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Background Extant literature has identified Major Depressive Disorder (MDD) as a comorbid disorder in individuals with seropositive human immunodeficiency disorder (HIV), and this may affect HIV-treatment efficacy. However, there is a paucity of literature evaluating the effects of antidepressant use on antiretroviral therapies (ART) in HIV-positive individuals. Herein, the following review assesses the effects of antidepressant medications on ART adherence in HIV-positive individuals with diagnosed MDD. Methods A systematic search on PubMed, Scopus, Web of Science, and Google Scholar search engines were conducted between database inception to June 12th, 2020 using the search and MeSH terms: (HIV) AND (antiretroviral or treatment) AND (depress*) AND (antidepressants) AND (adherence). Results We identified nine articles that evaluated ART adherence in HIV-positive individuals using antidepressants. Of the nine included articles, eight articles evaluated participants undergoing ART, and one article evaluated participants undergoing highly active antiretroviral therapy (HAART). Our primary findings suggest that patients who took antidepressant treatment for depression demonstrated greater adherence to HIV treatments and a reduction in missed HIV medication dosage. Limitations The heterogeneity of study design between the included studies was high. Conclusion The current review suggests that response to antidepressant medication may improve adherence to HIV treatments in HIV-positive individuals with comorbid depression. Further studies should expand the findings to explore the effects of disparate psychotropic agents on adherence behaviors among patients with HIV to identify the benefits of these agents on long-term health outcomes in this vulnerable clinical population.

Accurate automated wide QRS complex tachycardia (WCT) differentiation into ventricular tachycardia (VT) and supraventricular wide complex tachycardia (SWCT) can be accomplished using calculations derived from computerized electrocardiogram (ECG) data of paired WCT and baseline ECGs.Develop and trial novel WCT differentiation approaches for patients with and without a corresponding baseline ECG.We developed and trialed WCT differentiation models comprised of novel and previously described parameters derived from WCT and baseline ECG data. In Part 1, a derivation cohort was used to evaluate five different classification models: logistic regression (LR), artificial neural network (ANN), Random Forests [RF], support vector machine (SVM), and ensemble learning (EL). In Part 2, a separate validation cohort was used to prospectively evaluate the performance of two LR models using parameters generated from the WCT ECG alone (Solo Model) and paired WCT and baseline ECGs (Paired Model).Of the 421 patients of the derivation cohort (Part 1), a favorable area under the receiver operating characteristic curve (AUC) by all modeling subtypes: LR (0.96), ANN (0.96), RF (0.96), SVM (0.96), and EL (0.97). Of the 235 patients of the validation cohort (Part 2), the Solo Model and Paired Model achieved a favorable AUC for 103 patients with (Solo Model 0.87; Paired Model 0.95) and 132 patients without (Solo Model 0.84; Paired Model 0.95) a corroborating electrophysiology procedure or intracardiac device recording.Accurate WCT differentiation may be accomplished using computerized data of (i) the WCT ECG alone and (ii) paired WCT and baseline ECGs.

Background Automated wide complex tachycardia (WCT) differentiation into ventricular tachycardia (VT) and supraventricular wide complex tachycardia (SWCT) may be accomplished using novel calculations that quantify the extent of mean electrical vector changes between the WCT and baseline electrocardiogram (ECG). At present, it is unknown whether quantifying mean electrical vector changes within three orthogonal vectorcardiogram (VCG) leads (X, Y, and Z leads) can improve automated VT and SWCT classification. Methods A derivation cohort of paired WCT and baseline ECGs was used to derive five logistic regression models: (i) one novel WCT differentiation model (i.e., VCG Model), (ii) three previously developed WCT differentiation models (i.e., WCT Formula, VT Prediction Model, and WCT Formula II), and (iii) one “all‐inclusive” model (i.e., Hybrid Model). A separate validation cohort of paired WCT and baseline ECGs was used to trial and compare each model's performance. Results The VCG Model, composed of WCT QRS duration, baseline QRS duration, absolute change in QRS duration, X‐lead QRS amplitude change, Y‐lead QRS amplitude change, and Z‐lead QRS amplitude change, demonstrated effective WCT differentiation (area under the curve [AUC] 0.94) for the derivation cohort. For the validation cohort, the diagnostic performance of the VCG Model (AUC 0.94) was similar to that achieved by the WCT Formula (AUC 0.95), VT Prediction Model (AUC 0.91), WCT Formula II (AUC 0.94), and Hybrid Model (AUC 0.95). Conclusion Custom calculations derived from mathematically synthesized VCG signals may be used to formulate an effective means to differentiate WCTs automatically.

Introduction Point-by-point 3-dimensional (3D) electroanatomic mapping (EAM) is used to guide catheter ablation of premature ventricular complexes (PVCs). Due to the differences in the spatial excursion of the cardiac chambers during cardiac cycles in PVCs vs sinus rhythm, the 3D location registration during PVCs is shifted relative to sinus rhythm. In this study, we describe our strategy to adjust for this displacement in real-time during PVC mapping. Methods and results We report 21 patients who underwent catheter ablation of 23 unique PVCs using Carto 3. After mapping the earliest site for each PVC, we reregistered its 3D location to a sinus rhythm beat in real-time, and used this to guide ablation lesion delivery. The PVC earliest location was spatially displaced from the successful ablation lesion in sinus rhythm by average 6.7 (range 3.3-13.0) mm. Offline, we subsequently analyzed 25 unique chamber maps and 606 PVC points. For each point, we reregistered the 3D location to a preceding sinus beat. The PVC points were displaced from sinus rhythm location by average 4.4 (0.3-13.7) mm. The maximally displaced point for each chamber was 7.7 (4.7-13.7) mm. The general direction of shift during PVC was leftward and inferior relative to sinus rhythm. Conclusions During electroanatomic mapping of PVCs using the Carto 3 system, points mapped during PVCs are spatially displaced relative to their location in sinus rhythm. Electrophysiologists should recognize this phenomenon and account for the shift to guide accurate delivery of ablation lesions.

Purpose/Objective(s) Noninvasive cardiac radioablation (CRA) is increasingly used for treatment of high-risk ventricular tachycardia (VT). In an effort to promote consistency and disseminate best practices learned from our experience and that of other centers, we developed a remote education and peer review program via our Center for Noninvasive Cardiac Radioablation (CNCR). We report structure and international engagement via the CNCR program. Materials/Methods Centers that contacted CNCR with interest in starting a CRA program were provided with a digital packet of relevant literature on CRA, as well as brief guidance documents for optimizing simulation, image reorientation, and targeting. An introductory video call was scheduled with representatives from electrophysiology and radiation oncology between the site and CNCR. A consistent set of topics was discussed with each center in light of their local capabilities, including general principles of patient selection, targeting, simulation, motion management, treatment planning, delivery, and follow-up, and when appropriate, regulatory and billing issues. To facilitate consistent approaches to discussion of targeting, the American Heart Association 17-segment model construct was employed. For centers with a potential CRA case(s), interactive peer review was accomplished for targeting and planning, with the final decision for treatment at the discretion of the treating centers. Results From 2019 to present, 50 centers have engaged with CNCR through our program, representing 11 countries across 5 continents. Following initial engagement, 35/50 (70%) have treated at least one patient (range, 1-7), with 82 patients treated to date. Ninety-seven percent (34/35) of centers have maintained active engagement with CNCR following initial treatment of their first patient. Subsequently, three of those centers have develop prospective IDE trials through the FDA. All centers have committed to engagement in a newly established international registry and enrollment on developing clinical trials. Conclusion Cardiac radioablation is undergoing rapid uptake as a potential treatment for patients with high-risk VT, with the potential for wide variability in implementation. The CNCR remote education and peer review program has enabled rapid engagement with centers around the world, with a focus on best practices, establishing relationships for mutual sharing and collaboration, and encouraging prospective evaluation of safety and efficacy for CRA.

Objective Converging evidence suggests abnormalities in monetary reward processing may underlie the shared pathophysiology between major depressive disorder and obesity. As such, there is a need to parse deficits in specific subcomponents of monetary reward functioning (i.e., valuation, learning and anticipation). Methods PsycINFO, Google Scholar and PubMed databases were searched for English-language articles published between database inception to June 6th, 2020. Studies were identified using the following medical search heading (MeSH) terms and search strings: (reward (valuation OR motivation OR anticipation OR learning OR functioning OR decision-making OR reinforcement)) AND ((obesity OR overweight OR obese). Results Findings were reviewed from 11 studies evaluating the association between obesity and monetary reward processing. Four studies found significant differences in reward learning in individuals with obesity compared to normal-weight participants. Five studies found body mass index (BMI) to be predictive of willingness to expend effort (i.e., valuation) for a monetary reward. Three studies found changes in neural activations in the ventral striatum during anticipatory phases preceding receipt of a monetary reward in participants with obesity. Conclusions Participants with obesity demonstrated significantly poorer performance in task-based measures of reward learning, valuation, and anticipation, resulting in lower monetary reward outcomes across all studies compared to healthy controls. Notably, participants with obesity and comorbid depression performed worse than participants with no comorbid depression. Limitations There persists heterogeneity between studies with regards to inclusion of mood disorder populations and exclusion of psychiatric comorbidities in groups with obesity.

Studies comparing manual catheter navigation (MCN) to remote magnetic navigation (RMN) for atrial fibrillation (AF) ablation showed variable results. The aim of this meta-analysis is to compare the safety and clinical outcomes of AF radiofrequency (RF) ablation using MCN versus RMN with irrigated tip catheters. Medline and the Cochrane Central Register of Controlled Trials (CENTRAL) were queried from inception through January 2019. Studies comparing safety and clinical outcomes of AF ablation with RF using MCN versus RMN with irrigated tip catheters were included. Random effects meta-analysis was used to pool outcomes across studies. Study endpoints included freedom of AF at the end of the study, procedure total time, fluoroscopy time, and complications. A total of 14 studies (3 controlled non-randomized trials, 1 prospective observational, and 10 retrospective observational studies) involving 3375 patients (1871 in MCN and 1504 in RMN) were included in this meta-analysis. There was no significant difference between the two groups in terms of freedom of AF (OR 1.08, 95% CI 0.82–1.42, p = 0.52). The MCN group was associated with shorter procedure time (mean difference in minutes − 50.39, 95% CI − 67.99 to − 32.79, p

Differentiation of wide complex tachycardias (WCTs) into ventricular tachycardia (VT) or supraventricular wide complex tachycardia (SWCT) using conventional manually-operated electrocardiogram (ECG) interpretation methods is difficult. Recent research has shown that accurate WCT differentiation may be accomplished by automated approaches (e.g., WCT Formula) implemented by computerized ECG interpretation software.We sought to develop a new automated means to differentiate WCTs.First, a derivation cohort of paired WCT and baseline ECGs was examined to secure independent VT predictors to be incorporated into a logistic regression model (i.e., WCT Formula II). Second, the WCT Formula II was trialed against a separate validation cohort of paired WCT and baseline ECGs.The derivation cohort comprised 317 paired WCT (157 VT, 160 SWCT) and baseline ECGs. The WCT Formula II was composed of baseline QRS duration (p = 0.02), WCT QRS duration (p 0.001), frontal percent time-voltage area change (p 0.001), and horizontal percent time-voltage area change (p 0.001). The area under the curve (AUC) for VT and SWCT differentiation was 0.96 (95% CI 0.94-0.98) for the derivation cohort. The validation cohort consisted of 284 paired WCT (116 VT, 168 SWCT) and baseline ECGs. WCT Formula II implementation on the validation cohort yielded effective WCT differentiation (AUC 0.96; 95% CI 0.94-0.98).The WCT Formula II is an example of how contemporary ECG interpretation software could be used to differentiate WCTs successfully.

Objectives This study sought to map the epicardial electrophysiological (EP) substrate in early repolarization (ER) syndrome patients using noninvasive electrocardiographic imaging (ECGI), and to characterize substrate properties that support arrhythmogenicity. Background The ER pattern is a common ECG finding. Recent studies established a definitive clinical association between ER and fatal ventricular arrhythmias. However, the arrhythmogenic substrate of ER in the intact human heart has not been characterized. Methods Twenty-nine ER syndrome patients were enrolled, 17 of whom had a malignant syndrome. Characteristics of the abnormal EP substrate were analyzed using data recorded during sinus rhythm. The EP mapping data were analyzed for electrogram morphology, conduction, and repolarization. Seven normal subjects provided control data. Results The abnormal EP substrate in ER syndrome patients has the following properties: 1) abnormal epicardial electrograms characterized by presence of J waves in localized regions; 2) absence of conduction abnormalities, including delayed activation, conduction block, or fractionated electrograms; and 3) marked abbreviation of ventricular repolarization in areas with J waves. The action potential duration (APD) was significantly shorter than normal (196 ± 19 ms vs. 235 ± 21 ms; p Conclusions ER is associated with steep repolarization gradients caused by localized shortening of APD. Results suggest association of PVC initiation sites with areas of repolarization abnormalities. Conduction abnormalities were not observed.

Background Ischemic cardiomyopathy (ICM) can provide the substrate for ventricular tachycardia (VT). Objective To map noninvasively with high resolution the electrophysiologic (EP) scar substrate, identify its relationship to reentry circuits during VT, and stratify VT risk in ICM patients. Methods Noninvasive high-resolution epicardial mapping with electrocardiographic imaging (ECGI) was performed in 32 ICM patients (17 with clinical VT, 15 without VT). Abnormal scar EP substrate was determined based on electrogram (EGM) amplitude (as percentage of maximal peak-to-peak voltage over the entire ventricular epicardium; total scar [TS] Results Patients with VT had higher scar burden (TS: 51.0 ± 9.3% vs 36.5 ± 5.4%, P Conclusions ECGI noninvasively identified scar EP substrate that underlies abnormal conduction in ICM patients. It identified regions within the scar that aligned with critical elements of the reentry circuit during VT. ECGI can potentially be used for VT risk stratification in ICM patients.

Background: Case studies have suggested the efficacy of catheter-free, electrophysiology-guided noninvasive cardiac radioablation for ventricular tachycardia (VT) using stereotactic body radiation therapy, although prospective data are lacking. Methods: We conducted a prospective phase I/II trial of noninvasive cardiac radioablation in adults with treatment-refractory episodes of VT or cardiomyopathy related to premature ventricular contractions (PVCs). Arrhythmogenic scar regions were targeted by combining noninvasive anatomic and electric cardiac imaging with a standard stereotactic body radiation therapy workflow followed by delivery of a single fraction of 25 Gy to the target. The primary safety end point was treatment-related serious adverse events in the first 90 days. The primary efficacy end point was any reduction in VT episodes (tracked by indwelling implantable cardioverter defibrillators) or any reduction in PVC burden (as measured by a 24-hour Holter monitor) comparing the 6 months before and after treatment (with a 6-week blanking window after treatment). Health-related quality of life was assessed using the Short Form-36 questionnaire. Results: Nineteen patients were enrolled (17 for VT, 2 for PVC cardiomyopathy). Median noninvasive ablation time was 15.3 minutes (range, 5.4–32.3). In the first 90 days, 2/19 patients (10.5%) developed a treatment-related serious adverse event. The median number of VT episodes was reduced from 119 (range, 4–292) to 3 (range, 0–31; P P =0.008). Quality of life improved in 5 of 9 Short Form-36 domains at 6 months. Conclusions: Noninvasive electrophysiology-guided cardiac radioablation is associated with markedly reduced ventricular arrhythmia burden with modest short-term risks, reduction in antiarrhythmic drug use, and improvement in quality of life. Clinical Trial Registration: URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT02919618.

Many patients with heart failure continue cardiac resynchronization therapy (CRT) after continuous flow left ventricular assist device (CF-LVAD) implant. We report the first multicenter study to assess the impact of CRT on clinical outcomes in CF-LVAD patients.Analysis was performed on 488 patients (58±13 years, 81% male) with an implantable cardioverter defibrillator (ICD) (n=223) or CRT-D (n=265) who underwent CF-LVAD implantation at 5 centers from 2007 to 2015. Effects of CRT on mortality, hospitalizations, and ventricular arrhythmia incidence were compared against CF-LVAD patients with an ICD alone. Baseline differences were noted between the 2 groups in age (60±12 versus 55±14,In this large, multicenter CF-LVAD cohort, continued CRT was not associated with improved survival, hospitalizations, incidence of ventricular arrhythmia and ICD therapies, and was related to a significantly higher number of pulse generator changes.

Point-by-point 3D electroanatomic mapping is used to guide catheter ablation of PVCs. Due to differences in the spatial excursion of the cardiac chambers during cardiac cycles in PVCs versus sinus rhythm, 3D location registration during PVCs may be shifted relative to sinus rhythm. In this study, we

Electrocardiographic imaging is a noninvasive way to map premature ventricular contractions (PVC) and ventricular tachycardia (VT). The accuracy of Cardioinsight (Medtronic) in a clinical setting has not been rigorously validated. We included consecutive PVC/VT catheter ablation procedures

Remote magnetic navigation (RMN) is an alternative to manual catheter ablation of premature ventricular contractions (PVCs). When compared to manual, RMN has a theoretical advantage of tip stability, which could result in higher acute procedural success. However, RMN has a theoretical disadvantage

Ischemic cardiomyopathy (ICM) can provide the substrate for ventricular tachycardia (VT).To map noninvasively with high resolution the electrophysiologic (EP) scar substrate, identify its relationship to reentry circuits during VT, and stratify VT risk in ICM patients.Noninvasive high-resolution epicardial mapping with electrocardiographic imaging (ECGI) was performed in 32 ICM patients (17 with clinical VT, 15 without VT). Abnormal scar EP substrate was determined based on electrogram (EGM) amplitude (as percentage of maximal peak-to-peak voltage over the entire ventricular epicardium; total scar [TS]30%; dense scar [DS]15%), fractionation, and presence of late potentials (LPs). Scar burden was defined as the ratio of the scar size to the total epicardial surface area. The VT activation pattern was mapped and correlated with the EP substrate to identify components of the reentry circuit.Patients with VT had higher scar burden (TS: 51.0 ± 9.3% vs 36.5 ± 5.4%, P0.05; DS: 29.5 ± 7.3% vs 16.8 ± 6.8%, P0.05) with lower normalized unipolar EGM voltage (TS: 0.107 ± 0.027 vs 0.153 ± 0.031, P0.05; DS: 0.073 ± 0.023 vs 0.098 ± 0.026, P0.05), greater prevalence of fractionated EGMs (TS: 44.1 ± 10.6% vs 26.8 ± 6.3%, P0.05; DS: 50.8 ± 10.8% vs 30.9 ± 7.0%, P0.05), and LPs (TS: 26.8 ± 10.7% vs 15.8 ± 5.3, P0.05). VTs were mapped in eight patients; the reentry circuits were closely related to the EP substrate.ECGI noninvasively identified scar EP substrate that underlies abnormal conduction in ICM patients. It identified regions within the scar that aligned with critical elements of the reentry circuit during VT. ECGI can potentially be used for VT risk stratification in ICM patients.

Background— Cardiac memory refers to the observation that altered cardiac electrical activation results in repolarization changes that persist after the restoration of a normal activation pattern. Animal studies, however, have yielded disparate conclusions, both regarding the spatial pattern of repolarization changes in cardiac memory and the underlying mechanisms. The present study was undertaken to produce 3-dimensional images of the repolarization changes underlying long-term cardiac memory in humans. Methods and Results— Nine adult subjects with structurally normal hearts and dual-chamber pacemakers were enrolled in the study. Noninvasive electrocardiographic imaging was used before and after 1 month of ventricular pacing to reconstruct epicardial activation and repolarization patterns. Eight subjects exhibited cardiac memory in response to ventricular pacing. In all subjects, ventricular pacing resulted in a prolongation of the activation recovery interval (a surrogate for action potential duration) in the region close to the site of pacemaker-induced activation from 228.4±7.6 ms during sinus rhythm to 328.3±6.2 ms during cardiac memory. As a consequence, increases are observed in both apical-basal and right-left ventricular gradients of repolarization, resulting in a significant increase in the dispersion of repolarization. Conclusions— These results demonstrate that electrical remodeling in response to ventricular pacing in human subjects results in action potential prolongation near the site of abnormal activation and a marked dispersion of repolarization. This dispersion of repolarization is potentially arrhythmogenic and, intriguingly, was less evident during continuous right ventricular pacing, suggesting the novel possibility that continuous right ventricular pacing at least partially suppresses pacemaker-induced cardiac memory.

Evaluation of: Weerasooriya R, Khairy P, Litalien J et al. Catheter ablation for arial fibrillation; are results maintained at 5 years of follow-up? J. Am. Coll. Cardiol. 57, 160–166 (2011).Atrial fibrillation is the most common arrhythmia faced in clinical practice with a substantial impact on morbidity, mortality, and heathcare expenditures. Patients with atrial fibrillation in which a rhythm control strategy is desired to improve quality of life have had limited options. The discovery of the role of pulmonary vein triggers has led to the development of catheter ablation techniques that have shown promising short-term success rates. Long-term outcomes were until recently, lacking. These results confirm the inherently recurrent nature of atrial fibrillation and the need for multiple procedures to achieve reasonable long-term successful maintenance of sinus rhythm.

Objective The purpose of this study was to determine whether resting myocardial deformation and rotation may be altered in diabetic patients with significant epicardial coronary artery disease (CAD) with normal left ventricular ejection fraction. Design A prospective observational study. Setting Diagnosis of epicardial CAD in patients with diabetes. Patients and Methods Eighty-four patients with diabetes suspected of epicardial CAD scheduled for cardiac catheterization had a resting echocardiogram performed prior to their procedure. Echocardiographic measurements were compared between patients with and without significant epicardial CAD as determined by cardiac catheterization. Main Outcome Measures Measurement of longitudinal strain, strain rate, apical rotation, and rotation rate, using speckle tracking echocardiography. Results Eighty-four patients were studied, 39 (46.4%) of whom had significant epicardial CAD. Global peak systolic apical rotation was significantly increased (14.9 ± 5.1 vs. 11.0 ± 4.8 degrees, P < 0.001) in patients with epicardial CAD along with faster peak systolic apical rotation rate (90.4 ± 29 vs. 68.1 ± 22.2 degrees/sec, P < 0.001). These findings were further confirmed through multivariate logistic regression analysis (global peak systolic apical rotation OR = 1.17, P = 0.004 and peak systolic apical rotation rate OR = 1.05, P < 0.001). Conclusions Patients with diabetes with significant epicardial CAD and normal LVEF exhibit an increase in peak systolic apical counterclockwise rotation and rotation rate detected by echocardiography, suggesting that significant epicardial CAD and its associated myocardial effects in patients with diabetes may be detected noninvasively at rest.

The purpose of this study was to assess tumor implantation at abdominal wound sites following manipulation of a solid abdominal tumor. GW-39 human colon cancer cells were injected into the omentum of golden Syrian hamsters. At 2 weeks, an omental tumor was harvested and animals were randomized to bivalve (A), crush (B), strip (C), or excision (D), with or without pneumoperitoneum. Four 5-mm trocars were inserted into the abdomen, and the tumor was reinserted through the midline, swept through four quadrants, and removed. The incision was closed and pneumoperitoneum at 7 mmHg was maintained for 10 min. Tumor implantation at wound sites was documented at 7 weeks. Implantation at trocar sites was 53 and 49% with and without pneumoperitoneum in the manipulated groups (A, B, C), respectively (p = 0.993). Implantation at trocar sites was reduced in the control group (D) at 9 and 10% with and without pneumoperitoneum, respectively (p < 0.001). Tumor implantation at trocar sites is due to spillage of tumor during manipulation and not to pneumoperitoneum.

An 84 y/o man had worsened symptoms (NYHA class III, LVEF 25%) following implant of a biventricular (BiV) cardioverter defibrillator (Biotronik, Lumax 540) at another institution. He also had frequent premature ventricular contractions (PVCs, 35%) that interfered with cardiac resynchronization therapy (CRT) and triggered BiV pacing. At electrophysiology (EP) study, the left ventricular (LV) lead was discovered to be within the anterior interventricular vein. His native QRS (113 ms) was much narrower than during CRT; thus, BiV pacing was disabled to allow for native conduction. The dominant clinical PVC was mapped and successfully ablated from the coronary cusps. His symptoms improved dramatically within days of the procedure and programming change. Prior to ablation, Electrocardiographic Imaging (ECGI)1-2 was applied to noninvasively map and study the mechanisms of pacing induced dyssynchrony (Figure 1) and ineffectiveness of PVC-triggered pacing (Figure 2). Figure 1 QRS morphologies (12-lead ECG) and ECGI-reconstructed epicardial activation isochrones under native sinus rhythm (Panel A, left, and Panel B) and BiV Pacing (Panel A, right, and Panel C). Note that QRS in native sinus rhythm is much narrower than for ... Figure 2 QRS morphologies (12-lead ECG) and ECGI activation Isochrone maps during PVC-triggered BiV pacing (Panel A, left, and Panel B) and spontaneous PVC without pacing (Panel A, right, and Panel C). The activation maps are shown in posterior (top, POS) and ... This patient had a narrow QRS and consequently a predictable lack of benefit from CRT and inappropriate CRT indication. Moreover, his LV lead was anterior, which several studies have demonstrated not to be optimal for CRT. Inappropriate CRT in patients with synchronous LV activation could cause pacing induced dyssynchrony, leading to deteriorating LV function. 1, 3 In the context of heart failure, ECGI has been used to map the EP substrate2, to identify potential responders/nonresponders to CRT1, and to guide electrode placement4. Unlike the global body-surface QRSd, the ECGI derived cardiac electrical dyssynchrony (ED) index, computed as the standard deviation of all activation times on the LV, quantifies the spatial dispersion of activation over the LV (ED>28 ms is a marker of electrical dyssynchrony1). As shown in the ECGI image of Figure 1, pacing from the early-activated LV anterior wall during BiV created a functional line-of-block. This forced the activation front to propagate in a U-shaped pattern around the line-of-block, causing late dyssynchronous activation of the lateral LV base. The image in Figure 2 shows that during PVC-triggered pacing, the PVC site of origin was in close proximity to the anterior LV lead, but far from the RV sensing lead, which caused delayed sensing and pacing. Thus, BiV pacing triggered by PVC failed to capture the (already activated) ventricles and was ineffective. Because in many similar cases PVCs can impede the effective delivery of continuous CRT, PVC treatment (catheter ablation or antiarrhythmic drugs) to ensure high percentage of effective BiV pacing might be considered.

Intrauterine crowding has been implicated as a risk factor in several orthopaedic conditions, such as developmental dysplasia of the hip (DDH), metatarsus adductus, and torticollis. The goal of this study was to see whether orthopaedic conditions associated with intrauterine crowding were more frequent in multiple gestation pregnancies, specifically in triplets. The authors reviewed their experience over a 10-year period with 261 children who were products of triplet pregnancies. They surveyed 13 orthopaedic conditions and found only one condition, torticollis, that had a greater incidence than that reported in single gestation pregnancies. A 0% incidence of DDH was found in these patients. Routine ultrasound screening cannot be recommended in these patients based on these results.

The effect of wealth on consumption is an issue of longstanding interest to economists. Analysts believe that fluctuations in household wealth have driven major swings in economic activity. This paper considers so-called wealth effects—the impact of changes in wealth on household consumption and the overall macroeconomy. There is an extensive existing literature on wealth effects, but there are also many unanswered issues and questions. This paper reviews the important issues regarding the role wealth plays in the macroeconomy and argues that there is a need for much more wealth effect research as well as better data sources for conducting such analysis.

This paper uses panel data through 2011 to examine evidence of shifts in household balance sheet behavior following the financial crisis and Great Recession. The paper considers evidence of balance sheet repair through debt repayment as well as changes in the composition of households’ balance sheets and/or saving decisions to determine whether households’ desire for holding or investing in riskier versus safer assets has changed. The data show relatively small and limited balance sheet adjustment—especially for those households considered the most likely to have been impacted by the economic collapse. The adjustment that did occur typically raised households’ liquid asset holdings and/or saving and reduced their risky asset positions (stocks). There is also some evidence of increased nonhousing debt repayment and slower takeup of new nonhousing debt. Overall, the findings are inconsistent with major adjustments occurring in households’ balance sheet behavior—especially to the extent where these shifts would have contributed substantially to the sluggish economic recovery

Triage ambulatory electrocardiographic (ECG) analysis permits relatively unskilled office workers to submit 24-hour ambulatory ECG Holter tapes to an automatic instrument (model 563, Del Mar Avionics, Irvine, CA) for interpretation. The instrument system "triages" what it is capable of automatically interpreting and rejects those tapes (with high ventricular arrhythmia density) requiring thorough analysis. Nevertheless, a trained cardiovascular technician ultimately edits what is accepted for analysis. This study examined the clinical validity of one manufacturer's triage instrumentation with regard to accuracy and time efficiency for interpreting ventricular arrhythmia. A database of 50 Holter tapes stratified for frequency of ventricular ectopic beats (VEBs) was examined by triage, conventional, and full-disclosure hand-count Holter analysis. Half of the tapes were found to be automatically analyzable by the triage method. Comparison of the VEB accuracy of triage versus conventional analysis using the full-disclosure hand count as the standard showed that triage analysis overall appeared as accurate as conventional Holter analysis but had limitations in detecting ventricular tachycardia (VT) runs. Overall sensitivity, positive predictive accuracy, and false positive rate for the triage ambulatory ECG analysis were 96, 99, and 0.9%, respectively, for isolated VEBs, 92, 93, and 7%, respectively, for ventricular couplets, and 48, 93, and 7%, respectively, for VT. Error in VT detection by triage analysis occurred on a single tape. Of the remaining 11 tapes containing VT runs, accuracy was significantly increased, with a sensitivity of 86%, positive predictive accuracy of 90%, and false positive rate of 10%. Stopwatch-recorded time efficiency was carefully logged during both triage and conventional ambulatory ECG analysis and divided into five time phases: secretarial, machine, analysis, editing, and total time. Triage analysis was significantly (P < .05) more time efficient for the machine, analysis, and total time phases and required significantly more time in the editing phases. The triage analysis was limited by the inability of the automatic methodology to detect a specific VT waveform contained on one tape. This result which caused substantial loss of sensitivity for VT, emphasizes the necessity for careful quality control and editing of all automatic Holter analysis methods.

A 40-year-old woman with nonischemic cardiomyopathy and a left ventricular (LV) ejection fraction of 35% was referred for recurrent ventricular tachycardia (VT). She experienced 248 VT episodes treated by antitachycardia pacing (ATP) over 14 days. In 2005, she received an implantable cardioverter defibrillator for an episode of syncope and nonsustained VT. She later underwent an invasive electrophysiology study (EPS) with inducible VT and an ablation of the AV nodal reentrant tachycardia. Since then, she experienced symptomatic VT, terminated by ATP. Her VT was unresponsive to sotalol and mexiletine. Two EPS in early 2010 failed to induce VT despite intravenous isoproterenol and triple extrastimuli at two right ventricular (RV) sites; therefore, no ablations were performed.

Wage inequality has risen dramatically in the United States since at least 1980. This paper quantifies the role that the tax policies of the federal and state governments have played in mitigating wage inequality. The analysis, which isolates the contribution of federal taxes and state taxes separately, employs two approaches. First, cross-sectional estimates compare before-tax and after-tax inequality across the 50 states and the District of Columbia. Second, inequality estimates across time are calculated to assess the evolution of the effects of tax policies. The results from the first approach indicate that the tax code reduces wage inequality substantially in all states. On average, taxes reverse approximately the last two decades of growth in wage inequality. Most of this compression of the income distribution is attributable to federal taxes. Nevertheless, there is substantial cross-state variation in the extent to which state tax policies compress the income distribution. Cross-state differences in gasoline taxes have a surprisingly large impact on income compression, as do sales tax exemptions for food and clothing. The results of the second approach indicate that the mitigating influence of tax policy on wage inequality has increased very modestly since the early 1980s. The increase is due to the widening of the pre-tax wage distribution interacting with a progressive tax structure. In contrast, legislated tax changes over this period decreased income compression somewhat.

Deleveraging is the process by which households decide that their level of debt is inconsistent with their revised economic outlook and adjust their leverage accordingly, primarily by substituting debt repayment for consumption. Household deleveraging is a commonly cited reason for the sluggish consumption growth experienced during the current economic recovery from the Great Recession. This policy brief analyzes the impact of household debt repayment on consumer spending during and after the Great Recession by using aggregate and household-level data. Overall, the data show little evidence that deleveraging affected household consumption. Rather, movements in consumption prior to, during, and following the Great Recession are consistent with the standard relationships implied by fluctuations in household income and net worth.

Using data from the Panel Study of Income Dynamics, this paper examines the flow of U.S. households within and between two distinct segments of the housing market — renter-occupied properties and owner-occupied properties. The paper provides relevant empirical moments for microfounded models of the housing sector. In particular, net flows in the housing market are substantially smaller than the gross flows, as is the case in the literature on labor market flows. Housing market turnover also exhibits substantial heterogeneity in household moving rates, the long-run moving trends, and the cyclical patterns of household moving decisions. Moves by renters tend to lead movements in real GDP, while moves by homeowners are procyclical and/or slightly lag the cycle. The paper further shows that the secular decline in household moves over time is driven by reduced within-sector moves. Taken together, the paper's results imply that models aiming to describe housing market flows will have to feature substantial nonlinearities and/or multiple sector-specific (owner versus renter) shocks.

Income inequality has risen dramatically in the United States since at least 1980. This paper quantifies the role that the tax policies of the federal and state governments have played in mitigating this income inequality. The analysis, which isolates the contribution of federal taxes and state taxes separately, employs two approaches. First, cross-sectional estimates compare before-tax and after-tax inequality across the 50 states and the District of Columbia. Second, inequality estimates across time are calculated to assess the evolution of the effects of tax policies. The results from the first approach indicate that the tax code reduces income inequality substantially in all states, with most of the compression of the income distribution attributable to federal taxes. Nevertheless, there is substantial cross-state variation in the extent to which state tax policies compress the income distribution attributable to federal taxes. Cross-state differences in gasoline taxes have a surprisingly large impact on income compression, as do sales tax exemptions for food and clothing. The results of the second approach indicate that there has been little change since the early 1980s in the impact of tax policy on income inequality across almost all states.