-year follow-up. Among the elderly, at 1-year of follow-up, the cumulative event rate of the combined endpoint in the DE150 and warfarin was 8.9 and 15.9% respectively (p = 0.14). After adjustment for age and gender, patients who were treated with DE150 had a nonsignificant difference in the risk for the combined end point as patients treated with warfarin both among the elderly and among the younger population (HR 0.58, 95% C.I = 0.25–1.39 and HR = 1.12, 95% C.I 0.62–2.00, respectively [p for age-group-by-treatment interaction = 0.83). Conclusions: Our results suggest that Dabigatran 150 mg twice a day can be safely used among elderly AF patients with low bleeding risk.

Infections after placement of cardiac implantable electronic devices (CIEDs) are associated with substantial morbidity and mortality. There is limited evidence on prophylactic strategies, other than the use of preoperative antibiotics, to prevent such infections.We conducted a randomized, controlled clinical trial to assess the safety and efficacy of an absorbable, antibiotic-eluting envelope in reducing the incidence of infection associated with CIED implantations. Patients who were undergoing a CIED pocket revision, generator replacement, or system upgrade or an initial implantation of a cardiac resynchronization therapy defibrillator were randomly assigned, in a 1:1 ratio, to receive the envelope or not. Standard-of-care strategies to prevent infection were used in all patients. The primary end point was infection resulting in system extraction or revision, long-term antibiotic therapy with infection recurrence, or death, within 12 months after the CIED implantation procedure. The secondary end point for safety was procedure-related or system-related complications within 12 months.A total of 6983 patients underwent randomization: 3495 to the envelope group and 3488 to the control group. The primary end point occurred in 25 patients in the envelope group and 42 patients in the control group (12-month Kaplan-Meier estimated event rate, 0.7% and 1.2%, respectively; hazard ratio, 0.60; 95% confidence interval [CI], 0.36 to 0.98; P = 0.04). The safety end point occurred in 201 patients in the envelope group and 236 patients in the control group (12-month Kaplan-Meier estimated event rate, 6.0% and 6.9%, respectively; hazard ratio, 0.87; 95% CI, 0.72 to 1.06; P0.001 for noninferiority). The mean (±SD) duration of follow-up was 20.7±8.5 months. Major CIED-related infections through the entire follow-up period occurred in 32 patients in the envelope group and 51 patients in the control group (hazard ratio, 0.63; 95% CI, 0.40 to 0.98).Adjunctive use of an antibacterial envelope resulted in a significantly lower incidence of major CIED infections than standard-of-care infection-prevention strategies alone, without a higher incidence of complications. (Funded by Medtronic; WRAP-IT ClinicalTrials.gov number, NCT02277990.).

BACKGROUND There are limited data available regarding the relationship between atrial fibrillation (AF) clinical type, oral anticoagulation (OAC) treatment, and clinical outcome after transcatheter aortic valve replacement (TAVR). The study was designed to evaluate this relationship. METHODS We analyzed data from the Rabin Medical Center TAVR registry, including 319 consecutive patients who underwent TAVR from 2008 to 2014. Patients were divided into three groups based on their history of AF: sinus rhythm (SR), paroxysmal AF (PAF), or nonparoxysmal AF (NPAF). RESULTS There were 211 (66%), 56 (18%), and 52 (16%) patients in the SR, PAF, and NPAF groups, respectively. The cumulative risk for stroke or death at 2 years was highest among patients with NPAF (38%), but similarly low in PAF (15%) and SR patients (16%, P < 0.001). By multivariate analysis, patients with NPAF demonstrated a significantly higher risk of stroke or death (HR = 2.76, 95% CI 1.63-4.66, P < 0.001), as compared with SR. In contrast, patients with PAF had a similar risk of stroke or death compared with SR (HR = 0.80, P = 0.508). Patients with NPAF not treated with OAC demonstrated an 8.3-fold (P < 0.001) increased risk of stroke or death, whereas patients with PAF not treated with OAC had a similar risk of stroke or death compared with the SR group (HR = 1.25, P = 0.569). CONCLUSION History of NPAF, but not PAF, is associated with a significant increased risk of stroke or death compared with sinus rhythm in patients undergoing TAVR.

We have previously shown that a response score, including 7 baseline clinical and echocardiographic factors, can be used to predict CRT-D benefit among patients enrolled in MADIT-CRT over a median of 2.4 years. We aimed to evaluate the yield of the score for the assessment of the long-term clinical

Introduction Life expectancy of less than 1 year is usually a contraindication for implantable cardioverter defibrillator (ICD) implantation. The aim was to identify patients at risk of death during the first year after implantation. Methods and results Data were derived from a prospective Israeli ICD Registry. Two groups of patients were compared, those who died and those who were alive 1 year after ICD implantation. Factors associated with 1-year mortality were identified on a derivation cohort. A risk score was established and validated. A total of 2617 patients have completed 1 year of follow-up after ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Age greater than 75 years (hazard ratio [HR], 2.7; 95% confidence interval [95% CI], 1.6 to 4.4), atrial fibrillation (AF; HR, 1.9; 95% CI, 1.12 to 3.17), chronic lung disease (HR, 2.0; 95% CI, 1.1 to 3.76), anemia (HR, 2.3; 95% CI, 1.3 to 3.93) and chronic renal failure (CRF; HR, 3.4; 95% CI, 1.74 to 6.6) were independent risk factors for 1-year mortality. We propose a simple AAACC ("triple A double C") score for prediction of 1-year mortality after ICD implantation: Age greater than 75 years (3 points(pts)), anemia (2 pts), AF (1 pt), CRF (3 pts) and chronic lung disease (1 pt). Mortality risk increased with rising number of points (from 1% with 0 pts to 12.5% with >4 pts). The risk score was evaluated with receiver operating characteristic curve and the area under the curve of the validation curve is 0.71 (95% CI, 0.66 to 0.76). Conclusions Age greater than 75, AF, chronic lung disease, anemia, and CRF were independent risk factors for 1-year mortality. AAACC risk score identifies patients at high risk of death during 1 year after ICD implantation.

Heart failure is an increasingly common condition arising from a variety of different pathophysiological processes. Little is known about the unique features of Israeli Arabs who present with heart failure and who undergo cardiac device implantation. The study population comprised of 4,671 patients who were enrolled in the national Israeli Implantable Cardioverter Defibrillator registry. We compared demographic, clinical, and echocardiographic characteristics; device-related indications; and outcomes between Israeli Arabs (n = 733) and Jews (n = 3,938), who were enrolled in the registry from July 2010 through December 2013. Israeli Arabs constituted 15.7% of the study population. They were younger at presentation compared with Jews (57 ± 15 vs 66 ± 12 years, respectively; p0.001), with a greater burden of co-morbidities, including diabetes mellitus and chronic obstructive lung disease and smoking. In addition, Arab patients had a greater frequency of non-ischemic cardiomyopathy (40.2% vs 24.6%, respectively; p0.001), which was associated with a greater frequency of familial history of sudden cardiac death. During 15 ± 9 month follow-up, the mortality rates and appropriate device therapy were similar in both ethnic groups. In conclusion, Israeli Arab patients implanted with implantable cardioverter defibrillators display unique clinical features with greater prevalence of non-ischemic cardiomyopathy characterized by an early-onset and rapid deterioration.

Background High admission blood glucose (ABG) level has been associated with a poor short-term outcome among non-diabetic patients with heart failure (HF). We aimed to investigate the association between ABG levels and long-term (10 years) mortality in patients with or without pre-existing diabetes mellitus (DM) admitted with HF. Methods We analyzed data on 1811 patients with DM and 2182 patients without pre-existing DM who were hospitalized with HF during a prospective national survey. The relationship between ABG and 10-year mortality was assessed using the Cox proportional hazard model adjusting for multiple variables. ABG was analyzed both as a categorical (200 mg/dL) and as a continuous variable. Results At 10 years of follow-up the cumulative probability of mortality was 85 and 78% among patients with DM and patients with no pre-existing DM (p 200 mg/dL had an increased mortality risk (>200 mg/dL versus 200 mg/dL is associated with increased mortality risk.

Aim: Many publications in recent decades have reported a temporal link between medical events and environmental physical activity. The aim of this study was to analyze the time of occurrence of electrical heart storms against levels of cosmological parameters. Methods: The sample included 82 patients (71 male) with ischemic cardiomyopathy treated with an implantable cardioverter defibrillator at a tertiary medical center in 1999‐2012 (5,114 days). The time of occurrence of all electrical heart storms, defined as three or more events of ventricular tachycardia or ventricular fibrillation daily, was recorded from the defibrillator devices. Findings were analyzed against data on solar, geomagnetic, and cosmic ray (neutron) activity for the same time period obtained from space institutions in the United States and Russia. Results: Electrical storms occurred in all months of the year, with a slight decrease in July, August, and September. Most events took place on days with lower-than-average levels of solar and geomagnetic activity and higher-than-average levels of cosmic ray (neutron) activity. There was a significant difference in mean daily cosmic ray activity between the whole observation period and the days of electrical storm activity (P = 0.0001). Conclusion: These data extend earlier findings on the association of the timing of cardiac events and space weather parameters to the most dangerous form of cardiac arrhythmia-electric storms. Further studies are needed to delineate the pathogenetic mechanism underlying this association. (PACE 2014; 37:1067‐1070)

Aims There are limited data regarding the effect of diabetes mellitus (DM) on the risks of both appropriate and inappropriate implantable cardioverter defibrillator (ICD) therapy. The present study was designed to compare the outcome of appropriate and inappropriate ICD therapy in patients with or without DM. Methods and results The risk of a first appropriate ICD therapy for ventricular tachyarrhythmias (including anti tachycardia pacing and shock) was compared between 764 DM and 1346 non-DM patients enrolled in the national Israeli ICD registry. We also compared the risks of inappropriate ICD therapy, and death or cardiac hospitalization between diabetic and non-diabetic patients. Diabetic patients were older, were more likely to have ischemic cardiomyopathy, lower ejection fraction, atrial fibrillation, and other co-morbidities. The 3-year cumulative incidence of appropriate ICD therapy was similar in the DM and non-DM groups (12 and 13%, respectively, p = 0.983). Multivariate analysis showed that DM did not affect the risk of appropriate ICD therapy (HR = 1.07, 95% CI 0.78–1.47, p = 0.694) or inappropriate therapy (HR = 0.72, 95% CI 0.42–1.23, p = 0.232). However, DM was associated with a 31% increased risk for death or cardiac hospitalization (p = 0.005). Results were similar in subgroup analyses including ICD and defibrillators with cardiac resynchronization therapy function recipients, primary or secondary prevention indication for an ICD. Conclusions Despite a significant excess of cardiac hospitalizations and mortality in the diabetic population, there was no difference in the rate of ICD treatments, suggesting that the outcome difference is not related to arrhythmias.

Environmental Physical Activity. Background: Studies by our group have shown an inverse relationship between sudden death and cardiac rhythm disturbances and environmental levels of geomagnetic activity (GMA). The aim of this study was to use the precise data provided by automatic implantable cardioverter defibrillators (ICDs) regarding the onset of ventricular fibrillation and ventricular tachycardia to link these events to GMA level. Patients and Methods: The study group included 25 patients (22 men; 22 with ischemic cardiomyopathy) aged 28-81 years in whom an ICD had been implanted between 1995 and 2004. Patients were referred to the cardiac intensive care unit after each event that induced one or more discharges. The number of events and the day on which they occurred were recorded. Data on GMA and other cosmophysical parameters were obtained from the U.S. National Geophysical and Space Service Centers and the Russian Academy of Sciences. GMA levels, graded from I (quiet) to IV (stormy) in the middle latitutes, were recorded for 1974-2003 (10,954 days) and for each day on which an ICD discharge occurred. Results: A total of 402 discharges were recorded on 137 days during the study period. Forty-six percent of the discharges took place on days of GMA I, compared with 38% - II, 13% - III, and 3% - IV. The daily distribution of GMA was as follows: level I - 35.2%, II - 37.3%, III - 21.86%, IV - 5.61%. Comparison of ICD discharge days and actual multiyear levels of GMA (in percent) yielded a ratio of 1.326 for GMA I, 1.076 - II, 0.459 - III, 0.390 - IV. There was a significant inverse correlation between GMA level and number of discharges (r = -0.97, P = 0.03) and days of treatment (r = -0.96, P = 0.039), and a significant difference between ICD discharges on days of GMA I and GMA II-IV (Χ 2 = 5.05, P = 0.02). Conclusion: The higher number of ICD discharges on days of lowest GMA maybe explained by a possible antiarrhythmic effect of GMA. Environmental arrhythmogenic factors that act inversely to GMA may be activated at times of low GMA.

Thirty- to 35% of patients after transcatheter aortic valve implantation undergo implantation of a permanent pacemaker (PPM) because of development of atrioventricular block (AVB) or development of a condition with high risk of progression to AVB. There are insufficient data regarding long-term follow-up on pacing dependency. From February 2009 to July 2011, 191 transcatheter aortic valve implantation procedures were performed at the Rabin Medical Center (125 CoreValve and 66 Edwards SAPIEN). Thirty-two patients (16.7%) received a PPM (30 with CoreValve and 2 with Edwards SAPIEN). Data from the pacemaker clinic follow-up was available in 27 patients. After a mean follow-up of 52 weeks (range, 22 to 103), only 8 (29%) of 27 patients were pacing dependent. The indication of PPM in these 8 patients was complete AVB. In conclusion, in our center, the rate of PPM implantation was 16%, which is lower than that reported in the published works. Only 29% of those patients implanted with PPM were pacemaker dependent. Further studies are necessary to define reliable predictors for long-term pacing.

Percutaneous coronary intervention (PCI) in octogenarian patients has been associated with increased cardiovascular morbidity and mortality. This study aimed to assess acute and intermediate-term clinical outcomes among octogenarians undergoing PCI.The authors identified 97 consecutive patients agedor =80 years who underwent PCI using stents between November 2000 and February 2002 at their institution. The patients were divided into three groups according to clinical presentation: (1) acute myocardial infarction (AMI, n = 31); (2) unstable angina pectoris (UAP, n = 28); and (3) stable angina pectoris (SAP, n = 38). Procedural data, and in-hospital and six-month clinical outcomes were obtained and adjudicated for all patients.Overall mean age was 84 +/- 3 years, 67% of patients were males and 73% had multivessel coronary disease. In-hospital outcomes varied according to clinical presentation: procedural success was 78% in AMI patients (including shock patients), 93% in UAP, and 95% in SAP patients. Likewise, hospital mortality was 26% in AMI, 3.6% in UAP, and 0% in SAP patients (p = 0.0003). Among AMI patients, hospital mortality was extremely high in patients with cardiogenic shock (67% versus 4.6% in AMI without shock, p0.0001). Cumulative event rate at six months also varied according to clinical presentation: mortality/MI and target vessel revascularization (TVR) rates were 29%, 3.6%, and 0% in AMI, 7.1%, 7.4%, and 11% in UAP and 0%, 5.3%, and 7.9% in SAP patients. Multivariate analysis identified cardiogenic shock as the most powerful risk factor for predicting mortality (odds ratio = 42, p = 0.03).These results show that clinically stable octogenarian patients undergoing PCI have favorable procedural and intermediate-term prognosis. In contrast, cardiogenic shock has a profound negative prognostic impact on octogenarians despite 'aggressive' PCI attempts.

Background : Since its introduction, the implantable cardioverter defibrillator (ICD) has evolved to its present status as the dominant therapeutic modality for patients with life-threatening arrhythmias. Several randomized studies have shown the benefit of ICD implantation as the first choice of treatment for primary as well as secondary indications for ventricular arrhythmias. Therefore, it is expected that the use of ICDs will increase further. The main objectives of this study were to analyze the Israeli experience with ICD implantation from 1993 to 1999, to examine the diffusion of ICD therapy in Israel and the evolution of implantation patterns and indications. Methods : We conducted a retrospective review and analysis of an ICD registry for the period of January 1993–December 1999. Data collected included demographic, administrative, clinical and survival data. Results : A total of 732 new implantations were identified and reviewed. The mean length of follow up of all patients was 30.7±21.1 months. 86% of patients were males and the mean age at implantation was 62.6±12.4 years. 79% of patients had CAD and the mean EF of all patients was 29.2±11.2%. 135 patients (18.4%) died during follow-up. One, two and three-year survival rates were calculated and were 92.7%, 87.8% and 82.0% respectively. A steady increase in implantation rate and in implanting centers was observed over the years. Conclusions : ICD therapy is relatively expensive; therefore a national registry which is continuously monitored may be the most expedient method to follow clinical and economic aspects of the utilization of this therapeutic modality.

Aim To evaluate the incidence and prognostic implications of ventricular tachyarrhythmias (VTAs) complicating acute myocardial infarction (MI). Methods and results We evaluated 7669 MI patients [ST elevation ( n = 3573) and non-ST-elevation acute coronary syndrome (ACS) ( n = 4096)] from the Acute Coronary Syndrome Israeli Survey for the incidence of VTA. Ventricular tachyarrhythmia occurred in 3.8% of patients [2.1% early (≤48 h) and 1.7% late (>48 h) VTA]. In-hospital mortality rates were higher for patients with VTA when compared with patients with no VTA ( P < 0.001). Consistent with these findings, multivariable analysis demonstrated that early and late VTAs were associated with increased risk of in-hospital death [hazard ratio (HR) = 3.84; 95% confidence interval (CI) 1.77–6.78, P < 0.001, and HR = 8.23; 95% CI 4.84–13.98, P < 0.001, respectively]. In contrast, post-discharge outcomes demonstrated that only late VTA was independently associated with a significant increased risk of 30-day mortality (HR = 5.17; 95% CI 1.54–17.27, P = 0.007) with a trend towards an increased 1-year mortality risk (HR = 1.69; 95% CI 0.79–3.62, P = 0.17). The long-term risk associated with in-hospital VTA was driven by sustained ventricular tachycardia (VT) (HR = 3.28; 95% CI 1.92–5.60, P < 0.001) but not ventricular fibrillation (HR = 1.27; 95% CI 0.65–2.49, P = 0.47). Conclusions Our findings suggest that in patients with ACS, both early and late VTAs are associated with an increased risk of in-hospital mortality. However, only late VTA, mostly sustained VT, is associated with long-term adverse outcome.

Background: In vitro studies showed that low-frequency ultrasound (US) causes blood clot dissolution. This effect is augmented with thrombolytics, microbubbles and microparticles. However, in animal models of transcutaneous delivery, US alone is not effective, probably due to attenuation of US energy by overlying skin. When combined with thrombolytics or microbubbles, transcutaneous US is highly effective. Purpose: To assess the synergistic effect of low-intensity low-frequency US and saline, hydroxyethyl starch (HAES) (a non-gas filled microparticle containing solution), streptokinase (STK), and their combination on blood clot disruption. Methods: Human blood clots from 4 healthy donors, 2–4 hours old, were immersed for 0, 15, or 30 min in 37°C in 10 ml of the above-mentioned solutions, and then were randomized to 10 sec of 20 kHz US or no US. The % difference in weight was calculated. Results: Immersion for 30 min without US resulted in 13.8 ± 1.2% clot lysis in saline, and 22.0 ± 1.3%, 21.7 ± 2.1%, and 23.2 ± 1.9% in STK, HAES, and STK + HAES, respectively (p = 0.002). US augmented clot lysis in all groups and at all time points. With low-intensity US, HAES was not better than saline. However, the combination of HAES + STK with US resulted in larger clot disruption at 15 sec incubation time (46.7 ± 3.2%) than with saline (29.6 ± 2.1%), HAES (29.6 ± 2.5%), and STK (32.8 ± 3.6%) (p < 0.001). Conclusion: low-frequency, low-intensity US combined with HAES and STK resulted in greater clot disruption at short incubation times. This combination may assist in achieving faster reperfusion in in vivo models.

The most effective pharmacological management of frequent ventricular tachyarrhythmia events in patients with an implantable defibrillator who failed or did not tolerate amiodarone is unknown. The aim of this retrospective cohort study was to assess the efficacy and tolerability of mexiletine in such patients. The patients served as self-controls. The number of treated ventricular tachyarrhythmia episodes (primary outcome); mortality, shocks from the defibrillator, and electrical storm events (secondary outcomes) during mexiletine therapy was compared with a matched duration of observation just before initiating mexiletine in 29 patients who were treated with a median dose of 300 mg/d of mexiletine and were followed for a median of 12 months. None of the patients had to stop mexiletine due to side effect. There was a significant reduction in the incidence of ventricular tachycardia/fibrillation episodes (median 2 vs. 12 events, P = 0.001) and shocks (median 0 vs. 2 events, P = 0.003) in the first 3 months of treatment, but long-term efficacy was only observed among patients who continued amiodarone therapy. In conclusion, mexiletine, when added to amiodarone in case of amiodarone inefficacy, reduces ventricular tachycardia/fibrillation events and appropriate therapies in patients with an implantable cardioverter defibrillator. A randomized trial should validate the efficacy and safety of mexiletine as an adjunctive therapy to amiodarone.

Atrial Signal Amplitude Measurements in VDD Systems According to Body Position. Single lead VDD pacing is an established therapy in patients with AV block. Body position may influence the amplitude of the atrial signal recorded through the floating atrial electrode. This study analyzed the degree of posture related variation in the signal amplitude of floating atrial electrodes in 63 patients (mean age 72 ′ 21 years) implanted with a VDD system. The average atrial amplitude in the supine position was 1.59 ′ 1.15 mV and decreased significantly in the sitting position (1.37 ′ 1.08, P < 0.014), right decubitus (1.33 ′ 0.83, P < 0.007), and the abdominal position (1.24 ′ 0.86, P < 0.001). The left side decubitus showed a nonsignificant increase in atrial amplitude (1.66 ′ 1.02, P < 0.64). Body position significantly affects P wave amplitude and may be the cause of intermittent atrial undersensing. P wave amplitude measurement in different body postures should be performed in cases where suspected atrial undersensing occurs.

Background Limited data suggest that optimal atrioventricular (AV) and interventricular (VV) delays are different at rest than during exercise in patients with heart failure. We assessed the feasibility and reproducibility of an electrogram-based method of optimization called QuickOpt at rest and during exercise. Methods Patients with a St Jude Medical cardiac resynchronization therapy implantable cardioverter-defibrillator were subjected to a graded treadmill test, and QuickOpt was repeatedly measured prior to, during, and after the exercise. Results Twenty-four patients (16 males, aged 67.4 ± 7.7 years) participated. At rest, delays (in ms) were 110.4 ± 20.1 for sensed AV delay and –70 (LV pacing first) to +20 (RV pacing first) for VV delay. The changes in QuickOpt-derived delays at rest were not significant despite change in body position. During exercise, QuickOpt-derived AV delays did not change in 11 patients, were shorter during peak exercise in 8 patients, and were longer in 3 patients (average value during peak exercise was 126.5 ± 15.8 ms, P = 0.04 compared to baseline). The QuickOpt-derived VV delay gradually shifted toward earlier right ventricular pacing during exercise in 19 patients, while no changes were seen in 3 patients, and a shift occurred toward earlier left ventricular pacing in 2 patients (average value during peak exercise was –30.7 ± 22.2; P = 0.001 compared to baseline). There was no correlation between changes in the QuickOpt-derived AV and VV delays and heart rate. Conclusions The application of electrogram-based algorithm is feasible both at rest and during exercise. The results are reproducible. QuickOpt-derived AV and VV delays individually change during exercise.

Ablation of the cavotricupsid isthmus (CTI) for the prevention of atrial flutter has traditionally been guided anatomically (1). Recently, an atrial electrogram (EGM) voltage-guided approach was described (2,3). It has been hypothesized that muscle bundles in the CTI are predominantly responsible for conduction through this area, and targeted ablation of those muscle bundles is an efficient and effective means to achieve bidirectional conduction block across the CTI. The muscle bundles can be identified by the highest-amplitude local atrial bipolar EGM recorded along any given ‘line’ between the tricuspid annulus and the inferior vena cava. A voltage map of the CTI bipolar atrial EGM was generated with a 4 mm, steerable irrigated-tip ablation catheter (Cool Path; St Jude Medical Inc, USA) during CTI-dependent atrial flutter (cycle length 243 ms) using a three-dimensional mapping system (NavX; St Jude Medical Inc). Figure 1 shows a caudal left anterior oblique view of the three-dimensional bipolar voltage map. A discrete line of high voltages was seen, demonstrating electrical activity of a single muscle bundle along the CTI. Figure 1) Three-dimensional bipolar voltage map (caudal left anterior oblique veiw). A discrete line of high voltages (purple colour, arrows) is seen, demonstrating electrical activity of a single muscle bundle along the cavotricuspid isthmus. The voltages corresponding ... In voltage maps, the voltages corresponding to the colour codes are indicated on the colour bar. Voltages higher than 1.8 mV (set arbitrarily) are shown in purple. The lowest voltages are shown in red. In the present voltage map, the region of the His potential was indicated by red dots. A duodecapolar catheter was in the right atrium, the ablation catheter was in the inferior vena cava and a reference catheter was in the coronary sinus. Visualization of the high-voltage area of the CTI with endocardial voltage mapping supports the muscle bundle hypothesis and helps with the understanding of the voltage-guided ablation approach for CTI-dependent atrial flutter.

Background Left atrial radiofrequency ablation is the most common technique for the treatment of atrial fibrillation during mitral valve surgery. Reported failure rates range between 15% and 30%, with some patients remaining in atrial fibrillation and others experiencing atrial flutter. The incidence and nature of the postoperative atrial flutter is not yet well defined. Methods The study group consisted of 50 patients with atrial fibrillation who underwent mitral valve surgery combined with left atrial radiofrequency ablation, and were followed for a mean period of 15 ± 7 months. The majority of patients (39; 78%) had persistent or permanent atrial fibrillation. Placement of the ablation lines was as follows: encircling the pulmonary veins, isolating the base of the left atrial appendage, and bridging the lateral or posterior mitral annulus and the margin of the pulmonary vein or the appendage-encircling ablation lines. Results There were three hospital deaths (6%). Thirty-four (72%) patients were free of any atrial tachyarrhythmia events, and 37 (79%) patients were in sinus rhythm by the end of the study's follow-up. During the follow-up, 6 patients (12.7%) experienced atrial flutter and 1 patient had atrial tachycardia. Electrophysiologic study was performed in 5 of 6 patients with postoperative atrial flutter. In 4 of them, the study findings were consistent with left atrial flutter. One patient with typical isthmus-dependent right atrial flutter underwent successful ablation. Conclusions Left atrial surgical radiofrequency ablation is associated with a high rate of postoperative atrial flutters that appear to be predominantly of left-sided origin.

We investigated the synergistic effect between low-frequency ultrasound (US) and hydroxyethyl starch (HAES) on blood clot disruption, using different HAES concentrations, US duration and intensity. Human blood clots, 200 to 400 mg in weight, were placed in tubes containing 10 mL of normal saline alone or with HAES 0.1%, 1% or 2%. Clots were randomized to four intensities of US exposure: none, low, medium and high (maximal amplitude of motion at the tip of the horn: 0, 96, 144 and 192 μm, respectively), and for three durations of US exposure (10, 20 and 40 s). After treatment, the clots were reweighed, and the percent differences in weights were calculated. US intensity, US duration and HAES concentration had a significant effect on the blood clot dissolution (p < 0.001 for all three variables). HAES augmented clot dissolution only when US intensity was medium or high. With low intensity, HAES did not augment clot lysis. Conclusions: microparticle-containing solutions, such as HAES, have a potential for augmenting clot disruption by US. This effect is highly dependent on US intensity.

We assessed the correlation between ST deviation in each of the six precordial leads and the presence of regional wall motion abnormalities (RWMA) as assessed by transthoracic echocardiography in 109 patients with first inferior acute myocardial infarction. ST depression in lead V1 and V2 was associated with higher incidence of RWMA of the mid-posterior segment (p < 0.02 for both leads). The specificity of ST segment depression in leads V1 and V2 for RWMA in mid-posterior segment was 87 and 57%, and the sensitivity 36 and 70%, respectively. Patients with ST depression in leads V2 or V3 had worse global RWMA score than patients without ST depression in these leads (p = 0.009 and p = 0.025, respectively). Patients with an ST elevation in lead V1, but not in leads V2 or V3, had a higher prevalence of right ventricular involvement (p < 0.0001). ST elevation in lead V5 was associated with more frequent involvement of the apical portion of the inferior wall (p < 0.02), with specificity of 88% and sensitivity of 33%. Global RWMA score was significantly worse for patients with ST elevation than for patients with isoelectric ST in lead V5 (p = 0.024). ST elevation in lead V6 was associated with RWMA in the mid-posterior segment (p < 0.006), with specificity of 91% and sensitivity of 33%, and worse global RWMA score (p = 0.022).