Search

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

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

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

Recent evidence has shown an increase in recurrence and a decrease in overall survival in patients treated with laparoscopic radical hysterectomy (LRH) and robotic assisted radical hysterectomy (RRH) open techniques (ORH). In addition, several high quality trials were recently published regarding the laparoscopic treatment of early stage cervical cancer. We sought out to reassess the recurrence rates, overall survival, complications and outcomes associated with laparoscopic radical hysterectomy (LRH) techniques against open techniques (ORH) when robotic assisted techniques were excluded. We searched PubMed, Medline, Cochrane CENTRAL, SCOPUS, ClinicalTrials.Gov and Web of Science for relevant clinical trials and observational studies. We included all studies that compared with early stage cervical cancer receiving LRH compared with ORH. We included randomized clinical trials, prospective cohort, and retrospective cohort trials. We included studies that included LRH and RRH as long as data was available to separate the two arms. We excluded studies that combined LRH and RRH without supplying data to differentiate. Of 1244 total studies, we used a manual three step screening process. Sixty studies ultimately met our criteria. We performed this review in accordance with PRISMA guidelines. We analyzed continuous data using mean difference (MD) and a 95% confidence interval (CI), while dichotomous data were analyzed using odds ratio (OR) and a 95% CI. Review Manager and Endnote software were utilized in the synthesis. We found that when excluding RRH, the was no significant difference regarding 5-year overall Survival (OR = 1.24 [0.94, 1.64], (P = 0.12), disease free survival (OR = 1.00 [0.80, 1.26], (P = 0.98), recurrence (OR = 1.01 [0.81, 1.25], (P = 0.95), or intraoperative complications (OR = 1.38 [0.94, 2.04], (P = 0.10). LRH was statistically better than ORH in terms of estimated blood loss (MD = − 325.55 [− 386.16, − 264.94] (P P = 0.002), postoperative complication rate (OR = 0.70 [0.55, 0.90], (P = 0.005), and length of hospital stay (MD = − 3.64[− 4.27, − 3.01], (P P = 0.007) and number of resected lymph nodes (MD = − 2.80 [− 4.35, − 1.24], (P = 0.004). The previously seen increase recurrence and decrease in survival is not seen in LRH when robotic assisted techniques are included and all new high quality is considered. LRH is also associated with a significantly shorter hospital stay, less blood loss and lower complication rate.Prospero Prospective Registration Number: CRD42022267138.

This systematic review and meta-analysis compares adverse neonatal outcomes among mothers exposed to marijuana during pregnancy vs mothers not exposed to marijuana during pregnancy in 16 cohort studies., Key Points Question Are adverse neonatal outcomes associated with exposure to marijuana among mothers during pregnancy? Findings In this meta-analysis of 16 studies including 59 138 patients, maternal marijuana exposure during pregnancy was associated with increased risk of preterm deliveries and neonatal intensive care unit admission and decreased mean birth weight, 1-minute Apgar score, and head circumference of babies. There were no differences in mean 5-minute Apgar score or total infant length. Meaning This study found that women using marijuana during pregnancy may be at increased risk of some adverse neonatal outcomes., Importance While some studies have found an association between marijuana use and adverse neonatal outcomes, results have not been consistent across all trials. Objective To assess available data on neonatal outcomes in marijuana-exposed pregnancies. Data Sources PubMed, Medline, ClinicalTrials.gov, Cochrane, Scopus, and Web of Science were searched from each database's inception until August 16, 2021. Study Selection All interventional and observational studies that included pregnant women who were exposed to marijuana compared with pregnant women who were not exposed to marijuana and that reported neonatal outcomes were included. Data Extraction and Synthesis Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Data were extracted by 2 authors for all outcomes, which were pooled using a random-effects model as mean difference or risk ratio (RR) and 95% CI. Data were analyzed from August through September 2021. Main Outcomes and Measures All outcomes were formulated prior to data collection. Outcomes included incidence of birth weight less than 2500 g, small for gestational age (defined as less than the fifth percentile fetal weight for gestational age), rate of preterm delivery (defined as before 37 weeks’ gestation), gestational age at time of delivery, birth weight, incidence of neonatal intensive care unit (NICU) admission, Apgar score at 1 minute, Apgar score at 5 minutes, incidence of an Apgar score less than 7 at 5 minutes, fetal head circumference, and fetal length. Results Among 16 studies including 59 138 patients, there were significant increases in 7 adverse neonatal outcomes among women who were exposed to marijuana during pregnancy vs those who were not exposed during pregnancy. These included increased risk of birth weight less than 2500 g (RR, 2.06 [95% CI, 1.25 to 3.42]; P = .005), small for gestational age (RR, 1.61 [95% CI, 1.44 to 1.79]; P

Cesarean scar ectopic pregnancy (CSP) is a rare form of ectopic pregnancy, and treatment of CSP with uterine artery embolization (UAE) is a novel approach. With increasing numbers of cesarean sections being performed annually, the incidence of this condition is likely to increase. The authors became aware of an unusually high number of published studies originating in mainland China regarding this unusual treatment and sought to perform a meta-analysis to provide comprehensive evidence on this novel practice. Methods: We performed a thorough search and included all forms of quality studies on this topic that reported UAE as a part of first-line management of CSP. We included only studies originating in China. Ultimately, 37 studies were included for qualitative and quantitative synthesis of evidence. After screening retrieved records and extracting data from eligible studies, we pooled continuous data as a mean estimate and 95% confidence interval (CI), and dichotomous data as proportion and 95% CI. Results: CSP patients treated with protocols including UAE had a mean time of 30 days for serum β-hCG normalization, 95% CI [26.816, 33.881]. They had a mean estimated intraprocedural blood loss of 4.19 ± 3.76 mL, a mean hospital stay of nine days, 95%CI [7.914, 9.876], and a success rate of 93.4%, 95%CI [0.918, 0.951]. The severe complication rate was 1.2%, 95%CI [0.008, 0.017]. Conclusion: UAE, in combination with other procedures is being used effectively for the treatment of CSP in China. Protocols including UAE have a success rate of approximately 93.4%, and a severe complication rate of approximately 1.2%. This data’s utility is limited by vast differences in the studied protocols and questionable feasibility outside of China.

ObjectiveAlthough many studies have been performed, no consensus exists as to the ideal entry for laparoscopic gynecologic surgery. We sought out to compare the safety of direct trocar insertion with that of the Veress needle entry technique in gynecologic laparoscopic surgery.DesignSystematic review with meta-analysis.SettingWe searched Medline, ClinicalTrials.Gov, PubMed, Cochrane CENTRAL, SCOPUS, and Web of Science from their inception through 31 July 2021 for relevant studies. We included only controlled trials and ultimately seven trials were included in our meta-analysis.ParticipantsInclusion criteria included women undergoing gynecological laparoscopic surgery.InterventionThe intervention of direct trocar insertion technique compared with Veress needle entry technique.Main outcome measuresWe compared five different outcomes associated with the efficacy and complications of laparoscopic entry.ResultsThe pooled analysis showed that Veress needle entry was associated with a significant increase in the incidences of extraperitoneal insufflation (RR=0.177, 95% Cl (0.094 to 0.333), pConclusionsWhen excluding all data apart from gynecologic surgery, the Veress needle entry technique may have an increased incidence of some, but not all complications of laparoscopic entry. It may also have a higher incidence of failed entry compared with direct entry techniques. Care should be taken in extrapolating these general results to specific surgeon experience levels.Trial registration numberCRD42021273726

Cervical insufficiency (CI) may result in preterm delivery. We sought out to perform this review and analysis to compare the efficacy of laparoscopic and open transabdominal cerclage (TAC) in patients suffering with CI.Our search included PubMed, Scopus, MEDLINE, ClinicalTrials.Gov, Cochrane and Web of Science. We analyzed the data with Open Meta-Analyst Software as well as Review Manager Software. We included observational and randomized controlled trials that included patients with CI that underwent laparoscopic cerclage or TAC.We included a total of 43 studies. Laparoscopic and TAC had a positive effect by increasing gestational age (GA); for the laparoscopic group (mean deviation (MD)) = 14.86 weeks (W), 95% CI [10.67, 19.05], P 0.001) and TAC (MD = 12.79 W, 95% CI [10.97, 14.61], P 0.001). Furthermore, improvements in all outcomes assessed (total fetal survival rate, neonatal weight, and prevention of delivery at a gestational age of24 weeks) were all significant with the exception of the prevention of all preterm deliveries37 weeks; for both laparoscopic at (RR = 0.116, 95% CI [-0.006, 0.238], P = 0.063) and TAC at (MD = 1, 95% CI [0.45, 2.24], P = 1), and for prevention of deliveries34 weeks for the laparoscopic group (RR = 0.446, 95% CI [-0.323, 1.215], P = 0.256) only.Although limited data prevented pregnancy and prepregnancy subgroups as well as a head-to-head comparison, we still found that in patients suffering from CI, both TAC and laparoscopic approaches to cerclage revealed a positive effect in preserving the pregnancy.

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

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

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

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

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

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

Fasciculoventricular Pathway in PRKAG2 Disease. Mutations in the PRKAG2 gene that regulates the gamma 2 subunit of the AMP-dependent protein kinase A have been associated with the development of AV accessory pathways, cardiac hypertrophy, and conduction system abnormalities. The accessory pathways described in PRKAG2 disease have mostly been AV bypass tracts, as mutations in the PRKAG2 gene disrupt the normal AV junction development. There have also been a few reports of nodoventricular tracts associated with PRKAG2 mutations, as these tracts also involve the AV junction. We describe a case of a fasciculoventricular pathway with PRKAG2 mutation suggesting a more widespread involvement of the PRKAG2 gene in the development of the cardiac conduction system. (J Cardiovasc Electrophysiol, Vol. 21, pp. 329–332, March 2010)

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

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

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

To investigate the presence of any regional myocardial deformation abnormalities in Marfan syndrome (MFS) and determine the benefits of using advanced echocardiography compared to conventional techniques.Myocardial dysfunction in MFS may be caused by extracellular matrix remodeling thus, resulting in uniform reduced functionality. However, increased aortic stiffness may cause segmental ventricular abnormalities. Strain rate imaging (SRI) constitutes a validated technique to assess regional deformation in various clinical conditions. With this in mind, we aimed to investigate biventricular function in MFS using SRI.Forty-four MFS patients (mean age 30 ± 12 years, 26 men) and 49 controls without valvular disease were examined using SRI. Ejection fraction (EF) was calculated by the Simpson's biplane method. Biventricular deformation was assessed by measuring strain/strain rate. Strain values were divided by left ventricular (LV) end-diastolic volume to adjust LV deformation for geometry changes providing a strain index (SI). Aortic stiffness was evaluated using the β-stiffness index.EF (%) was reduced in MFS patients (59 ± 5 vs 72 ± 4, P0.001), whereas β-stiffness was increased (P0.001). LV radial and LV and right ventricular (RV) long-axis strain values (%) were reduced in the patient group (70 ± 17 vs 93 ± 10; 19 ± 2 vs 25 ± 2; 30 ± 9 vs 36 ± 8, respectively, P0.001). Strain rate measurements were also reduced (P0.001). In a multiple regression analysis, MFS diagnosis was negatively associated with LV SI (-0.262 [-0.306, -0.219], P0.001). β-Stiffness was negatively associated with SI obtained from the septum, inferior and anterior walls. ROC analyses demonstrated that SRI, when compared with conventional echocardiography, had higher sensitivity and specificity in predicting biventricular dysfunction in MFS.Our study showed a uniform reduction in biventricular deformation in MFS. These findings suggest that assessment of myocardial function using advanced echocardiographic techniques could be more accurate in MFS patient evaluation than conventional echocardiography alone.

Extracellular matrix remodeling in the aortic wall results in increased aortic stiffness (AoS) in Marfan syndrome (MFS). Pulsed-wave velocity (PWV) constitutes the best indirect AoS measurement. We aimed to assess PWV in MFS patients using two-dimensional (2D) and Doppler echocardiography.Thirty-one MFS patients, (mean age 31 ± 14 years, 16 men) and 31 controls were examined. Blood flow was recorded in the aorta near the aortic valve and immediately after in the descending aorta with simultaneous electrocardiography. PWV was calculated by dividing the distance between the two sample volume positions (D) by the time difference (TD) between the intervals from the QRS start to the ascending and descending aortic flow onsets. B-stiffness was also measured.TD (described in "Methods" section) and, aortic arch length were significantly increased in MFS patients, P0.001. Thus, PWV values were significantly higher in patients when compared with controls, 7.20 m/s (5.12, 9.43) versus 4.64 m/s (3.37, 6.24), P0.001. B-stiffness was also significantly increased in MFS patients; 5.15 (3.69, 7.65) versus 2.44 (1.82, 3.66), P0.001. Multiple regression analysis showed a positive association with MFS diagnosis and age, (P = 0.002 and 0.009, respectively). Reproducibility of PWV measurements was5%.AoS was significantly higher in MFS patients as expected. Our data demonstrated that PWV measurements can be performed, in the absence of serious musculoskeletal abnormalities in MFS adults, as part of a cardiac ultrasound scan. This technique can be helpful in diagnosis and management in MFS.

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

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

The objective of this study was to determine the prevalence of conventional risk factors in sudden arrhythmic death syndrome (SADS) probands with Brugada syndrome (BrS).Patients with BrS and previous aborted sudden cardiac death (SCD) are at high risk of recurrent events. Other universally accepted clinical features associated with higher risk include unheralded syncope and the presence of a spontaneous type 1 electrocardiogram (ECG).We analyzed reported symptoms and reviewed ECGs from SADS probands with familial diagnoses of BrS, established by cardiological evaluation, including ECG, 2-dimensional echocardiography, Holter monitoring, exercise tolerance testing, and ajmaline provocation. These cases underwent familial evaluation between 2003 and 2010.A total of 49 consecutive families with a confirmed SADS death and a diagnosis of BrS were evaluated, comprising assessment of 202 family members in total. One family had 2 members with SADS, resulting in a total of 50 probands included. Mean age of death of probands was 29.1 ± 10.6 years, with 41 males (82%) (p0.05). Antemortem ECGs were available for 5 SADS probands, 1 of which demonstrated a spontaneous type 1 pattern. In 45 probands, symptoms before death were reported reliably by family members. Of these, 9 (20%) had experienced at least 1 syncopal episode before the fatal event. Importantly, 68% of probands would not have fulfilled any current criteria for consideration of implantable cardioverter-defibrillator.The "low-risk" asymptomatic BrS group comprises the majority of SCD in this cohort. Current risk stratification would appear to be inadequate, and new markers of risk are vital.

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

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

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

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

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