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Giora Pillar,1 Murray Berall,2 Richard B Berry,3 Tamar Etzioni,1 Yaakov Henkin,4 Dennis Hwang,5 Ibrahim Marai,6,7 Faheem Shehadeh,6 Prasanth Manthena,8 Anil Rama,9 Rebecca Spiegel,10 Thomas Penzel,11 Riva Tauman12 1Sleep Laboratory, Carmel Medical Center and Technion Faculty of Medicine, Haifa, Israel; 2Center of Sleep and Chronobiology, University of Toronto, Toronto, ON, Canada; 3UF Health Sleep Center, University of Florida, Gainesville, FL, USA; 4Cardiology Department, Soroka Medical Center, Be’er Sheva, Israel; 5Kaiser Permanente San Bernardino County Medical Center, Fontana, CA, USA; 6Cardiology Department, Rambam Medical Center, Haifa, Israel; 7Baruch Padeh Medical Center and the Azrieli Faculty of Medicine in the Galilee, Poriya, Israel; 8Sleep clinic, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA; 9Sleep Clinic, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA; 10Department of Neurology and Sleep Center, Stony Brook University Hospital, Stony Brook, NY, USA; 11Charite Universitätsmedizin Berlin, Sleep Medicine Center, Berlin, Germany; 12Sleep Disorders Center, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelCorrespondence: Giora Pillar, Sleep Laboratory, Carmel Medical Center and Technion Faculty of Medicine, Haifa, 31096, Israel, Tel +972 4 8250258, Fax +972 48250699, Email gpillar@technion.ac.ilBackground: The WatchPAT (WP) device was shown to be accurate for the diagnosis of sleep apnea and is widely used worldwide as an ambulatory diagnostic tool. While it records peripheral arterial tone (PAT) and not electrocardiogram (ECG), the ability of it to detect arrhythmias is unknown and was not studied previously. Common arrhythmias such as atrial fibrillation (AF) or premature beats may be uniquely presented while recording PAT/pulse wave.Purpose: To examine the potential detection of common arrhythmias by analyzing the PAT amplitude and pulse rate/volume changes.Patients and Methods: Patients with suspected sleep disordered breathing (SDB) were recruited with preference for patients with previously diagnosed AF or congestive heart failure (CHF). They underwent simultaneous WP and PSG studies in 11 sleep centers. A novel algorithm was developed to detect arrhythmias while measuring PAT and was tested on these patients. Manual scoring of ECG channel (recorded as part of the PSG) was blinded to the automatically analyzed WP data.Results: A total of 84 patients aged 57± 16 (54 males) participated in this study. Their BMI was 30± 5.7Kg/m2. Of them, 41 had heart failure (49%) and 17 (20%) had AF. The sensitivity and specificity of the WP to detect AF segments (of at least 60 seconds) were 0.77 and 0.99, respectively. The correlation between the WP derived detection of premature beats (events/min) to that of the PSG one was 0.98 (p< 0.001).Conclusion: The novel automatic algorithm of the WP can reasonably detect AF and premature beats. We suggest that when the algorithm raises a flag for arrhythmia, the patients should shortly undergo ECG and/or Holter ECG study.Keywords: home sleep apnea test, WatchPAT, obstructive sleep apnea, arrhythmia, atrial fibrillation

Background: The complete left bundle branch block (CLBBB) results in ventricular dyssynchrony and a reduction in systolic and diastolic efficiency. We noticed a distinct clockwise rotation of the left ventricle (LV) in patients with CLBBB (“longitudinal rotation”). Aim: The aim of this study was to quantify the “longitudinal rotation” of the LV in patients with CLBBB in comparison to patients with normal conduction or complete right bundle branch block (CRBBB). Methods: Sixty consecutive patients with normal QRS, CRBBB, or CLBBB were included. Stored raw data DICOM 2D apical-4 chambers view images cine clips were analyzed using EchoPac plugin version 203 (GE Vingmed Ultrasound AS, Horten, Norway). In EchoPac–Q-Analysis, 2D strain application was selected. Instead of apical view algorithms, the SAX-MV (short axis—mitral valve level) algorithm was selected for analysis. A closed loop endocardial contour was drawn to initiate the analysis. The “posterior” segment (representing the mitral valve) was excluded before finalizing the analysis. Longitudinal rotation direction, peak angle, and time-to-peak rotation were recorded. Results: All patients with CLBBB (n = 21) had clockwise longitudinal rotation with mean four chamber peak rotation angle of −3.9 ± 2.4°. This rotation is significantly larger than in patients with normal QRS (−1.4 ± 3°, p = 0.005) and CRBBB (0.1 ± 2.2°, p = 0.00001). Clockwise rotation was found to be correlated to QRS duration in patients with the non-RBBB pattern. The angle of rotation was not associated with a lower ejection fraction or the presence of regional wall abnormalities. Conclusions: Significant clockwise longitudinal rotation was found in CLBBB patients compared to normal QRS or CRBBB patients using speckle-tracking echocardiography.

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 CLBBB results in sequential contraction and ventricular dyssynchrony, reducing systolic and diastolic efficiency. We have noticed a distinct clockwise rotation of the left ventricle (LV) in patients with LBBB (“longitudinal rotation”). Aim The aim of this study was to quantify this “longitudinal rotation” of the LV in patients with CLBBB in comparison to patients with normal conduction or RBBB. Methods 60 consecutive patients with normal QRS, RBBB or LBBB were included. Stored raw data DICOM 2D apical-4 chambers view images cine clips were analyzed using EchoPac plugin version 203 (GE Vingmed Ultrasound AS, Horten, Norway). In EchoPac – Q-Analysis/2D strain application was selected. Instead of apical views algorithms, SAX-MV (shore axis – mitral valve level) algorhithm was selected for analysis. A closed loop endocardial contour was drawn to initiate analysis. The “posterior” segment (representing the mitral valve) was excluded before finalizing analysis. Longitudinal rotation direction, peak angle and time to peak rotation were recorded. Results All patients with CLBBB (n = 21) had clockwise longitudinal rotation with mean 4 chamber peak rotation angle of -3.9 ± 2.4°. This rotation is significantly higher than patients with normal QRS (-1.4 ± 3°, p = 0.005) and RBBB (0.1 ± 2.2°, p = 0.00001). Clockwise rotation was found to be correlated to QRS duration in patients with non- RBBB pattern. The angle of rotation was not associated with low ejection fraction or the presence of regional wall abnormality or the strain software used. Conclusion significant clockwise longitudinal rotation was found in in CLBBB patients compared to normal QRS or RBBB patients using speckle tracking echocardiography.

Background Heart rate variability (HRV) has been suggested as an indicator of capacity to adapt effectively to physiological or environmental challenges and of physical and psychological health in old age. Aims The study assessed levels of high-frequency HRV (HF-HRV) among older adults in relation to positive and negative affect and the mediating role of positive and negative affect in the association between coping resources (perceived social support and sense of mastery) and HF-HRV. Method Participants were 187 men and women in three assisted-living residences who were independent in activities of daily living (93.4% participation rate). The participants completed sense of mastery, multidimensional scale of perceived social support, and positive and negative affect questionnaires. HF-HRV was derived from electrocardiography data measured by a Holter monitoring device for 15 minutes. Results The empirical model showed good fit indices indicating that higher HF-HRV was associated with lower negative affect, and negative affect mediated the association between perceived social support and HF-HRV. In addition, perceived social support and sense of mastery were associated with higher positive affect and lower negative affect. Conclusions Although this was a cross-sectional study, it suggests that HF-HRV may be a link between affect and health in old age. It also suggests the importance of identification and intervention with older adults and their support systems to reduce negative affect.

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

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

The effect of contrast media (CM), delivered prior to- and during transcatheter aortic valve implantation (TAVI), on kidney function, following the procedure, is debatable. Consequently, the performance of CM-based, acute kidney injury (AKI) risk prediction models is also questionable. We retrospectively studied 210 patients that underwent TAVI. We recorded the dose of CM used prior and during TAVI, calculated the results of different AKI risk assessment models containing a CM module, and tested their association with AKI after the procedure. AKI was diagnosed in 38 patients (18.1%). The baseline estimated glomerular filtration rate (eGFR) was lower in the AKI+ group compared to AKI− group (51 ± 19.3 versus 64.5 ± 19 mL/min/1.73 mr2, respectively). While the dose of CM delivered prior to TAVI, during TAVI or the cumulative amount of both did not differ between the groups, the results of all tested risk models were higher in AKI+ patients. However, by multivariable analysis, only eGFR had a consistent independent association with AKI. We suggest that the dose of CM delivered prior or during TAVI is not associated with AKI and that the predictive power of CM based AKI risk models is, in all probability, limited to eGFR alone.

Background: The complete left bundle branch block (CLBBB) results in ventricular dyssynchrony and a reduction in systolic and diastolic efficiency. We noticed a distinct clockwise rotation of the left ventricle (LV) in patients with CLBBB (“longitudinal rotation”). Aim: The aim of this study was to quantify the “longitudinal rotation” of the LV in patients with CLBBB in comparison to patients with normal conduction or complete right bundle branch block (CRBBB). Methods: Sixty consecutive patients with normal QRS, CRBBB, or CLBBB were included. Stored raw data DICOM 2D apical-4 chambers view images cine clips were analyzed using EchoPac plugin version 203 (GE Vingmed Ultrasound AS, Horten, Norway). In EchoPac–Q-Analysis, 2D strain application was selected. Instead of apical view algorithms, the SAX-MV (short axis—mitral valve level) algorithm was selected for analysis. A closed loop endocardial contour was drawn to initiate the analysis. The “posterior” segment (representing the mitral valve) was excluded before finalizing the analysis. Longitudinal rotation direction, peak angle, and time-to-peak rotation were recorded. Results: All patients with CLBBB (n = 21) had clockwise longitudinal rotation with mean four chamber peak rotation angle of −3.9 ± 2.4°. This rotation is significantly larger than in patients with normal QRS (−1.4 ± 3°, p = 0.005) and CRBBB (0.1 ± 2.2°, p = 0.00001). Clockwise rotation was found to be correlated to QRS duration in patients with the non-RBBB pattern. The angle of rotation was not associated with a lower ejection fraction or the presence of regional wall abnormalities. Conclusions: Significant clockwise longitudinal rotation was found in CLBBB patients compared to normal QRS or CRBBB patients using speckle-tracking echocardiography.

Gabby Elbaz-Greener,1,&ast; Guy Rozen,2– 4,&ast; 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&ast;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.

PURPOSE: To simulate the effect of decreasing conduction velocity (Cvel) on average segmental myocardial strain using mathematical modeling. METHODS: The simulation was run using MatLab version 7.4 (The MathWorks, Inc. Natick, Massachusetts). A normal strain-time curve pattern was sampled from a normal human echo study using the 2D strain imaging software (GE Healthcare, Milwaukee, Wisconsin). Contraction was simulated from simultaneous segmental activation (Cvel=∞) through normal activation (Cvel=400cm/sec) to pacing Cvel (100 to 10cm/sec). The simulation generated average segmental strain-time waveforms for each velocity and peak strain as a function of Cvel and time to peak strain as a function of Cvel curves. RESULTS: With decreasing Cvel, average peak segmental strain was found to be decreased and delayed. The following correlation equation represents the correlation betweenpeak strain and Cvel : strain= -20.12+27.65 x e (-0.29 x Cvel). At the highest pacing Cvel (100cm/sec) average peak segmental strain dropped by 10%, at 50cm/sec by 30% and at the lowest pacing Cvel (10cm/sec) peak strain dropped by >90%. Time to peak segmental strain was minimally longer with decreasing Cvel down to 70cm/sec (pacing velocity range). Further decreased velocity dramatically increased time to peak strain of the simulated segment. CONCLUSIONS: The simulation yielded a predictive correlation between slower conduction velocities and decreased and delayed segmental strain.

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

Objectives To examine the associations between intensity of providing regular grandchild care and positive affect (PA) and negative affect (NA), heart rate variability (HRV) and somatic symptoms. Methods This was a cross-sectional study involving 104 individuals (aged 59–82) who provide at least 5 h a week of regular care for their grandchildren. The study model was assessed using structural equation modeling. Results Intensity of regular care (mean hours per week: M = 14.8, SD = 11.2) was associated with higher PA and lower NA. Higher perceived role overload, higher NA and lower PA were associated with lower HRV and somatic symptoms. The fit indices indicated a good model fit. Conclusions The results suggest that healthcare professionals should be aware of the positive and negative implications of caring for grandchildren on their older patients, including the increased risk of future morbidity, as indicated by lower HRV.

Objectives: To study post-traumatic stress symptoms and post-traumatic growth and heart rate variability among elderly Holocaust survivors and a matched comparison group and the mediational effect ...

Background: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation in both paroxysmal and persistent AF. However, this procedure is still challenging and time consuming. Objective: The aim of this study was to present our approach for PVI using a novel circular irrigated multielectrode mapping and ablation catheter (nMARQTM) and to present acute and mid-term results. Methods: The study included 31 consecutive patients with symptomatic AF (4 had persistent and 27 had paroxysmal AF) who underwent PVI using the nMARQTM catheter. Circular ablation was guided by CT image integrated into fast anatomical map and by intra cardiac echo. Isolation of pulmonary veins was identified using the nMARQTM catheter if it was possible to advance it into the veins, otherwise Lasso catheter was used. Patients were followed up to 20 months. Results: PVI was achieved in 119 (98%) out of 121 pulmonary veins identified, and final PVI was obtained in 30 (97%) out of 31 patients. Lasso catheter was needed for PVI confirmation in 16 (52%) patients. Touch up ablation using standard catheter guided by Lasso catheter was needed in 4 (13%) patients. Pericardial tamponade occurred in 1 patient who was treated with pericardiocentesis. No other major complications were detected. During follow-up (mean 15.9 ± 3.6 months, range 9 - 20 months), 4 (13%) patients had recurrence of atrial tachyarrhythmia. Conclusion: PVI using the novel nMARQTM catheter is safe with good acute and mid-term efficacy. Long term follow up trials are needed.

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.

Recent research in systemic lupus erythematosus (SLE) yielded new antigens and antibodies in SLE patients. We describe the various autoantibodies that can be detected in patients with SLE. A literature review, using the terms “autoantibody” and “systemic lupus erythematosus”, was conducted to search for articles on autoantibodies in SLE, their target antigens, association with disease activity and other clinical manifestations. One hundred and eighty autoantibodies were so far described in SLE patients. These include autoantibodies that target nuclear antigens, cytoplasmic antigens, cell membrane antigens, phospholipid-associated antigens, blood cells, endothelial cells, and nervous system antigens, plasma proteins, matrix proteins, and miscellaneous antigens. The target of an autoantibody, the autoantigen properties, autoantibody frequencies in SLE, as well as clinical associations, and correlation with disease activity are described for all 180 autoantibodies. SLE is so far the autoimmune disease with the largest number of detectable autoantibodies. Their production could be antigen-driven, the result of a polyclonal B cell activation, impaired apoptotic pathways, or the outcome of an idiotypic network dysregulation.

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.

The Micra transcatheter leadless pacemaker, a single-chamber leadless ventricular pacemaker, is implanted percutaneously through the femoral vein. We present the case of a patient in whom the Micra leadless pacemaker was implanted during valve surgery.

Background: Reliable reference annotation is critical for accurate activation mapping. Currently used referencing algorithms can be limited by suboptimal detection and stability performance. The advanced reference annotation (ARA) algorithm, a novel algorithm using a weighted reference across multiple electrodes, has been developed to optimize reference annotation. Materials and Methods: To evaluate ARA, recordings using CARTO from 26 clinical cases with complex cardiac arrhythmias, representing mapping of various rhythms, were segmented into test vectors consisting of roughly 62,000 annotation events. These were annotated by an expert clinician (gold standard [GS]) and compared with the legacy/ARA algorithms on detection rate and stability and positive predictive value (PPV). Results: The ARA algorithm detection rate uniformly outperformed legacy, when compared with GS (97 ± 4% vs. 81 ± 19%, respectively; P = 0.001). ARA was performed with high fidelity with an average stability metric (the percentage of true positive ARA annotations within 10 ms of the GS annotation) of 98 ± 3% with most test vectors achieving perfect (100%) stability. Overall, the PPV of ARA annotations was 98 ± 4%; nearly all ARA-annotated activation corresponded to clinically observed events; ARA was superior to legacy across all analyzed test vectors (98 ± 4% vs. 88 ± 23%, P = 0.004); all ARA test vector groups had PPV >90%. Conclusion: The ARA algorithm outperformed the clinical standard, compared to an expert clinician GS. These improvements may translate into greater mapping accuracy/efficiency and procedural outcomes in diagnosis of complex cardiac arrhythmias.

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.

To investigate the impact of using computed tomography (CT) and contact force (CF) technology on recurrence of atrial tachyarrhythmia after atrial fibrillation (AF) ablation.This non-randomized study included 2 groups of patients. All patients had symptomatic recurrent paroxysmal or persistent AF and were treated with at least 1 anti arrhythmic medication or intolerant to medication. The first group included 33 patients who underwent circumferential pulmonary veins isolation (PVI) for AF during 2012 and 2013 guided by CT image integration (Cartomerge, Biosense Webster, Diamond Bar, CA, United States) of left atrium and pulmonary veins into an electroanatomic mapping (EAM) system (CT group) using standard irrigated radiofrequency catheter (ThermoCool, Carto, Biosense Webster, Diamond Bar, CA, United States) or irrigated catheter with integrated CF sensor (Smart Touch, Carto, Biosense Webster, Diamond Bar, CA, United States). The second group included immediately preceding 32 patients who had circumferential PVI by standard irrigated catheter (ThermoCool) using only EAM (Carto) system (EAM group). Linear lesions were performed according to the discretion of operator.Sex, age, and persistent AF were not different between groups. PVI was achieved in all patients in both groups. Linear ablations including cavo-tricuspid isthmus and or roof line ablation were not different between groups. Free of atrial tachyarrhythmia during follow-up of 24 mo was significantly higher among CT group compared to EAM group (81% vs 55%; respectively; P = 0.027). When 11 patients from CT group who had ablation using Smart Touch catheter were excluded, the difference between CT group and EAM became non significant (73% vs 55%; respectively; P = 0.16). Sub analysis of CT group showed that patients who had ablation using Smart Touch catheter tend to be more free of atrial tachyarrhythmia compared to patients who had ablation using standard irrigated catheter during follow-up (100% vs 73%; respectively; P = 0.07). Major complications (pericardial effusion, cerebrovascular accident/transient ischemic attack, vascular access injury requiring intervention) did not occurred in both groups.These preliminary results suggest that CT image integration and CF technology may reduce the recurrence of atrial tachyarrhythmia after catheter ablation for AF.

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.