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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.

Assessment of diastolic function by echocardiography may be indeterminate as demonstrated in previous studies where diastolic measurement is a discrepant. We aimed to assess whether left atrial (LA) function may contribute to left ventricle filling evaluation in patients with indeterminate diastolic function (IndtDFx). This retrospective study included 3 groups of patients based on diastolic function: normal diastolic function (NDFx), definite diastolic dysfunction (DDFx) and IndtDFx. All patients had sinus rhythm with left ventricular ejection fraction ≥ 45%. Diastolic function was determined according to the following echocardiographic parameters: mitral E', mitral E/E' ratio, LA maximal volume index, and pulmonary pressure. NDFx was defined as having less than 2 abnormal parameters, DDFx as more than 2 abnormal parameters, and IndtDFx as 2 abnormal parameters. LA function analysis was performed in all patients using echocardiographic 2D speckle tracking. Sixty seven patients were included in strain analysis. The DDFx group (n = 21) and IndtDFx (n = 19) were significantly different from NDFx (27) in some demographics, cardiovascular risk factors, presentation and echocardiographic parameters. Some of the phasic LA function (phasic LA volumes and strains) parameters in the IndtDFx group were similar to DDFx and significantly different from the NDFx group, while other parameters fell in between the two groups. Phasic LA minimal volume index was found to be associated with heart failure symptoms. The IndtDFx group is a heterogeneous group demonstrating clinical and echocardiographic profiles that closely resemble that of DDFx group. LA phasic function analysis may help in re-classification of patients with IndtDFx as actual DDFx or as NDFx.

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: Early diagnosis and treatment of sleep apnea in patients with atrial fibrillation (AF) is critical. The WatchPAT (WP) device was shown to be accurate for the diagnosis of sleep apnea; however, studies using the WatchPAT device have thus far excluded patients with arrhythmias due to the potential effect of arrhythmias on the peripheral arterial tonometry (PAT) amplitude and pulse rate changes. Purpose: To examine the accuracy of the WP in detecting sleep apnea in patients with AF. Patients and Methods: Patients with AF underwent simultaneous WP and PSG studies in 11 sleep centers. PSG scoring was blinded to the automatically analyzed WP data. Results: A total of 101 patients with AF (70 males) were recruited. Forty-six had AF episodes during the overnight sleep study. A significant correlation was found between the PSG-derived AHI and the WP- derived AHI (r=0.80, p

A wide range of ejection fraction (EF) thresholds have been used to categorize patients with heart failure (HF) with “preserved” EF. Our goal was to characterize the clinical and echocardiographic differences among patients with cardiac structural/functional alterations and mid-range EF (mrEF) (EF 40–49%) compared to preserved EF (pEF) (EF ≥ 50%), irrespective of HF. Patients with an EF ≥ 40% and echocardiographic evidence of structural alterations (left atrial enlargement and/or left ventricular hypertrophy) and/or functional alterations (evidence of diastolic dysfunction) were retrospectively selected. Patients with acute coronary syndromes and ≥ moderate left sided valvular diseases were excluded. Patients were divided according to EF to pEF group (n = 578) and mrEF (n = 86). Patients with mrEF were twice as likely to be men, had higher prevalence of hyperlipidemia, diabetes and smoking, compared to patients with pEF. History of coronary artery disease (CAD) was more frequent among mrEF (50% vs. 28%, p

Aims The aims of the study are to assess the levels of coronary sinus (CS) miRNAs of systolic heart failure (HF) patients in samples obtained during cardiac resynchronization therapy (CRT) device implantation and compare them to the peripheral systemic venous miRNA expression. Methods and Results The cardiac specific miRNA levels were assessed in 60 patients, 39 HF patients with reduced ejection fraction and 21 control patients. The levels of four cardiac specified miRNAs (miR‐21‐5p, miR‐92b‐3p, miR‐125b‐5p, and miR‐133a‐3p) were compared between the peripheral samples of HF and controls and between peripheral venous in CS in the HF groups. Compared with controls, HF patients had higher peripheral serum venous levels of miR‐125b‐5p and miR‐133‐3p. In the HF group, the levels of expression were higher for miR‐125b‐5p and lower for miR‐92, and miR‐21‐5p in the CS, compared with the peripheral venous circulation. Conclusions The differences in miRNA expressions in CS compared with those in the periphery suggest that changes that may occur at the levels of the myocardial tissue in HF may be more relevant to our understanding of the biological linkage between miRNA expression and HF, than the traditional analysis of systemic serum miRNA expression.

Background: The association between Body Mass Index (BMI) and clinical outcomes following coronary artery bypass grafting (CABG) remains controversial. Our objective was to investigate the real-world relationship between BMI and in-hospital clinical course and mortality, in patients who underwent CABG.Methods: A sampled cohort of patients who underwent CABG between October 2015 and December 2016 was identified in the National Inpatient Sample (NIS) database. Outcomes of interest included in-hospital mortality, peri-procedural complications and length of stay. Patients were divided into 6 BMI (kg/m2) subgroups; (1) under-weight ≤19, (2) normal-weight 20–25, (3) over-weight 26–30, (4) obese I 31–35, (5) obese II 36–39, and (6) extremely obese ≥40. Multivariable logistic regression model was used to identify predictors of in-hospital mortality. Linear regression model was used to identify predictors of length of stay (LOS).Results: An estimated total of 48,710 hospitalizations for CABG across the U.S. were analyzed. The crude data showed a U-shaped relationship between BMI and study population outcomes with higher mortality and longer LOS in patients with BMI ≤ 19 kg/m2 and in patients with BMI ≥40 kg/m2 compared to patients with BMI 20–39 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 complex, U-shaped relationship between BMI and mortality was documented, confirming the “obesity paradox” in the real-world setting, in patients hospitalized for CABG.

Gabby Elbaz-Greener,1,* Guy Rozen,2– 4,* Shemy Carasso,5,6 Fabio Kusniec,5,6 Ibrahim Marai,5,6 Maneesh Sud,7 Bradley Strauss,7 Frank W Smart,8 David Planer,1 Offer Amir1,5,6 1Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; 2Cardiology Division, Hillel Yaffe Medical Center, Hadera, Israel; 3The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; 4Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; 5Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poriya, Israel; 6The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel; 7Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; 8LSU School of Medicine, New Orleans, LA, USA*These authors contributed equally to this workCorrespondence: Gabby Elbaz-GreenerDepartment of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Room Number 114, Jerusalem, IsraelTel +972(2)6776564Fax +972(2)6411028Email Gabbyelbaz@yahoo.comBackground: The association between body mass index (BMI) and clinical outcomes following an acute myocardial infarction (AMI) remains controversial. Our objective was to investigate the relationship between BMI and AMI presentation, in-hospital clinical course and mortality in the contemporary era of AMI management.Methods: Patients, hospitalized for an AMI between October 2015 and December 2016, were identified in the National Inpatient Sample (NIS) database. Socio-demographic and clinical data, including BMI, were collected and outcomes, including length of stay and mortality, were analyzed. Patients were divided into 6 BMI (kg/m2) subgroups; under-weight (≤ 19), normal-weight (20– 25), over-weight (26– 30), obese I (31– 35), obese II (36– 39) and extremely obese (≥ 40). Multivariable logistic regression model was used to identify predictors of in-hospital mortality. Linear regression model was used to identify predictors of length of stay (LOS).Results: An estimated total of 125,405 hospitalizations for an AMI across the US were analyzed. Compared to the other BMI subgroups, the under-weight, normal-weight and extremely obese groups presented with a non-ST segment elevation AMI (NSTEMI) more frequently and were less likely to undergo coronary revascularization. The data show a J-shaped relationship between BMI and study outcomes with lower mortality in patients with BMI over 25 compared to normal- and low-weight patients. In the multivariate regression model, BMI group was found to be an independent predictor of mortality.Conclusion: J-shaped relationship between BMI and mortality was documented in patients hospitalized for an AMI in the recent years. These findings confirm that the “obesity paradox” persists during the contemporary era of an AMI management.Keywords: body mass index, BMI, acute myocardial infarction, obesity paradox

Purpose The Biotronik LinoxSmart DX implanted cardioverter defibrillator (ICD) lead is a novel VDD lead with the advantage of integrated atrial sensing dipole combined with a special augmentation and filtering mechanisms. We sought to determine the efficacy of the Biotronik LinoxSmart DX ICD lead. Methods Non-randomized consecutive patients implanted with Biotronik LinoxSmart DX lead at Sheba Medical Center were included in this study. Electrical parameters and arrhythmic events were recorded during follow up of one year. Results Seventy-three patients (69 males (94.5%), mean age 61 ± 12 years) were included. All patients were successfully implanted with a Biotronic VR-T DX device and LinoxSmart DX ICD lead (DX-17 in 37% and DX-15 in 63% patients). Mean P wave amplitude at time of implantation was 3.66 ± 2.9 mV and improved significantly throughout the follow-up (5.29 ± 4.39 mV, p = 0.009). Appropriate atrial sensing (defined as P wave amplitude of ≥0.8 mV) rate of 100% at implantation significantly decreased to 89% (p = 0.015) at 12 months. Three out of 67 (4.5%) patients without a known history of atrial fibrillation had documented new onset paroxysmal atrial fibrillation. Appropriate shocks occurred in 4 (5.5%) patients. One patient with atrial sensing less than 0.4 mV had inappropriate shock. Conclusions Among patients implanted with the Biotronik LinoxSmart DX ICD lead in our single center, appropriate atrial sensing rate decreased over 12 months. Larger studies are needed to evaluate the reliability of long term appropriate atrial sensing.

Background An early failure of Biotronik Linox implantable cardioverter defibrillator (ICD) leads has been reported from several centers. Aim To compare the performance of Linox ICD leads with different other ICD leads as a report of the Sheba Medical Center experience. Methods All patients who had implantation of Linox ICD leads between 2007 and 2016 were included in this study. ICD lead failure was defined as low- or high-voltage impedance; failure to capture, sense, or defibrillate; or the presence of nonphysiological signals not due to external interference. The survival probability of Linox leads was determined and compared to Medtronic Sprint Quattro ICD leads. Results A total of 340 patients (age 64.4 ± 1.8 years) were included in this analysis. They were followed up to 105 months (mean 45.7 ± 7, median 44 (Interquartile range (IQR) 26-63) months). Twelve patients (3.5%) met the criteria for lead failure within 61.2 ± 22.9 months (median 66.5 [IQR 48-85 months]) post implantation. Noise with inappropriate ventricular arrhythmias detection, with or without therapy, was seen in 10 patients (83%). High pacing thresholds and high impedances were detected in two patients (17%). The survival probability of Linox leads at 60 months (97.3%) was similar to the survival probability of Sprint Quattro leads (98.2%) (P = .58). Nevertheless, the survival probability at 105 months was much lower (81% vs 97%, Linox ICD lead and Sprint Quattro lead, respectively, P = .0039). Conclusion Linox ICD leads have higher late failure rates compared to Sprint Quattro leads. These findings need to be confirmed in larger scale studies.

Background: Traditionally, the only effective treatment for aortic stenosis was surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) was approved in the United States in late 2011 and provided a critical alternative therapy. Our aims were to investigate the trends in the utilization of SAVR in the early vs. late TAVR era and to assess SAVR and TAVR outcomes.Methods: Using the 2011–2017 National Inpatient Sample database, we identified hospitalizations for patients with a most responsible diagnosis of aortic stenosis during which an aortic valve replacement (AVR) was performed, either SAVR or TAVR. Patients' sociodemographic and clinical characteristics, procedure complications, length of stay, and mortality were analyzed. Multivariable analyses were performed to identify predictors of in-hospital mortality. Piecewise regression analyses were performed to assess temporal trends in SAVR and TAVR utilization.Results: A total of 542,734 AVR procedures were analyzed. The utilization of SAVR was steady until 2014 with a significant downward trend in the following years 2015–2017 (P = 0.026). In contrast, a steady upward trend was observed in the TAVR procedure with a significant increase during the years 2015–2017 (P = 0.006). Higher in-hospital mortality was observed in SAVR patients. The mortality rate declined from 2011 to 2017 in a significantly higher proportion in the TAVR compared with the SAVR group.Conclusion: Utilization of SAVR showed a downward trend during the late TAVR era (2015–2017), and TAVR utilization demonstrated a steady upward trend during the years 2011–2017. Higher in-hospital mortality was recorded in patients who underwent SAVR.

Background Atrial fibrillation (AF) is common and bears a major clinical impact in patients with hypertrophic cardiomyopathy (HCM). We aimed to investigate the use and real‐world safety of catheter ablation for AF in patients with HCM. Methods and Results We drew data from the US National Inpatient Sample to identify cases of AF ablation in HCM patients between 2003 and 2015. Sociodemographic and clinical data were collected, and incidence of catheter ablation complications, mortality, and length of stay were analyzed, including trends between the early (2003–2008) and later (2009–2015) study years. Among a weighted total of 1563 catheter ablation cases in patients with HCM, the median age was 62 (interquartile range, 52–72), 832 (53.2%) were male, and 1150 (73.6%) were white. The average annual volume of AF ablations in patients with HCM doubled between the early and the later study period (79–156). At least 1 complication occurred in 16.1% of cases, and the in‐hospital mortality rate was 1%. Cardiac and pericardial complications declined from 8.8% to 2.3% and from 2.8% to 0.9%, respectively, between the early and the later study years ( P Conclusions Despite some decline in procedural complications over the years, catheter ablation for AF is still associated with a relatively high periprocedural morbidity and even mortality in patients with HCM. This emphasizes the importance of careful clinical consideration, by an experienced electrophysiologist, in referring patients with HCM for an AF ablation.

Up to 10% of non-ST-segment elevation myocardial infarction (NSTEMI) patients require coronary artery bypass graft (CABG) surgery during their hospitalization. Contemporary, real-world, data regarding CABG utilization and safety in NSTEMI patients are lacking. Our objectives were to investigate the contemporary trends in utilization and outcomes of CABG in patients admitted for NSTEMI. Using the 2003 to 2015 National Inpatient Sample data, we identified hospitalizations for NSTEMI, during which a CABG was performed. Patients' sociodemographic and clinical characteristics, incidence of surgical complications, length of stay, and mortality were analyzed. Multivariate analyses were performed to identify predictors of in-hospital complications and mortality. An estimated total of 440,371 CABG surgeries, during a hospitalization for NSTEMI, were analyzed. The utilization of CABG was steady over the years. The data show increasing prevalence of individual co-morbidities as well as cases with Deyo Co-morbidity Index ≥2 (p

Ablation of outflow flow ventricular arrhythmia (VA) originating from aortic cusps can be challenging. The aim of this study was to describe our approach for this ablation.All patients with outflow VA suspected to originate from aortic cusps according to ECG or after failed ablation from right ventricular outflow tract (RVOT) underwent cardiac CT and radiofrequency ablation. CT image of aortic cusps and coronary arteries was integrated into electroanatomic mapping system by point (left main ostium)-based registration. Ablation was performed at the earliest activation site.Ten patients were included in this case cohort. The ablation catheter was easily maneuvered above and below the aortic valve after registration. Two patients who had previous failed ablation of RVOT focus had successful ablation at right coronary cusp (RCC) and at left coronary cusp (LCC). A patient who had previous failed ablations of RVOT and LCC focuses had successful ablation at RCC-LCC junction. A patient who had previous failed ablation at LCC had successful ablation at RCC-LCC junction. Three patients had successful ablation at RCC-LCC junction, and one patient at LCC. One patient had successful ablation at anterior interventricular vein-great cardiac vein junction. One patient had successful ablation at non-coronary cusp. During follow-up (12-30 months), one patient had recurrence of VA controlled by flecainide. The remaining patients were free of VA without medications.Catheter ablation of VA originating from aortic cusps is safe and effective. CT image integration into electroanatomic mapping system can be helpful in this challenging ablation.

Pharmacological stress tests using dipyridamole are considered to be safe. However, cases of atrioventricular (AV) block have been reported. We retrospectively analyzed ECG at baseline and during dipyridamole stress tests of 2010 consecutive patients (patients with second or third degree AV block were excluded). At baseline, 350 (17.4%) patients had conduction abnormalities. Following dipyridamole infusion 16 patients (0.8%) developed a transient change in AV conduction (15 patients) and or sinus arrest (1 patient). Compared to patients without baseline conduction abnormalities, patients with any conduction abnormalities at baseline were at a higher risk for the development of AV block after dipyridamole infusion [0.3% vs 3.14%, respectively; P

Background Randomized clinical trials have shown conflicting data on the benefit of implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with more advanced heart failure (HF) symptoms. Using the Israeli ICD Registry data, we sought to examine the effect of HF functional class on the outcome of patients who receive device therapy in a real-world setting. Methods The association between HF functional class (categorized as baseline New York Heart Association [NYHA] functional class I and II in [61%] vs class III and IV in [39%]) and clinical outcomes was assessed among 913 patients who received an ICD (n = 514) or a cardiac resynchronization therapy with a defibrillator (CRT-D; n = 399) device and were prospectively followed in the Israeli ICD Registry between July 2011 and June 2013. Results The risk associated with advanced HF functional class was significantly different in ICD and CRT-D recipients. In the former group, patients with NYHA classes III and IV experienced >3-fold increased risk of HF or death (hazard ratio [HR] = 3.28; P < 0.001), whereas among CRT-D recipients the risk was similar between patients with NYHA III/IV and those with less advanced HF symptoms (HR = 0.97 [95% confidence interval (CI) 0.54–1.78]; P = 0.42; P value for NYHA functional class by device type interaction = 0.002). The risk for ventricular arrhythmia (VA) was significantly lower among patients with more advanced NYHA functional class, regardless of device type (overall HR = 0.52; 95% CI 0.33–0.91; P = 0.04). Conclusion Our findings suggest that patients with less advanced HF symptoms experience a greater risk for VA and the development of HF is attenuated in CRT-D recipients with more advanced NYHA functional class.

Papillary muscles (PMs) were reported to be origin of ventricular arrhythmia (VA). Radiofrequency (RF) ablation was reported to be acutely effective in eliminating VA. However, the recurrence rate is high. Recently, cryoablation guided by intracardiac echocardiography, 3-dimensional mapping system, and image integration was introduced as alternative strategy for this challenging ablation. We present a case of ventricular tachycardia originating from anterior PM of left ventricle treated by cryoablation guided only by intracardiac echocardiography.

Background Calsequestrin-associated catecholaminergic polymorphic ventricular tachycardia (CPVT2) can cause sudden death in young individuals in response to stress. Beta-blockers are the mainstay medical treatment for patients with CPVT2. However, they do not prevent syncope and sudden death in all patients. Flecainide was reported to reduce exercise-induced ventricular arrhythmias (EIVA) in patients with ryanodine receptor-associated CPVT. The role of flecainide in CPVT2 is not known. Objective To summarize our experience in combining flecainide and beta-blockers in high-risk patients with CPVT2. Methods All patients with CPVT2 (10 patients) who have high-risk features (syncope, EIVA, or appropriate implantable cardioverter-defibrillator [ICD] shocks) despite beta-blockers with or without calcium channel blockers were treated with a combination of flecainide and beta-blockers. Exercise test was done before and after beginning treatment with flecainide. Results All patients had EIVA and 4 had appropriate ICD shocks before flecainide treatment. EIVA-included frequent ventricular premature beats and or ventricular tachycardia during the exercise test while on high dose of beta-blockers with or without calcium channel blockers before treatment with flecainide. After combination therapy with flecainide and beta-blockers, EIVA were suppressed completely in all patients. During follow-up of 15.5 ± 10.4 months (range 2–29 months), 8 patients were free of symptoms and free of arrhythmias. Two patients had 1 VT storm episode with recurrent ICD shocks despite repeated normal stress test. Conclusions Flecainide can completely prevent ventricular arrhythmia during exercise and partially prevent recurrent ICD shocks in high-risk patients with CPVT2.

Background: Twenty to thirty percent of patients with left heart failure in randomized trials do not respond clinically to cardiac resynchronization therapy (CRT). The objectives of our work were to estimate the effec-tiveness of CRT in our routine practice, and to find predictors of favorable response to CRT. Methods: Retrospective analysis of consecutive patients who underwent CRT from 2003-2007. Results: Fifty six consecutive patients (73.2% men, age 66.3 ± 10.2 years) with left heart failure (LHF) (ischemic cardiomyopathy 60.7%) received CRT and were followed for a mean of 27 months. After the implantation: Mean NYHA improved by one class (p < 0.001), LHF admissions were reduced by 79% (p < 0.0001) and mean ejection fruction improved by 31% (19.5% vs 25.6%, p < 0.002). Significant improvement in severity of mitral regurgitation (MR) was an important predictor of high responsiveness (p = 0.004). Improvement of MR was associated with complete left bundle branch block (CLBBB) (p = 0.04) and lower total mortality (p = 0.005). Improvement in synchronization between the mid lateral and mid septal segments, as was calculated with longitudinal strain using echocardiography (105 ± 38 vs 20 ± 23 msec, p = 0.008) was predictor of super responsiveness and reduction in MR among patients with moderate to severe MR prior to implantation. Worsening the delay between the mid posterior and mid anterior septal segments (21 ± 27 vs 120 ± 0 msec, p = 0.006) was associated with absence of response and lack of improvement in MR. Conclusions: Patients who improve mid segments dyssynchrony in four chamber view, have more chance to improve MR and to become super responders.

Background Current guidelines suggest the use of atrial synchronous mode (VDD) pacemakers in patients with atrioventricular (AV) block and normal sinus node function. However VDD mode is being used much less than expected. The objectives of our study were to evaluate the efficacy of VDD pacing in long-term follow-up and to find risk factors for VDD loss. Methods We retrospectively evaluated all patients with VDD pacemakers who were implanted in our center between 1995 and 2007. Results During the study period, 123 consecutive patients with AV block (51% men, age 62 ± 17.8 years) received a VDD pacemaker. Mean follow up duration was 4.5 ± 3.2 years. At the last follow up visit, 21 patients (21.6%) lost their original VDD mode and were programmed to ventricular-based pacing (VVIR) (undersensing, 11; chronic AF, 7; SND, 3). In 28 patients, VDD mode was restored or maintained by increasing atrial sensitivity. No episodes of atrial oversensing were observed. In multivariate analysis history of paroxysmal AF (p = 0.007, odds ratio 36.6, 95% confidence interval 2.7–493.7) and p wave lower than 1 mv during the follow up (p = 0.021, odds ratio 7, 95% confidence interval 1.3–36.7), were found risk factors to VDD loss. Conclusions VDD pacing has good long-term performance. Absence of paroxysmal AF history predicts maintenance of VDD pacing mode. Taking into account that no atrial oversensing was observed, our recommendation is to increase atrial sensitivity when P wave amplitude declines to less than 1 mv. Copyright © 2010 Wiley Periodicals, Inc.

The aim of this study was to characterize the abnormalities in glucose homeostasis in intensive care unit patients following an acute coronary event. The study population included all non-diabetic patients ages 20-80 years that were admitted to a coronary intensive unit. Glucose, insulin and C-peptide levels during an oral glucose tolerance test (OGTT) were measured during the acute admission. From January to September 2003, 277 patients were admitted to the coronary unit. Of these, 127 patients underwent an OGTT. Of these, only 29 patients (23%) exhibited normal glucose metabolism. The remainder had type 2 diabetes (32%), impaired glucose tolerance (37%) or isolated impaired fasting glucose (8%, 100-125 mg/dl). Based on homeostasis model assessment (HOMA) calculations, diabetic patients had impaired beta-cell function and patients with elevated fasting glucose levels were insulin resistant. Beta-cell dysfunction during the acute stress seems to contribute to the glucose abnormalities. Most patients who experience an acute coronary event demonstrate abnormal glucose metabolism. Post glucose-load abnormalities are more common than abnormal fasting glucose level in this situation. It is postulated that the acute stress of a coronary event may contribute to the dysglycemia.

Background and objectives The main limitation of primary PCI in acute MI is lack of tissue reperfusion due to distal embolization. We sought to examine the safety and feasibility of a manual thrombus aspiration device in patients undergoing primary PCI. Methods Seventy-eight consecutive patients with ST-elevation MI eligible for primary PCI were included. The device was used immediately after guidewire crossing only if a total occlusion (thrombolysis in myocardial infarction [TIMI] flow 0) existed or if a large filling defect was observed. End points were TIMI flow immediately after thrombus aspiration and at the end of procedure and ST resolution of more than 70%. Results Mean age was 59±12 years, and 79% of patients were males. Risk factor profile included smoking in 62%, diabetes in 21%, hypertension in 46%, and hyperlipidemia in 45%. The infarct-related artery was LAD in 42%, RCA in 36%, and LCX in 22%. Initial TIMI flow was 0 in 71%, I in 10%, and II/III in 19%. Immediately after aspiration, TIMI flow was II/III in 89% of patients and I in 9%. Direct stenting was performed in 73%. Final TIMI flow was III in 90%, II in 9%, and 0 in 1%. ST-segment resolution of more than 70% was observed in 76% of patients. No major device-related complications occurred. Conclusions Based on this preliminary data, manual thrombus aspiration using the Export device during primary PCI appears to be feasible and safe. The advantages over routine primary PCI should be further evaluated in randomized trials.

The D1790G mutation was found in all 24 patients of an extended long QT family but not in 200 chromosomes carried by healthy individuals. We describe a 37-year-old man presenting with a typical spontaneous type 1 Brugada pattern who in electrophysiological testing had easily inducible ventricular fibrillation. At the age of 47 years he had an atrial ventricular type 2 block documented by an exercise test and a Holter monitor. Genetic analysis revealed a known D1790G mutation in the gene encoding of the sodium channel (SCN5A) that until now has been associated only with the long QT phenotype. Although this mutation has not been associated with a reduction of sodium channel expression, we hypothesize that sodium currents are further diminished due to the 20-mV shift of the steady-state inactivation curve, and this could contribute to the Brugada phenotype. This case is important as it allows a better understanding of the underlying molecular mechanisms of Brugada syndrome. Moreover, this observation raises concern about the safety of class IC drug therapy in long QT type 3 patients and quinidine therapy in Brugada patients, and emphasizes the importance of a thorough clinical and genetic evaluation.

Aims: To compare the clinical response of patients with right ventricular apical pacing (RVAP) upgraded to cardiac resynchronization therapy (CRT) to that of previously nonpaced heart failure (HF) patients who had de novo CRT implantation. Background: The role of CRT in patients with wide QRS and HF due to RVAP is less well established than in other CRT candidates. Methods: Ninety-eight consecutive patients with CRT were studied (mean age 70, mean ejection fraction 0.23). Group A: patients having RVAP prior to CRT implantation (n = 25), group B: patients without prior RVAP (n = 73). Clinical and echocardiographic parameters were recorded prior to, and 3 months after, CRT implantation. Results: Group A patients had a wider QRS at baseline compared to group B (203 ± 32 ms vs 163 ± 30 ms respectively, P < 0.001), and a shorter 6-minute walking distance (222 ± 118 m vs 362 ± 119 m, respectively, P < 0.005). Otherwise, clinical and echocardiographic parameters were not different. At follow up, group A patients had an average 0.7 ± 0.5 decrease in their NYHA functional class, compared to 0.3 ± 0.7 in group B patients (P < 0.05). Six-minute walking distance increased by 93 ± 113 m in group A, versus 36 ± 120 m in group B (P = 0.22). There was no difference in echocardiographic response to CRT between the groups. Conclusions: HF patients with prior RVAP demonstrate clinical improvement after upgrading to CRT that is comparable, and in some aspects, even better than that observed in HF patients with native conduction delay who undergo de novo CRT implantation.

Percutaneous closure of an atrial septal defect (ASD) has been established as a safe and effective alternative to surgical management. We describe a case of a 41-year-old patient in whom an Amplatzer septal occluder device was used to close a moderately large ASD and who subsequently developed incessant intra-atrial macro-reenterant tachycardia. The tachycardia was terminated by radiofrequency ablation guided by electroanatomical mapping.

QTc interval prolongation after dipyridamole administration was reported only in patients who had positive pharmacological stress test results. We report a case of QTc prolongation after dipyridamole administration with no evidence of myocardial ischemia.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare but highly malignant inherited arrhythmic disorder. Although a standardized exercise stress test (ST) is the most reliable way to diagnose CPVT, in 30% only single ventricular premature beats (VPCs) were recorded.To evaluate whether electrocardiographic characteristics of VPCs during ST distinguish patients with CPVT from healthy subjects.Electrocardiographic characteristics of VPCs during ST in 16 calsequestrin-2 (CASQ2) mutation carriers CPVT patients were compared with that in 36 healthy subjects.CPVT patients had more VPCs (31 ± 14 vs 3 ± 4, P0.0001), longer QRS duration (139 ± 18 ms vs 121 ± 21, P = 0.004), and coupling interval (CI; 476 ± 58 ms vs 355 ± 61 ms, P0.0001). The most sensitive characteristics for CPVT were10 VPCs/test (100% sensitivity, 100% negative predictive value [NPV]), left bundle branch block (LBBB) pattern with inferior axis (88% sensitivity, 94% NPV), and CI longer than 400 ms (88% sensitivity, 94% NPV). Bigeminy or trigeminy or LBBB pattern with inferior axis was most specific for CPVT at 100% (100% positive predictive value PPV, 92% NPV). First VPC during the recovery period and VPC recording more than 1 minute during the recovery period were most specific for healthy subjects (100% specificity, 100% PPV). In multivariate analysis, QRS duration120 ms (odds ratio 4.2, 95% confidence interval 1-17.6, P = 0.04) and first VPC at ≥10 mets (odds ratio 9.1, 95% confidence interval 2.01-41.1, P = 0.004) each predicted the presence of CPVT.Several electrocardiographic criteria can help distinguish VPCs originating from CPVT compared with healthy subjects.

In this study, the clinical and implantable cardioverter-defibrillator (ICD)–related follow-up of patients with catecholaminergic polymorphic ventricular tachycardia (CPVT) with homogenous missense mutations in CASQ2 was summarized. Patients were followed in a pediatric cardiology clinic and an ICD clinic. All patients were treated with high-dose β blockers. ICDs were recommended for patients who remained symptomatic despite medical treatment. Twenty-seven patients were followed for 1 to 15 years (median 9). Twenty patients (74%) were symptomatic at diagnosis; 13 (65%) remained symptomatic after treatment with high-dose β blockers and thus were advised to receive ICDs. Eight of these patients refused ICDs, and eventually 6 (75%) died suddenly. Four of the 5 patients who received ICDs had ventricular tachycardia storms treated but not terminated by recurrent ICD shocks. These ventricular tachycardia storms (2 episodes in 2 patients and 1 episode in 2 patient) terminated spontaneously after finishing the programmed ICD shocks, without degeneration to ventricular fibrillation. None of the patients who received ICDs died. In conclusion, patients with CASQ2-associated CPVT should be recommended to receive ICDs to prevent sudden death when medical therapy is not effective. These patients may have recurrent ventricular tachycardia storms treated but not terminated by recurrent ICD shocks, without degeneration to ventricular fibrillation.

Background Endothelial dysfunction is considered an important prognostic factor in atherosclerosis. The aim of this study was to detect the long-term association of peripheral vascular endothelial function and clinical outcome in healthy subjects without apparent coronary artery disease (CAD). Methods We prospectively assessed brachial flow-mediated dilation (FMD) in 435 consecutive healthy subjects: 281 (65%) men, mean age 54±12 years and body mass index 28±4 kg/m 2 . After overnight fasting and discontinuation of all medications for ≥12 h, FMD and endothelium-independent nitroglycerin-mediated vasodilation were assessed using high resolution linear array ultrasound. Results Subjects were divided into 2 groups: below ( n =221) and above ( n =214) the median FMD of 10.7%, and were comparable regarding CAD risk factors, lipoproteins, fasting glucose, C-reactive protein, and concomitant medications, with a mean clinical follow-up of 32±2 months. Composite cardiovascular endpoints (all-cause mortality, non-fatal myocardial infarction, heart failure or angina pectoris hospitalization, stroke, coronary artery bypass grafting and percutaneous coronary interventions) were significantly more common in subjects with below median FMD of 10.7%, than above (11.8% vs 4.7%, p =0.007, respectively). Univariate analysis demonstrated that median FMD significantly predicted cardiovascular events [odds ratio (OR) of 2.78 and 95% CI 1.35 to 5.71 ( p =0.003)]. After multivariate analysis including conventional CAD risk factors, median FMD was the best independent predictor of long-term cardiovascular adverse events [OR of 2.70 and 95% CI 1.16 to 6.32 ( p =0.011)]. Conclusions Brachial artery median FMD independently predicts long-term adverse cardiovascular events in healthy subjects in addition to traditional risk factor assessment.

Background Sleep-disordered breathing (SDB) has been associated with various benign cardiac arrhythmias occurring during sleep. Objective The purpose of this study was to demonstrate that SDB contributes to the development of life-threatening ventricular arrhythmias in patients with an established arrhythmic substrate. Methods We prospectively studied the association between SDB and timing of life-threatening ventricular arrhythmic events in 45 patients with an implantable cardioverter-defibrillator (ICD). SDB was defined as an apnea-hypopnea index (AHI) >10 events/hour based on an overnight sleep study. The primary outcome measure was appropriate ICD therapy, defined as antitachycardia pacing or shock for ventricular tachycardia or ventricular fibrillation during 1-year follow-up. Results SDB was present in 26 (57.8%) patients. Appropriate ICD therapies were higher among patients with SDB (73% vs 47%, P = .02). Logistic regression identified SDB as a predictor of any appropriate ICD therapy (odds ratio 4.4, 95% confidence interval 1.4–15.3, P = .01). The risk for ventricular arrhythmias was higher in patients with SDB solely due to an increase in events occurring between midnight and 6 AM (odds ratio 5.6, 95% confidence interval 2.0–15.6, P = .001) with no discernible effect on appropriate ICD therapy during nonsleeping hours (odds ratio 0.7, 95% confidence interval 0.2–2.3, P = .61). Conclusion Patients with an ICD and SDB have a striking increase in the onset of life-threatening ventricular arrhythmic events during sleeping hours. These findings provide a rationale for SDB screening in patients with appropriate ICD therapy if device interrogation reveals a predominance of nocturnal onset of arrhythmias.

Endothelial dysfunction is considered an important marker in atherosclerosis, having a prognostic value. Antiphospholipid antibodies are considered prothrombotic and have recently been reported to be associated also with atherosclerosis. This study was conducted to investigate a possible association of endothelial dysfunction with various antiphospholipid autoantibodies in healthy subjects and patients with cardiovascular disease. In a single-center, prospective study, 2 groups were included. The study group included patients with cardiovascular diseases (coronary disease and/or cerebrovascular disease) and healthy subjects without apparent heart disease who were referred to the endothelial function laboratory for the assessment of endothelial function. Flow-mediated dilatation, which indicates endothelial function, and nitroglycerin-mediated vasodilatation, which indicates smooth-muscle function, were measured. The 2 groups were evaluated for autoantibodies, including anticardiolipin (aCL; immunoglobulin G [IgG], immunoglobulin M [IgM], and immunoglobulin A [IgA]), antinuclear antibody, anti-beta2-glycoprotein I (IgG, IgM, and IgA), and oxidized low-density lipoprotein. One hundred seven subjects were included in the study: 45 patients (42%) and 62 healthy controls (58%). Flow-mediated dilatation was significantly lower in patients compared with healthy controls (8.0 +/- 9.5% vs 8.0 +/- 13.5%, p = 0.012). In addition, nitroglycerin-mediated vasodilatation was nonsignificantly lower in patients than in healthy controls (8.0 +/- 13.4% vs 11.0 +/- 16.7%, p = 0.084). The mean levels of anti-beta2-glycoprotein I (IgG, IgM, and IgA), aCL (IgM and IgA), antinuclear antibody, and oxidized low-density lipoprotein were not different between groups. However, the mean level of IgG aCL was significantly higher in patients than in healthy controls. In conclusion, in accordance with previous reports of an association between aCL and atherosclerosis, patients with cardiovascular disease had endothelial dysfunction and elevated levels of aCL.

We report a case of a 55-year-old woman with idiopathic ventricular fibrillation (VF) who suffered from recurrent implantable cardioverter-defibrillator shocks triggered by short coupled ventricular premature beat (VPB). This VPB was mapped and ablated from the myocardium of right ventricle close to the lateral tricuspid annulus. Learning objective: Triggering ventricular premature beat (VPB) in idiopathic ventricular fibrillation was reported to originate from the myocardium of right ventricular outflow tract or from Purkinje system. In this case, the origin of triggering VPB is the myocardium of right ventricle close to the lateral tricuspid annulus.>