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• Median heart rate is significantly lower in COVID-19 related ARDS (C-ARDS). • Heart rate variability is severely impaired in C-ARDS and non-related ARDS (NC-ARDS). • HRV analysis might suggest a sympathovagal imbalance with vagal overtone in C-ARDS. Bradycardia and dysautonomia observed during SARS-Cov2 infection suggests involvement of the autonomic nervous system (ANS). Limited data exists on ANS dysregulation and its association with outcomes in patients with acute respiratory distress syndrome (ARDS) related to COVID-19 (C-ARDS) or other etiologies (NC-ARDS). We aimed to explore sympathovagal balance, assessed by heart rate variability (HRV), and its clinical prognostic value in C-ARDS compared with NC-ARDS. A single-center, prospective case-control study was conducted. Consecutive patients meeting ARDS criteria between 2020 and 2022 were included. HRV was assessed using 1-hour electrographic tracing during a stable, daytime period. Twenty-four patients with C-ARDS and 19 with NC-ARDS were included. Age, sex and ARDS severity were similar between groups. The median heart rate was markedly lower in the C-ARDS group than in the NC-ARDS group (60 [53–72] versus 101 [91–112] bpm, p <.001). Most of HRV parameters were significantly increased in patients with C-ARDS. HRV correlated with heart rate only in patients with C-ARDS. A positive correlation was found between the low-to high-frequency ratio (LF/HF) and length of intensive care unit stay (r = 0.576, p <.001). This study confirmed that C-ARDS was associated with marked bradycardia and severe ANS impairment, suggesting a sympathovagal imbalance with vagal overtone. Poor outcomes appeared to be more related to sympathetic rather than parasympathetic hyperactivation. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the present study was to identify the incidence of common perioperative anaesthetic complications in cats undergoing anaesthesia for neutering in three UK first opinion practices. Methods: A retrospective anaesthetic record analysis was performed on cats anaesthetised for neutering at practices 1 and 2 between 9 December 2017 and 2 February 2021 and practice 3 between 9 March 2020 and 7 January 2021. A search of the practice management system identified all cats that had undergone neutering in the selected timeframe. Data from 1019 cats were included in the study. Information relating to patient characteristics and data from the anaesthesia session were extracted from electronic patient records and anaesthesia record charts and entered into an Excel spreadsheet. A definition of the complications was created after reviewing the literature and their incidence determined from the data set. Comparisons between different groups of cats in the study were made using a χ2 test for homogeneity or Fisher's exact tests to identify factors associated with increased incidence of complications. Results: The anaesthetic-related mortality was 1/1019 (0.10%). The most common complications were hypotension (22.6%), bradycardia (16.7%) and hypothermia (13.8%). Less common complications were hypocapnia (12.7%), hypercapnia (8.7%), tachycardia (6.6%), apnoea (3.1%), hyperthermia (1.7%), hypertension (1.4%), endotracheal tube obstruction (1.1%), hypoxia (0.3%), undesirable recovery (0.6%) and cardiac arrhythmia (0.2%). Factors associated with increased risk of hypotension were acepromazine pre-anaesthetic medication, higher maximum isoflurane dose, longer anaesthetic duration and lower body weight. Factors associated with increased risk of bradycardia were medetomidine pre-anaesthetic medication, longer anaesthetic duration and higher body weight. Factors associated with increased risk of hypothermia were higher maximum isoflurane dose, increased anaesthetic duration and lower body weight. Conclusions and relevance: This study showed that anaesthetic complications were frequently observed, with complications documented in 53.4% of the cats in the study. The information in this study may help to guide prioritisation of monitoring in feline anaesthesia. [ABSTRACT FROM AUTHOR]

BACKGROUND: The flow reaching the vocal folds may be lower than that at the output of high-flow nasal cannula (HFNC) system. This could be due to upper-respiratory obstruction, oxygen leakage, or other factors. The objective of this study was to observe the effect of flow through a nasopharyngeal airway on intrapharyngeal pressure (IPP) in subjects undergoing fiberoptic bronchoscopy (FOB). METHODS: Patients scheduled for FOB were invited to participate. Measurements were performed at flows of 0-60 L/min; the subjects wore WN-N95 folding medical protective masks (N95) and either underwent FOB or not. IPP at each flow was recorded following 15 s of ventilation, and the cross-sectional area (CSA) of the gastric sinus was measured before and after FOB. Hypoxemia, reflux aspiration, and other pertinent events were recorded. RESULTS: Sixty subjects undergoing FOB at the Affiliated Hospital of Jiaxing University participated in this trial from October 2022-September 2023. IPP increased significantly with an increase in flow and also increased after placing the N95 mask with the same flow (P < .001). When results from before to after FOB were compared, the difference in CSA was statistically significant 263.6 (220.7-300.5) mm² vs 305.5 (275.4-329.5) mm², P < .001, but the difference in the risk of reflux aspiration was not statistically significant (0% vs 6.7%, P = .13). Complication rates during treatment were 8.3% for hypoxemia, 0% for reflux aspiration, 1.7% for hypertension, 1.7% for hypotension, 6.7% for tachycardia, 5% for bradycardia, and 10% for postoperative nausea and vomiting. CONCLUSIONS: HFNC can provide effective oxygen therapy for people undergoing FOB, and increases in IPP with flow in the range of 0-60 L/min may not increase the risk of reflux aspiration. [ABSTRACT FROM AUTHOR]

Premature infants admitted to the NICU often require intravenous (IV) therapy. Peripheral intravenous catheter (PIVC) insertion is a common painful/stressful/invasive procedure. Repeated exposure to stressors produces toxic stress: a prolonged, frequent activation of the body's stress response that occurs when buffering relationships, that is, mother/supportive adult, are absent. This article presents an exemplar case study of a PIVC insertion to describe toxic stress responses a premature infant experienced during the procedure. The infant was admitted for extreme prematurity and respiratory failure. Twenty-nine days later, the infant developed possible necrotizing enterocolitis that necessitated cessation of enteral feedings, gastric decompression, IV administration of fluids, parenteral nutrients, and antibiotics. The PIVC insertion procedure was monitored and observed. The infant showed physiologic dysregulation, including bradycardia, tachycardia, oxygen desaturation, and high skin conductance responses, resulting from the stress exposure and insufficient nonpharmacologic/pharmacologic stress interventions. Education and practice change are needed to promote pain/stress management. [ABSTRACT FROM AUTHOR]

Implantable loop recorders (ILRs) are increasingly used to evaluate patients with unexplained syncope. Identification of all predictors of bradycardic syncope and consequent permanent pacemaker (PPM) insertion is of substantial clinical interest as patients in the highest risk category may benefit from upfront pacemaker insertion. We performed a systematic review and meta-analysis to identify risk predictors for PPM insertion in ILR recipients with unexplained syncope. An electronic database search (MEDLINE, Embase, Scopus, Cochrane) was performed in June 2023. Studies evaluating ILR recipients with unexplained syncope and recording risk factors for eventual PPM insertion were included. A random effects model was used to calculate the pooled odds ratio (OR) for clinical and electrocardiographic characteristics with respect to future PPM requirement. Eight studies evaluating 1007 ILR recipients were included; 268 patients (26.6%) underwent PPM insertion during study follow-up. PPM recipients were older (mean age, 70.2 ± 15.4 years vs 61.6 ± 19.7 years; P <.001). PR prolongation on baseline electrocardiography was a significant predictor of PPM requirement (pooled OR, 2.91; 95% confidence interval, 1.63–5.20). The presence of distal conduction system disease, encompassing any bundle branch or fascicular block, yielded a pooled OR of 2.88 for PPM insertion (95% confidence interval, 1.53–5.41). Injurious syncope and lack of syncopal prodrome were not significant predictors of PPM insertion. Sinus node dysfunction accounted for 62% of PPM insertions, whereas atrioventricular block accounted for 26%. Approximately one-quarter of ILR recipients for unexplained syncope require eventual PPM insertion. Advancing age, PR prolongation, and distal conduction disease are the strongest predictors for PPM requirement. [Display omitted] [ABSTRACT FROM AUTHOR]

Catheter-based neuromodulation of intrinsic cardiac autonomic nervous system is increasingly being used to improve outcomes in patients with vasovagal syncope and bradyarrhythmias caused by vagal overactivity. However, there is still no consensus for patient selection, technical steps, and procedural end points. This review takes the reader on a practical exploration of neuromodulation for bradyarrhythmias, concentrating on the critical aspects of proper patient selection, evidence-based insights, and anatomic intricacies within the intrinsic cardiac autonomic nervous system. Also discussed are different mapping techniques and outcome measures. Future directions to optimize the utilization of this technique in clinical practice are highlighted. [ABSTRACT FROM AUTHOR]

Copyright of Konuralp Medical Journal / Konuralp Tip Dergisi is the property of Duzce University Medical School and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

• Preterm infants' bradycardia, hypoxemia, and early intubation could increase the risk of bronchopulmonary dysplasia (BPD). • It is important for clinicians to closely monitor the infant's heart rate and oxygen saturation (SpO2) during the hospitalization. • Clinicians need to consider the necessity of intubation and carefully manage the infant's distress. • It is essential to have a multidisciplinary collaborative team to provide preterm infants with optimized and comprehensive care for preventing complications. Bronchopulmonary dysplasia (BPD) is the most common pulmonary complication in preterm infants. The study aimed to explore the effects of bradycardia, hypoxemia, and early intubation on BPD in very preterm infants. This is a prospective observational cohort study. Preterm infants with a mean gestational age of 28.67 weeks were recruited from two level III neonatal intensive care units (NICUs) in Taiwan. Continuous electrocardiography was used to monitor heart rates and oxygen saturation (SpO 2). Infants were monitored for heart rates of <100 beats per minute and SpO 2 levels of <90 % lasting for 30 s. Generalized estimating equations were used to analyze the effects of bradycardia, hypoxemia, and early intubation on BPD in very preterm infants. Model fit was visually assessed using receiver operating characteristic curve analysis. Bradycardia, hypoxemia, and early intubation significantly increased the odds of BPD among the preterm infants (N = 39) during NICU stay; the odds ratios for bradycardia, hypoxemia, and early intubation for BPD versus non-BPD were 1.058, 1.013, and 29.631, respectively (all p < 0.05). A model combining bradycardia, hypoxemia, and early intubation accurately predicted BPD development (area under the curve = 0.919). Bradycardia, hypoxemia, and early intubation significantly increased the odds of BPD among very preterm infants during NICU stay. The model combining bradycardia, hypoxemia, and early intubation accurately predicted BPD development. [ABSTRACT FROM AUTHOR]

A seven-year-old male castrated Labrador Retriever presented emergently due to concern for pacemaker malfunction five years after successful transvenous pacemaker implantation to treat partial atrial standstill. On presentation, the dog's pulse rate was 30–50 beats per minute. An electrocardiogram showed no spontaneous atrial activity or paced ventricular activity. Pacemaker interrogation revealed an increased impedance of 7557 ohms, indicating a lead malfunction. Thoracic radiographs confirmed the lead was fractured and had excessive coiling. The transvenous pacing system was turned off, left in place, and an epicardial pacing system was implanted the following day. The dog was discharged with no perioperative complications. The dog eventually required escalated medical therapy for progressive cardiac disease and was euthanized two years after implantation of the replacement pacemaker. This manuscript illustrates a complete lead fracture and excessive lead coiling, which has not previously been detailed in veterinary medicine. [ABSTRACT FROM AUTHOR]

Background: His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) emerge as better alternatives to right ventricular apical pacing (RVAP) in patients with bradycardia requiring permanent cardiac pacing. We aimed to compare the clinical outcomes of LBBAP, HBP, and RVAP in Japanese patients with bradycardia. Methods: A total of 424 patients who underwent successful pacemaker implantation (HBP, n = 53; LBBAP, n = 75; and RVAP, n = 296) were retrospectively enrolled in this study. The primary study endpoint was the cumulative incidence of heart failure hospitalization (HFH) during the follow-up. Results: The success rate for implantation was higher in the LBBAP group than in the HBP group (94.9% and 81.5%, respectively). Capture threshold increase >1V during the follow-up occurred in the HBP and RVAP groups (9.4% and 5.1%, respectively), while it did not in the LBBAP group. The cumulative incidence of HFH was significantly lower in the LBBAP group than the RVAP (adjusted hazard ratio, 0.12 [95% confidence interval: 0.02--0.86]; p = .034); it did not differ between the HBP and RVAP groups (adjusted hazard ratio, 0.48 [95% confidence interval: 0.17-1.34]; p = .16). Advanced age, mean percent right ventricular pacing (per 10% increase), left ventricular ejection fraction <50%, and RVAP were associated with HFH. Conclusions: Compared to RVAP and HBP, LBBAP appeared more feasible and effective in patients with bradycardia requiring permanent cardiac pacing. [ABSTRACT FROM AUTHOR]

Arrhythmias are a common problem in the critically ill and they can have significant effects on patient outcome. They often require immediate and swift action, and it is therefore essential that clinicians have a structured approach to the recognition and management of arrhythmias. Here, we provide a framework for the appropriate management of the more frequently encountered cardiac arrhythmias in critical care. We include the most recent algorithms from the 2021 Resuscitation Council Guidelines for reference. [ABSTRACT FROM AUTHOR]

The possibility of triggering the trigeminocardiac reflex (TCR) during oral surgery is considerably lower than that during other surgeries. A reduced heart rate (HR) of ≥20% from baseline is usually considered a diagnostical criterion for the TCR. Our automated anesthesia charting system often revealed cases of slight transient HR decrease during sedation. We aimed to explore its incidence and associated factors during local anesthesia administration under intravenous sedation. This study analyzed the data of 2636 cases that received infiltration anesthesia under intravenous sedation from 2008 to 2010 and had vital signs recorded using an automated anesthesia charting system. Especially, data concerning the average HR before anesthesia and the minimum HR between the initiation and end of anesthesia from anesthetic records were extracted. Moreover, data regarding patients' medical history and unusual reactions during dental treatment were collected. Multivariate logistic regression analysis was performed to identify factors associated with transient bradycardia (TB). TB occurred in 472 patients (17.9%); no patient developed hypotension or any associated symptoms, suggesting that intravenous sedation was effective in stabilizing vital signs. The factors associated with TB were younger age, gag reflex, and allergy to local anesthetics. There were no differences in sex, patient history, or dose of sedatives between patients with TB and those without TB. The incidence of TB during infiltration anesthesia under sedation was found to be higher than that previously reported. Additionally, young age and gag reflex were identified as factors associated with bradycardia development. [ABSTRACT FROM AUTHOR]

BACKGROUND: Unplanned extubation (UE) is defined as unintentional dislodgement of an endotracheal tube (ETT) from the trachea. UEs can lead to instability, cardiac arrest, and may require emergent tracheal re-intubation. As part of our hospital-wide quality improvement (QI) work, a multidisciplinary committee reviewed all UEs to determine contributing factors and evaluation of clinical outcomes to develop QI interventions aimed to minimize UEs. The objective was to investigate occurrence, contributing factors, and clinical outcomes of UEs in the pediatric ICU (PICU), cardiac ICU (CICU), and neonatal ICU (NICU) in a large academic children's hospital. We hypothesized that these would be substantially different across 3 ICUs. METHODS: A single-center retrospective review of UEs in the PICU, CICU, and NICU was recorded in a prospective database for the last 5 y. Consensus-based standardized operational definitions were developed to capture contributing factors and adverse events associated with UEs. Data were extracted through electronic medical records by 3 respiratory therapists and local Virtual Pediatric Systems (VPS) database. Consistency of data extraction and classification were evaluated. RESULTS: From January 2016-December 2021, 408 UEs in 339 subjects were reported: PICU 52 (13%), CICU 31 (7%), and NICU 325 (80%). The median (interquartile range) of age and weight was 2.0 (0-4.0) months and 5.3 (3.0-8.0) kg. Many UE events were not witnessed (54%). Common contributing factors were routine nursing care (no. = 70, 18%), ETT retaping (no. = 62, 16%), and being held (no. = 15, 3.9%). The most common adverse events with UE were desaturation < 80% (33%) and bradycardia (22.8%). Cardiac arrest occurred in 12%. Sixty-seven percent of UEs resulted in re-intubation within 72 h. The proportion of re-intubation across 3 units was significantly different: PICU 62%, CICU 35%, NICU 71%, P < .001. CONCLUSIONS: UEs occurred commonly in a large academic children's hospital. Whereas UE was associated with adverse events, re-intubation rates within 72 h were < 70% and variable across the units. [ABSTRACT FROM AUTHOR]

Cardiac pacemaker implantation after orthotopic heart transplantation declined dramatically after development of the bicaval anastomosis technique. However, much less is known about the rate, indications, and predictors of device implantation procedures with the current surgical technique. The purpose of this study was to evaluate the indications, patient characteristics, incidence, and survival related to cardiac implantable electronic device (CIED) implantation after heart transplantation. This was a single-center study of 399 consecutive adult recipients of orthotopic heart transplants with bicaval anastomosis from 1991 to 2017. The primary end point was freedom from pacemaker or implantable cardioverter-defibrillator (ICD) implantation, and the secondary end point was all-cause mortality. At the time of transplantation, the mean age of recipients was 50 ± 12 years and that of donors 31 ± 12 years. CIEDs were implanted in 8% of recipients (n = 31): 11 pacemakers (35%) for sinus node dysfunction, 17 (55%) for high-grade heart block, and 3 ICDs (10%) for the primary prevention of sudden cardiac death. Early CIED implantation (<30 days) was rare and absent for sinus node dysfunction. The risk for CIED implantation increased progressively during follow-up (0–30 years; median 11 years), with low-, moderate-, and high-risk periods between 0 and 10, between 10 and 20, and between 20 and 30 years, respectively. Recipients receiving CIEDs survived longer after transplantation (21 years vs 13 years; P <.01). Recipients receiving pacemakers for heart block were more likely to receive older donor hearts at the time of transplantation. The risk of pacemaker implantation increases progressively, while ICD implantation is rare. Donor age is the predominant risk factor for subsequent heart block. Early sinus node dysfunction requiring permanent pacing is rare. [ABSTRACT FROM AUTHOR]

Background: Nursing assessment of milk flow regulation and associated apnea, bradycardia, and desaturation (ABD events) contribute to considerations for the discharge of newborns from the acute care setting. Research regarding infant feeding-related (FR) events (sucking and swallowing difficulties) and ABD events in moderate to late-preterm and full-term infants is lacking. Purpose: This study observes the impact of FR and ABD events during feeding on hospital length of stay (LOS) and healthcare utilization (cost) in moderate-to-late preterm newborns, as well as full-term infants. Methods: In a retrospective study, bottle-fed infants admitted to the level II specialty care nursery of an academic community hospital in Southern California were observed for FR and ABD events. Statistical analyses were used to determine the impact of FR events on adjusted LOS, to evaluate the interaction between FR event status and adjusted LOS on total hospital charges, and to assess the statistical independence between FR events and diagnostic-related group severity. Results: The full sample of patient records included 308 infants born between 32- and 44-week gestational age between April 1, 2018, and October 31, 2022. LOS was twice as long in infants who had FR events. Total median charges were higher in the group with FR events at $160,165 versus $64,380 with non-FR events. Implications for Practice and Research: Increased knowledge in the epidemiology and nursing care of infants experiencing milk flow regulation and associated ABD events is critical for informing practices and guidelines related to the prevention of related morbidities. [ABSTRACT FROM AUTHOR]

Background: Phenylephrine is one of the drugs of choice in the prevention of spinal anaesthesia-induced hypotension in the elderly. The optimal dose is yet to be established in elderly patients, hence this study. Methods: This was a randomised, double-blind study on patients aged = 65 years undergoing elective lower limb and urological surgeries under subarachnoid block. A total of 57 patients were randomised into groups A, B, and C and each group contained 19 patients. Group A received 50 µg/min, group B received 75 µg/min, and group C received 100 µg/min of phenylephrine infusion immediately after the induction of spinal anaesthesia. Non-invasive blood pressure and pulse rate (PR) were recorded after the commencement of phenylephrine infusion. Onset of hypotension, episodes of hypotension, reactive hypertension, and bradycardia were recorded in each group and also compared across the groups. Results: Hypotension was prevented without any side effects of phenylephrine in group A; one patient (5.3%) in group B had an episode of hypotension at the sixth minute. The difference in the incidence of hypotension across the groups was not statistically significant (p = 0.617). Four patients (21.1%) in group B and nine (47.3%) in group C had reactive hypertension. The difference in the incidence of reactive hypertension among groups was statistically significant (p = 0.002). Bradycardia occurred in one patient (5.3%) in group B and three (15.8%) in group C. There was no statistically significant difference (p = 0.152) in the incidence of bradycardia across the three groups. Conclusion: The optimal dose of phenylephrine infusion that prevented spinal anaesthesia-induced hypotension without any side effects in elderly patients was 50 µg/min. [ABSTRACT FROM AUTHOR]

Background: Left bundle branch area pacing (LBBAP) is a novel conduction system pacing technique. In this multicenter study, we aimed to evaluate the procedural success, safety, and preoperative predictors of procedural failure of LBBAP. Methods: LBBAP was attempted in 285 patients with pacemaker indications for bradyarrhythmia, which were mainly atrioventricular block (AVB) (68.1%) and sick sinus syndrome (26.7%). Procedural success and electrophysiological and echocardiographic parameters were evaluated. Results: LBBAP was successful in 247 (86.7%) patients. Left bundle branch (LBB) capture was confirmed in 54.7% of the population. The primary reasons for procedural failure were the inability of the pacemaker lead to penetrate deep into the septum (76.3%) and failure to achieve shortening of stimulus to left ventricular (LV) activation time in lead V6 (18.4%). Thickened interventricular septum (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.15–5.35), severe tricuspid regurgitation (OR, 8.84; 95% CI, 1.22–64.06), and intraventricular conduction delay (OR, 8.16; 95% CI, 2.32–28.75) were preoperative predictors of procedural failure. The capture threshold and ventricular amplitude remained stable, and no major complications occurred throughout the 2‐year follow‐up. In patients with ventricular pacing burden >40%, the LV ejection fraction remained high regardless of LBB capture. Conclusions: Successful LBBAP was affected by abnormal cardiac anatomy and intraventricular conduction. LBBAP is feasible and safe as a primary strategy for patients with AVB, depending on ventricular pacing. [ABSTRACT FROM AUTHOR]

Cardioneuroablation (CNA) is a novel treatment for reflex syncope. The effect of aging on CNA efficacy is not fully understood. The purpose of this study was to assess the impact of aging on candidacy and efficacy of CNA for treating vasovagal syncope (VVS), carotid sinus syndrome (CSS), and functional bradyarrhythmia. The ELEGANCE (cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs) multicenter study assessed CNA in patients with reflex syncope or severe functional bradyarrhythmia. Patients underwent pre-CNA Holter electrocardiography (ECG), head-up tilt testing (HUT), and electrophysiological study. CNA candidacy and efficacy was assessed in 14 young (18–40 years), 26 middle-aged (41–60 years), and 20 older (>60 years) patients. Sixty patients (37 men; mean age 51 ± 16 years) underwent CNA. The majority (80%) had VVS, 8% had CSS, and 12% had functional bradycardia/atrioventricular block. Pre-CNA Holter ECG, HUT, and electrophysiological findings did not differ across age groups. Acute CNA success was 93%, without differences between age groups (P =.42). Post-CNA HUT response was negative in 53%, vasodepressor in 38%, cardioinhibitory in 7%, and mixed in 2%, without differences across age groups (P =.59). At follow-up (8 months, interquartile range 4–15), 53 patients (88%) were free of symptoms. Kaplan-Meier curves did not show differences in event-free survival between age groups (P =.29). The negative predictive value of a negative HUT was 91.7%. CNA is a viable treatment for reflex syncope and functional bradyarrhythmia in all ages, and is highly effective in mixed VVS. HUT is a key step in postablation clinical assessment. [ABSTRACT FROM AUTHOR]

Association between Henoch-Schönlein purpura and Helicobacter pylori infection is rarely reported in the literature. We present a case of Henoch-Schönlein purpura with severe gastrointestinal manifestations, bradycardia and euthyroid sick syndrome, which resolved only after the eradication of Helicobacter pylori infection. [ABSTRACT FROM AUTHOR]

Background: While most VVI pacemakers in bradycardic patients are set to a low limit of 60/min, the optimal lower limit rate for VVI pacemakers in atrial fibrillation has not been established. Although an increase in heart rate within the normal range in the setting of a VVI pacemaker might be expected to lead to an increase in cardiac output with the shortening of the diastolic time, the changes in cardiac output at different pacemaker settings have not been fully clarified. Methods: We included 11 patients with bradycardic atrial fibrillation who had VVI pacemakers implanted. Stroke volume was measured using the electrical cardiometry method (AESCULONⓇ mini; Osypka Medical) without pacing and at ventricular pacings of 60, 70, 80, and 90/min. Results: Stroke volume decreased stepwise at ventricular pacing rates of 60, 70, 80, and 90/min (63.6 ± 11.2, 61.9 ± 10.6, 59.3 ± 12.2, and 57.5 ± 12.2 mL, p <.001), but cardiac output increased (3.81 ± 0.67, 4.33 ± 0.74, 4.74 ± 0.97, and 5.17 ± 1.09 L/min, p <.001). The rate of increase in cardiac output at a pacing rate of 70/min compared to 60/min correlated with left ventricular end‐systolic volume (r = 0.711, p =.014). Conclusions: Cardiac output increased at a pacing rate of 70 compared to 60 in bradycardic atrial fibrillation patients, and the rate of increase in cardiac output was greater in those with larger left ventricular end‐systolic volume. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Any acute and profound reduction in fetal oxygenation increases the risk of anaerobic metabolism in the fetal myocardium and, hence, the risk of lactic acidosis. On the contrary, in a gradually evolving hypoxic stress, there is sufficient time to mount a catecholamine-mediated increase in the fetal heart rate to increase the cardiac output and redistribute oxygenated blood to maintain an aerobic metabolism in the fetal central organs. When the hypoxic stress is sudden, profound, and sustained, it is not possible to continue to maintain central organ perfusion by peripheral vasoconstriction and centralization. In case of acute deprivation of oxygen, the immediate chemoreflex response via the vagus nerve helps reduce fetal myocardial workload by a sudden drop of the baseline fetal heart rate. If this drop in the fetal heart rate continues for >2 minutes (American College of Obstetricians and Gynecologists' guideline) or 3 minutes (National Institute for Health and Care Excellence or physiological guideline), it is termed a prolonged deceleration, which occurs because of myocardial hypoxia, after the initial chemoreflex. The revised International Federation of Gynecology and Obstetrics guideline (2015) considers the prolonged deceleration to be a "pathologic" feature after 5 minutes. Acute intrapartum accidents (placental abruption, umbilical cord prolapse, and uterine rupture) should be excluded immediately, and if they are present, an urgent birth should be accomplished. If a reversible cause is found (maternal hypotension, uterine hypertonus or hyperstimulation, and sustained umbilical cord compression), immediate conservative measures (also called intrauterine fetal resuscitation) should be undertaken to reverse the underlying cause. In reversible causes of acute hypoxia, if the fetal heart rate variability is normal before the onset of deceleration, and normal within the first 3 minutes of the prolonged deceleration, then there is an increased likelihood of recovery of the fetal heart rate to its antecedent baseline within 9 minutes with the reversal of the underlying cause of acute and profound reduction in fetal oxygenation. The continuation of the prolonged deceleration for >10 minutes is termed "terminal bradycardia," and this increases the risk of hypoxic-ischemic injury to the deep gray matter of the brain (the thalami and the basal ganglia), predisposing to dyskinetic cerebral palsy. Therefore, any acute fetal hypoxia, which manifests as a prolonged deceleration on the fetal heart rate tracing, should be considered an intrapartum emergency requiring an immediate intervention to optimize perinatal outcome. In uterine hypertonus or hyperstimulation, if the prolonged deceleration persists despite stopping the uterotonic agent, then acute tocolysis is recommended to rapidly restore fetal oxygenation. Regular clinical audit of the management of acute hypoxia, including the "the onset of bradycardia to delivery interval," may help identify organizational and system issues, which may contribute to poor perinatal outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Dexmedetomidine is an α-2 receptor agonist commonly used as a continuous infusion for sedation and analgesia; however, dose-dependent hypotension may limit its utility. Despite its widespread use, there is no consensus on appropriate dosing and titration. OBJECTIVE: The objective of this study was to determine whether a dexmedetomidine dosing and titration protocol is associated with decreased rates of hypotension in trauma patients. METHODS: This pre-post intervention study took place at a Level II trauma center in the Southeastern United States from August 2021 to March 2022 and included patients admitted by the trauma service to either the surgical trauma intensive care unit or intermediate care unit and received dexmedetomidine for greater than or equal to 6 hours. Patients were excluded if they were hypotensive or on vasopressors at baseline. The primary outcome was incidence of hypotension. Secondary outcomes included dosing and titration practices, initiation of a vasopressor, incidence of bradycardia, and time to goal Richmond Agitation Sedation Scale (RASS) score. RESULTS: Fifty-nine patients met inclusion criteria: 30 in the pre-intervention group and 29 in the post-intervention group. Protocol adherence in the post group was 34% with a median of one violation per patient. Rates of hypotension were similar between the groups (60% vs. 45%, p =.243) but significantly lower in the post group patients with zero protocol violations (60% vs. 20%, p =.029). The post group also had a significantly lower maximal dose (1.1 vs. 0.7 μg/kg/hr, p <.001). There were no significant differences in the initiation of a vasopressor, incidence of bradycardia, or time to goal RASS. CONCLUSION: Adherence to a dexmedetomidine dosing and titration protocol significantly decreased incidence of hypotension and maximal dexmedetomidine dose without increasing time to goal RASS score in critically ill trauma patients. [ABSTRACT FROM AUTHOR]

The trigeminocardiac reflex (TCR) in maxillofacial surgical procedures can occasionally lead to sudden bradycardia in response to the manipulation of maxillofacial bony structures. However, asystole induced by TCR during maxillofacial surgery has rarely been reported. Here, we report an extremely rare case of ventricular asystole induced by the TCR in a 56-year-old female patient, which was caused by zygomatic fracture repositioning during the surgical repair of a zygomaticomaxillary complex fracture. Chest compressions that were performed immediately by the oral-maxillofacial surgeons was successful, and an electrocardiogram confirmed the patient's return to sinus rhythm. The patient's postoperative clinical course was unremarkable. [ABSTRACT FROM AUTHOR]

Background: While prior Micra trials demonstrated a high implant success rate and favorable safety and efficacy results, changes in implant populations and safety over time is not well studied. The objective of this analysis was to report the performance of Micra in European and Middle Eastern patients and compare to the Micra Investigational Device Exemption (IDE) and Micra Post Approval Registry (PAR) studies. Methods: The prospective, single‐arm Micra Acute Performance European and Middle Eastern (MAP EMEA) registry was designed to further study the performance of Micra in patients from EMEA. The primary endpoint was to characterize acute (30‐day) major complications. Electrical performance was analyzed. The major complication rate through 12 months was compared with the IDE and PAR studies. Results: The MAP EMEA cohort (n = 928 patients) had an implant success rate of 99.9% and were followed for an average of 9.7 ± 6.5 months. Compared to prior studies, MAP EMEA patients were more likely to have undergone dialysis and have a condition which precluded the use of a transvenous pacemaker (p <.001). Within 30 days of implantation, the MAP EMEA cohort had a major complication rate of 2.59%. Mean pacing thresholds were low and stable through 12 months (0.61 ± 0.40 V at 0.24 ms at implant and 12 months). Through 12 months post‐implantation, the major complication rate for MAP EMEA was not significantly different from IDE (p =.56) or PAR (p =.79). Conclusion: Despite patient differences over time, the Micra leadless pacemaker was implanted with a high success rate and low complication rate, in‐line with prior reports. [ABSTRACT FROM AUTHOR]

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is known to affect the cardiovascular system. Cardiac manifestations in COVID-19 can be due to direct damage to the myocardium and conduction system as well as by the disease's effect on the various organ systems. These manifestations include acute coronary syndrome, ST- segment elevations, cardiomyopathy, and dysrhythmias. Some of these dysrhythmias can be detrimental to the patient. Therefore, it is important for the emergency physician to be aware of the different arrhythmias associated with COVID-19 and how to manage them. This narrative review discusses the pathophysiology underlying the various arrhythmias associated with COVID-19 and their management considerations. [ABSTRACT FROM AUTHOR]

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A patient with bradycardia and an idioventricular rhythm was observed. According to cardiologists, there is no reliable drug treatment for bradycardia with an idioventricular rhythm; instead, the sole treatment is a pacemaker. In the course of this case, it was shown that acupuncture can restore the heart rhythm from bradycardia to normocardia, and from idioventricular with third-degree atrioventricular node block and an average heart rate of 34 BPM, to normal sinus rhythm with a heart rate of 71 BPM. Additionally, at the end of the treatment, the patient's number of episodes of ventricular extrasystole decreased 36 times (3289 versus 91 episodes). These results show that research on this technique should be continued. [ABSTRACT FROM AUTHOR]

We present a case of a 70 year old man with a history of paroxysmal atrial flutter who was admitted to the hospital with symptoms and imaging consistent with an acute stroke. Physical exam was notable for a pulse rate of 50 beats per minute and right sided facial droop with mild dysarthria. Admission ECG shows a junctional bradycardia with evidence of dual AV node physiology, rarely manifested in a retrograde fashion on a standard ECG. The patient likely experienced parasympathetic sinus node slowing in the setting of acute stroke. During post-stroke monitoring, the patient demonstrated return of sinus rhythm with chronotropic competence and he had no additional arrhythmia during admission. [ABSTRACT FROM AUTHOR]

66-year-old Bengali male with past medical history of hypertension, hyperlipidemia, and diabetes mellitus type 2 was referred to the cardiology clinic for the evaluation and management of angina pectoris. The patient's symptoms were characterized as exertional chest pressure, which worsened with minimal activity (walking for 5 minutes) and relieved with rest (after 10 minutes) and had been ongoing for the past 4-5 months. His existing medications included atenolol, valsartan, and empagliflozin. Based on his clinical history and his risk factors for ischemic heart disease, he had a high pre-test probability for ischemic heart disease. Coronary computed tomographic angiography (CCTA) is an accurate test for the identification of atherosclerotic coronary artery disease (CAD) in patients initially presenting for the evaluation of suspected CAD, especially in those individuals with a high pre-test probability of ischemic heart disease. An initial electrocardiogram demonstrated sinus bradycardia with no ischemic changes. Lipid panel demonstrated total cholesterol of 99 mg/dL, LDL of 35 mg/dL, HDL of 45 mg/dL, and triglycerides of 95 mg/dL. He was referred for CCTA to evaluate the extent and severity of atherosclerotic CAD. CCTA demonstrated moderate calcified coronary plaque with coronary artery calcium Agatston score of 155 and triple vessel disease with severe luminal stenosis as follows: • 50-70% distal left main stenosis comprised of predominantly noncalcified plaque (Image 1). • Diffuse narrowing of the proximal left anterior descending artery comprised of predominantly noncalcified plaque, stenosis quantification could not be done due to absence of a normal reference area (Image 1 & 2). • Subtotal occlusion of the moderately large second diagonal branch secondary to noncalcified plaque (Image 3). • >75% proximal OM1 plaque secondary to noncalcified plaque. • Subtotal occlusion of ostial OM3, followed by 70% stenosis of mid and distal OM3 secondary to noncalcified plaque (Image 4). • Subtotal occlusion of proximal/mid RCA secondary to noncalcified plaque with high-risk features of positive remodeling and low attenuation (Image 5A & 5B). CCTA cardiac functional analysis demonstrated normal ejection fraction, wall motion and chamber size. The patient was started on aspirin and high intensity rosuvastatin. He was referred for coronary angiography which confirmed the CCTA findings of severe triple vessel disease. He was referred for CABG. Post CABG, the patient is feeling well, and his activity level has improved. CCTA is an excellent noninvasive modality for the management of chest pain in patients with high pre-test probability. It is a readily available tool that can identify the severity and extent of CAD, and guide downstream preventative medical management such as aspirin and lipid lowering therapy, as well as invasive management such as coronary catheterization and CABG. When used as an initial gatekeeper modality it can identify those patients who would most benefit most from invasive workup of ischemic heart disease. No [ABSTRACT FROM AUTHOR]

Introduction: The long‐term performance of leadless pacemaker (LPM) has not been well evaluated. Methods: Between September 2017 and January 2021, 929 consecutive patients who underwent pacemaker implantation were grouped according to the types of pacemakers: LPM (LPM group, n = 368) and conventional pacemaker (PM group, n = 561). Results: The median follow‐up duration was 1.7 years (interquartile range 0.8–2.6 years). Hospitalization rate for heart failure in the LPM group was 9.3%, 15.6%, and 21.6% at 1, 2, 3 years, respectively. The LPM group had a significantly higher adjusted heart failure hospitalization risk than the PM group [hazard ratio (HR) 1.70, 95% confidence interval (CI) 1.09–2.64, p =.01]. More patients with symptomatic bradycardia caused by sinus node dysfunction (SND) in the LPM group (n = 150) were admitted to the hospital for heart failure compared to those in the PM group (n = 219) (HR 2.02, 95%CI 1.04–3.90, p =.03), whereas no significant difference was observed between the two groups in the patients with bradycardia caused by atrial fibrillation (LPM group, n = 71; PM group, n = 18) or atrioventricular block (LPM group, n = 147; PM group, n = 324). Conclusions: Patients who received LPM implantation had greater hospitalization risk for heart failure, compared to those who received conventional pacemaker implantation. The increased risk was mainly attributed to patients with SND. [ABSTRACT FROM AUTHOR]

Background/purpose: Inferior vena cava (IVC) interruption is rare and can be detected through prenatal or postnatal imaging. It usually occurs in patients with heterotaxy syndrome with bilateral left-sidedness (left isomerism or polysplenia syndrome), indicating a laterality defect. However, its long-term outcomes remain unclear.Methods: This retrospective study included a patient cohort with evidence of IVC interruption based on imagining data (1980-2019) selected from our institutional database.Results: We included 34 (male/female = 14/20) patients with IVC interruption. Most of the patients had left isomerism of the bronchopulmonary situs (96.4%) and cardiac atrial situs (90.3%). Splenic anomalies, including polysplenia (35.7%), lobulated spleen (39.3%), inversus solitary spleen (10.7%), and asplenia (3.6%), were common. Normal cardiac structure was noted in four (11.8%) patients. Congenital heart disease (CHD) was noted in 30 patients: 7 with simple CHD and 23 with severe CHD. Bradycardia occurred in 47.1% of the patients and was not associated with CHD. Splenic variations were not associated with CHD or bradycardia. The survival rates for the 10-, 20-, and 40-year age groups were 0.880, 0.792, and 0.441, respectively; severe CHD was the only risk factor.Conclusion: IVC interruption can present as an isolated lesion and be associated with CHD. Although bradycardia was common among the patients, CHD severity was the only risk factor for survival. Patients with IVC interruption commonly have left isomerism at the atrial and bronchopulmonary situs, but the spectrum of splenic abnormalities is wide, including polysplenia, lobulated spleen, solitary inversus spleen, and, rarely, asplenia. [ABSTRACT FROM AUTHOR]

In advanced tumour disease, the situation of patients may worsen due to paraneoplastic syndromes and the side effects of new therapies. In small cell lung cancer, immunotherapy has shown an improvement in outcomes for the first time in decades. Still, the prognosis remains dismal, challenging supportive care for new treatment side effects and the shared decision-making process at the end of life. we present a patient with advanced small cell lung cancer. His situation is complicated by ectopic ACTH production with severe hypokalaemia and immune-related myocarditis after treatment with atezolizumab, leading to changing ECG findings and bradycardia. At the end of life, priorities can shift, so medical treatments must be critically questioned regarding their benefit for the patient. New oncological treatment options may hazard the timely integration of palliative care and thus, lead to more extended hospital stays and more aggressive care. The challenging shared decision-making is time-consuming crucial in achieving goal-concordant care. [ABSTRACT FROM AUTHOR]

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Background: Cardiac arrhythmias have been identified as independent predictors of mortality in Coronavirus disease 2019 (COVID-19) patients. While some studies have reported poor prognosis with bradycardia in COVID-19 patients, others have not found any association between bradycardia and mortality in COVID-19 patients. This study aims to assess the relationship between bradycardia and mortality in COVID-19 patients by reviewing existing literature. Main body: Articles were obtained by systematically searching the PubMed and Google scholar databases. Qualitative and quantitative analyses of the studies on bradycardia and mortality in COVID-19 were done. A pooled estimate, with a sample size of 1320 patients, comparing the effect of patients that were bradycardic during their admission with those that were not on mortality showed that bradycardia did not lead to increased mortality in COVID-19 patients (OR 1.25, 95% CI 0.41–3.84, p = 0.7). Conclusions: This meta-analysis showed that bradycardia was not significantly associated with mortality in COVID-19 patients. However, this study is limited by the few studies on bradycardia and mortality in COVID-19 patients. Therefore, future studies should investigate this relationship so that clinicians can prognostically triage and treat COVID-19 patients appropriately. [ABSTRACT FROM AUTHOR]

Minimal information exists regarding epicardial pacemaker (EP) implantation in pet ferrets (Mustela putorius furo). The objectives were to describe the indications, surgical technique, and outcome of EP implantation in ferrets for the treatment of advanced atrioventricular block (AVB). Eight client-owned ferrets presenting to five veterinary referral centers. Signalment, physical exam findings, diagnostic tests, anesthesia protocols, surgical implantation techniques, postoperative treatment plans, and EP interrogations were reviewed. Intra- and postoperative, minor and major, and EP-related complications were established. Descriptive statistics were performed to report complication rates. Survival analyses were performed. All ferrets had advanced AVB: 3/8 had high-grade second-degree and 5/8 had third-degree. The primary clinical signs were collapse and weakness. Seven EP were implanted via a transdiaphragmatic approach and one via a left intercostal thoracotomy. Intraoperative complications occurred in 2/8 ferrets, both major. One ferret with severe comorbidities died during general anesthesia. Postoperative pacemaker-related complications were minor: inappropriate sinus beat sensing in 2/8 and occasional muscle fasciculations in 1/8. Two ferrets were alive at the time of manuscript submission, at 10 and 21 months postoperatively. The overall median survival time was 24 months. Implantation of EP was performed successfully in most ferrets for treatment of advanced AVB and was well tolerated. Ferrets with advanced AVB may experience resolution of clinical signs associated with their cardiac disease following EP implantation. Additional studies are warranted to investigate the effects of epicardial pacing on survival times in this species. [ABSTRACT FROM AUTHOR]