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Background Several authors have recently compared the outcomes and complications of surgical procedures that preserve or remove the uterus in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Following the publication of several high quality randomized control trials on this topic we performed a new systematic review and meta analysis of this data. Methods We performed a systematic literature search in ClinicalTrials.gov, PubMed, Scopus, Ovid, EBSCO host, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled and cohort trials of uterine sparing prolapse repair (hysteropexy) versus hysterectomy with suspension. A total of 1285 patients from 14 studies were included in our systematic review and meta-analysis. Results Uterine sparing procedures (hysteropexy) were comparable to hysterectomy with suspension for recurrence rates (RR = 0.908, 95% CI [0.385, 2.143]), reoperation rates (RR = 1.517, 95% CI [0.802, 2.868]), length of hospital stay, (SMD = − 0.159 days, 95% CI [−0.375, 0.057]), voiding dysfunction (RR = 1.089, 95% CI [0.695, 1.706]), and intraoperative blood loss (SMD = − 0.339, 95% CI [−0.631, 0.047]). However, hysteropexy had shorter operative time than hysterectomy with suspension (SMD = − 1.191 h, 95% CI [−1.836, −0.545]), and fewer visceral injuries (RR = 0.421, 95% CI [0.244, 0.725]). Conclusion We found no significant differences in the outcomes or major complications of uterine preserving surgical procedures versus those which include hysterectomy in the treatment of POP. Hysteropexy procedures may be associated with a shorter operative time and fewer visceral injuries. This is consistent with older analyses.

OBJECTIVE Following the publication of several high quality randomized controlled trials regarding the comparison of similar laparoscopic gynecologic procedures being performed with or without robotic assistance, we aimed to perform a systematic review to identify any differences in patient safety and expected incidence of complications in these procedures. DATA SOURCES Articles on ClinicalTrials.Gov, Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were retrieved and screened for eligibility up to April 1st 2021. METHODS OF STUDY SELECTION In addition to meeting our screening algorithm, we included studies that met all the following: randomized control trials (RCT), enrolling patients for indicated laparoscopic gynecologic procedures, and comparing Robotic Surgery (RS) with Laparoscopic Surgery (LS) in terms of safety or complications. TABULATION, INTEGRATION, AND RESULTS Data was pooled as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI). Ultimately, six studies were included in this meta-analysis. Pooled data revealed that RS and LS have similar risk for intraoperative complications (RR = 0.87; 95% CI [0.23, 3.36], P = 0.84), postoperative complications (RR = 1.07; 95% CI [0.57, 2.01], P = 0.83), significant intraoperative hemorrhage (RR = 1.40; 95% CI [0.59, 3.34], P = 0.44), postoperative hemorrhage (RR = 0.43; 95% CI [0.15, 1.22], P = 0.11), vaginal cuff dehiscence (RR = 1.13; 95% CI [0.24, 5.41], P = 0.88), postoperative wound infection, urinary tract infection, and urinary bladder or ureteral injury. RS had "surgeon declared" lower estimated blood loss (MD = 85.27; 95% CI [46.45, 124.09], P

Objective We set out to evaluate whether the instillation of bupivacaine versus a saline solution into the peritoneal cavity at time of laparoscopic gynecologic surgery will reduce postoperative pain and postoperative opioid consumption. Data sources We searched six databases: Web of Science, SCOPUS, Cochrane CENTRAL, ClinicalTrials.Gov, MEDLINE and PubMed. Our search strategy had no restriction on time or languages and included all studies that met our search algorithm up to March of 2021. Methods of study selection We included only randomized trials that met our search strategy for the outcomes of 1) pain intensity 24 hours after surgery, 2) pain intensity 6 hours after surgery, and 3) length of hospital stay. Tabulation integration and results We analyzed continuous data using mean difference (MD) with relative 95% confidence interval (CI). We included 8 randomized clinical trials. We found that intraperitoneal bupivacaine showed significant difference from the saline group regarding pain intensity 24 hours after surgery (MD= -0.73 [-1.10, -0.36]) (P = 0.01) and pain intensity 6 hours after surgery (MD= -1.12 [-2.22, -0.02]) (P = 0.05). Overall, patients allocated to the placebo group seemed to need other analgesics earlier than patients allocated to the bupivacaine group (MD=145.08 [51.37, 238.79] (P = 0.02)). There was no significant difference regarding the length of hospital stay (MD= -0.44 [-1.44, 0.56]) (P = 0.39). Conclusion Bupivacaine significantly reduced the visual analog pain score for pain compared with that of the placebo at 6 and 24 hours postoperatively. There was no significant difference in hospital stay. Prospero registration CRD42021254268.

BACKGROUND: Atrial fibrillation (AF) is a bi-atrial disease yet little attention has been given to right heart function in AF. We propose that the assessment of right atrial (RA) and right ventricular function (RV) using two-dimensional speckle tracking echocardiography (2D-STE) could be valuable in predicting AF recurrence in patients with paroxysmal AF (PAF). METHODS: Thirty patients with PAF were prospectively recruited from a dedicated AF clinic. Right atrial size, volume, and area and RV dimensions were analyzed along with RA and RV strain derived from 2D-STE at baseline and at 3 and 12 months. RESULTS: Higher RA booster strain independently predicted sinus rhythm (SR) maintenance for up to 1 year (P = 0.001). RV strain was impaired in patients with recurrent AF compared to those in SR (P

Early repolarization (ER) in the inferior electrocardiogram leads is associated with idiopathic ventricular fibrillation, but the majority of subjects with ER have a benign prognosis. At present, there are no risk stratifiers for asymptomatic ER.To examine the response to ajmaline provocation and exercise in potentially high-risk subjects with ER and without a definitive cardiac diagnosis.Electrocardiographic data were reviewed for ER at baseline and during ajmaline and exercise testing in 229 potentially high-risk patients (mean age 37.7±14.9 years; 55.9% men). ER was defined as J-point elevation in ≥2 consecutive leads and stratified by type, territory, J-point height, and ST-segment morphology.Baseline ER was present in 26 (11.4%; 19 men) patients. During ajmaline provocation and exercise, there were no new ER changes. ER with rapidly ascending ST-segment and lateral ER consistently diminished. There were 7 patients with persistent ER during ajmaline and/or exercise. They were all men with inferior or inferolateral ER and horizontal/descending ST segment. Those with persistent ER during exercise were more likely to have a history of unexplained syncope than those in whom ER changes diminished (P.01). Subtle nondiagnostic structural abnormalities were demonstrated in 3 of these patients.ER with horizontal/descending ST-segment morphology in the inferior or inferolateral leads that persists during exercise is more common in patients with prior unexplained syncope and may identify patients at higher risk of arrhythmic events. ER that persists during ajmaline provocation and/or exercise may reflect underlying subtle structural abnormalities and should prompt further investigation.

AIMS: We propose to assess the value of exercise-induced change in N-terminal-pro atrial natriuretic peptide (NT-proANP) and left atrial expansion index (LAEI) in predicting AFR after cardioversion and their effect on AF-free survival. METHODS AND RESULTS: Fifty-five patients with persistent AF of

Background: Right precordial (V1–3) elevated electrode placement ECG (EEP-ECG) is often used in the diagnosis of Brugada syndrome (BrS). However, the specificity of this has only been studied in smaller studies in Asian populations. We aimed to study this in a larger European population. Methods: Two different populations consisting of healthy subjects were used. A total of 340 subjects were included, 80% were men, the median age was 43 year (interquartile range: 31–51) and all were of European ethnicity. Results: No type 1 ECG patterns were identified but 16 (4.7%) subjects with a type 2 ECG and 32 (9.4%) subjects with a type 3 ECG were identified in any lead placement. In total 43 (13%) subjects had any BrS ECG pattern in any lead placement. The specificity was 100% (one-sided 97.5% CI: 99%) for the use of EEP-ECG to uncover type 1 pattern. For type 2 pattern the specificity was 95% (95% CI: 92–97%) and for type 3 pattern 91% (95% CI: 88–94%). Conclusions: Elevated electrode placement ECG in the diagnosis of BrS seems to have a very high specificity with regards to the finding of a type 1 ECG pattern in a European population; conversely a finding of a type 2 or 3 pattern is of a significantly lower specificity and should perhaps be disregarded.

Background The clinical assessment of left atrial function during atrial fibrillation is challenging and often inaccurate because of the beat-to-beat variability in the cycle length. The aim of this study was to validate the use of an index beat, the beat following two preceding cardiac cycles of equal duration, for the measurement of left atrial functional indices, including area, volume, and expansion index. The index beat was compared with the conventional but time-consuming method of averaging multiple consecutive cardiac cycles. Methods Thirty patients with persistent or permanent atrial fibrillation were studied using two-dimensional echocardiography, and left atrial indices were measured from the average of 17 consecutive cardiac cycles compared with that of an index beat taken from outside of these 17 cycles. Results The index beat showed good correlation with the averaging technique, and comparison of the two methods showed them to be interchangeable. Clinically, the differences in left atrial functional indices between the two methods were minor. Conclusions Use of the index beat to measure dynamic left atrial function in atrial fibrillation can easily be performed and is as accurate as and less time consuming than the onerous method of averaging of multiple cardiac cycles.

Background: Extracellular matrix remodeling in the aortic wall results in increased aortic stiffness (AoS) in Marfan syndrome (MFS). Pulsed-wave velocity (PWV) constitutes the best indirect AoS measurement. We aimed to assess PWV in MFS patients using two-dimensional (2D) and Doppler echocardiography. Methods: Thirty-one MFS patients, (mean age 31 ± 14 years, 16 men) and 31 controls were examined. Blood flow was recorded in the aorta near the aortic valve and immediately after in the descending aorta with simultaneous electrocardiography. PWV was calculated by dividing the distance between the two sample volume positions (D) by the time difference (TD) between the intervals from the QRS start to the ascending and descending aortic flow onsets. B-stiffness was also measured. Results: TD (described in “Methods” section) and, aortic arch length were significantly increased in MFS patients, P < 0.001. Thus, PWV values were significantly higher in patients when compared with controls, 7.20 m/s (5.12, 9.43) versus 4.64 m/s (3.37, 6.24), P < 0.001. B-stiffness was also significantly increased in MFS patients; 5.15 (3.69, 7.65) versus 2.44 (1.82, 3.66), P < 0.001. Multiple regression analysis showed a positive association with MFS diagnosis and age, (P = 0.002 and 0.009, respectively). Reproducibility of PWV measurements was

Background Leads V 1 and V 2 recorded from the standard position (fourth intercostal space) have insufficient sensitivity to detect the diagnostic type 1 Brugada ECG pattern. Objective The purpose of this study was to compare the sensitivity of bipolar leads with a positive pole at V 2 and a negative pole at V 4 or V 5 with that of the standard unipolar lead V 2 for detection of the type 1 Brugada pattern. Methods We analyzed digital 15-lead ECGs (12 standard leads plus leads V 1 to V 3 recorded from the third intercostal space [V 1h to V 3h ]) acquired during diagnostic ajmaline testing in 128 patients (80 men, age 37 ± 15 years) with suspected Brugada syndrome and standard 12-lead ECGs recorded in 229 healthy subjects (111 men, age 33 ± 4 years). Bipolar leads between V 2 (positive pole) and V 4 or V 5 (leads V 2–4 , V 2–5 ) were derived by subtracting leads V 4 and V 5 from V 2 . All ECGs were examined for the presence of type 1 Brugada pattern. Results During 21 (16.4%) positive ajmaline tests, type 1 pattern was observed in lead V 2h during 20 tests (95.2%) and in V 2 during 10 tests (47.6%). Type 1 pattern appeared in lead V 2–4 or V 2–5 in all tests when it was present in V 2 and in seven tests during which it was observed in lead V 2h but not V 2 (17 tests [81%]). Type 1–like pattern was observed in lead V 2–4 or V 2–5 during two nonpositive tests (1.9%) and in one healthy subject (0.4%). Conclusion Bipolar leads V 2–4 and V 2–5 are more sensitive than lead V 2 for detection of the type 1 Brugada pattern.

Background Current consensus documents on Brugada syndrome recommend the diagnostic intravenous administration of a Na-channel blocker to be stopped when the QRS prolongs to ≥130% of baseline, presumably because of increased arrhythmic risk. Objective This study sought to assess QRS prolongation during ajmaline testing and its relation to arrhythmic risk. Methods We analyzed an electrocardiographic (ECG) database collected during ajmaline testing in 148 patients (92 men, age 36 ± 15 years). The QRS was measured at baseline and during the 1st to 7th, 10th, and 15th minute after the beginning of ajmaline administration. Results The average QRS prolongation was 36% ± 16% (range 9% to 88%), not significantly different between positive (n = 30) and negative (n = 118) tests. QRS prolonged to ≥130% during 16 (55%) positive and 71 (61%) negative tests ( P = .50), with no clinical side effects. The incidence of ventricular arrhythmias was not significantly different between patients with and without QRS prolongation. Short runs (3 to 8 complexes) of nonsustained ventricular tachycardia occurred in 3 patients with QRS prolongation ≥130%. In 40% of positive tests, prolongation ≥130% occurred earlier by >1 minute than diagnostic Brugada ECG changes, i.e., early termination of the test could possibly have resulted in false-negative outcomes. Conclusion QRS prolongation ≥130% occurs in >50% of all tests. In 40% of positive tests it occurs before diagnostic ECG changes. Always terminating the test when QRS prolongs ≥130% could possibly result in loss of important diagnostic information. It is appropriate to adjust the criteria for early termination of the test to the baseline QRS and possibly other factors.

Aims The authors sought to assess the value of the high right precordial leads (RPL) to detect the Type I Brugada ECG pattern in patients suspected of carrying Brugada syndrome (BrS). Methods Ajmaline testing using 15-lead ECGs was performed in 183 patients suspected of carrying BrS. Standard 12-lead ECG with V1–V3 recorded from the fourth intercostal space and an additional three leads placed over V1–V3 recorded from the third intercostal space were analysed. ECGs were analysed for a Type I ECG pattern in either the standard or high RPLs. Results Of the 183 tests, 31 (17%) were positive, and 152 were negative. In all positive studies, at least one high RPL became positive. In 13/31 (42%) cases, the Type I ECG pattern could be observed only in the high RPLs. Standard or high V3 were never positive before standard or high V1–V2. In seven patients, a Type I pattern was seen in one standard and one high RPL (vertical relationship). Conclusions The high RPLs are more sensitive than the conventional 12-lead ECG alone and initial observations suggest that they remain specific for BrS, while standard and high lead V3 offer redundant data. A vertical relationship of type 1 patterns may have a similar diagnostic value to that of a horizontal pair.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and represents a significant health care issue. The diagnosis and management of AF uses a significant proportion of the health care budget and is responsible for substantial morbidity and mortality. Restoration and maintenance of sinus rhythm is still an important treatment option for symptomatic AF. Anti-arrhythmic drugs (AADs) have had inconsistent results for the prevention of recurrent AF and have been hampered by significant adverse effects. Catheter ablation has rapidly evolved and is fast becoming an alternative for AF prevention. Although multiple treatment options exist, no single modality is effective for all patients. This review outlines best current practice for AF prevention and future perspectives, focusing on new and promising developments in antiarrhythmic drug therapy, strategies for ablation therapy, and forms of hybrid therapy that may offer improved outcomes in selected patients.

Background: Although cases of Brugada-type electrocardiographic (ECG) pattern in peripheral (limb) leads have been reported (“atypical” Brugada syndrome [BS]), their incidence in patients investigated for BS is unknown. Methods: We retrospectively analyzed an ECG database collected during ajmaline test in 143 patients (89 men) with suspected BS. In 42 patients, 12-lead ECGs were recorded, whereas in 101 patients, leads V1–V3 from the third intercostal space were also recorded. The presence of types 1, 2, and 3 Brugada pattern in each limb and precordial lead was noted and the PR, QRS, and QTc intervals were calculated. Results: There were 114 (79.7%) negative and 29 (20.3%) positive tests. Type 1 pattern developed in ≥1 limb lead in six patients (4.2%) (3/29 with positive tests, 10.3%); all of them were male, symptomatic, and/or with family history of BS or sudden cardiac death. Their pre- and posttest QRS were significantly longer compared with the rest with positive (n = 26) or negative (n = 111) test (pretest: 129 ± 31 ms vs 101 ± 11 ms and 97 ± 12 ms, P < 0.001; posttest: 175 ± 44 ms vs 134 ± 14 ms and 131 ± 19 ms, P < 0.001). The posttest QTc was longer in patients with peripheral changes compared with the rest (507 ± 47 ms vs 453 ± 22 ms and 447 ± 24 ms, P < 0.001). The pretest QTc and pre- and posttest heart rate and PR intervals were not significantly different between the three groups. Conclusions: Type 1 Brugada pattern in the peripheral leads was observed in 4.2% of patients during ajmaline test (10.3% of positive tests) and was associated with longer QRS and greater QTc prolongation compared with the rest of the patients.

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias, and its prevalence continues to rise as the aged population increases. Comparative studies of rhythm control and rate control have been equivocal; however, the benefits of rhythm control may have been offset by the limitations of antiarrhythmic drugs. More recently, nonpharmacological therapies have emerged that provide hope of more effective rhythm control. Catheter ablation techniques have gained favour with high success rates in specialized centers, although these techniques are not without complications and require considerable expertise. Pacing therapies designed to reduce harmful right ventricular pacing and increase physiological pacing have shown benefit in AF patients with bradycardia. Despite this progress, no single modality confers benefit for all patients. Strategies to combine these treatment modalities in a hybrid approach has shown increasing promise for subgroups of AF patients.

Atrial fibrillation is the commonest form of arrhythmia affecting millions of people. Early detection of patients with paroxysmal atrial fibri- llation (PxAF) and rapid restoration of sinus rhythm (SR) not only ensures better quality of life but also minimizes the risk of chronicity, stroke, and

[Figure][1] A 68-year-old woman with troublesome palpitations and intolerant of several antiarrhythmics was referred for ablation of frequent (>25,000 in 24 h) symptomatic premature ventricular complexes (PVCs) with an inferior axis, positive QRS polarity in leads II, III, and aVF, and a

LEFT ATRIAL EXPANSION INDEX IN PATIENTS WITH ATRIAL FIBRILLATION IS A PREDICTOR OF SINUS RHYTHM MAINTENANCE AFTER CARDIOVERSION