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Background and Aims: Antipsychotic drugs are critical in managing psychosis but they also carry risks when misused, leading to toxicity. Case Presentation: A patient overdosed on olanzapine, resulting in anticholinergic toxidrome with symptoms like tachycardia and altered mental status. Immediate recognition and management of antipsychotic toxicity-induced toxidromes in emergency settings are crucial. Treatment strategy includes maintaining airway, breathing and circulation along with decontamination. There is no specific antidote. Conclusion: This case underscores the need for emergency physicians to remain vigilant and proactive in identifying and addressing such toxicity by identification of toxidromes to prevent complications and missed diagnosis in emergency department. [ABSTRACT FROM AUTHOR]

Introduction: The novel Confirm Rx™ implantable cardiac monitor (ICM) with SharpSense™ technology incorporates a new P‐wave discriminator designed to improve AF detection. This study aimed to evaluate the diagnostic performance of the Confirm Rx™ ICM in detecting AF episodes of varying durations. Methods: We conducted a multicenter retrospective analysis of consecutive patients implanted with a Confirm Rx™ ICM (v1.2) across nine UK hospitals, all with documented AF lasting at least 6 min. Electrocardiograms (ECGs) were manually adjudicated by cardiologists. To account for intra‐ and inter‐reviewer variability, a random sample of 10% of ECGs underwent additional review. Disagreements were resolved by a third reviewer. Diagnostic performance was determined by calculating the gross and patient‐averaged positive predictive value (PPV) for AF episodes of different duration. The source of false positive (FP) detection was also categorized. Results: Overall, 16,230 individual ECGs from 232 patients were included. The median AF episode duration was 14 min. R‐wave amplitude remained stable during follow‐up (0.52 ± 0.27 mV [initial] vs. 0.54 ± 0.29 mV [end of follow‐up], p =.10). The gross and patient‐averaged PPV were 75.0% and 67.0%, respectively. Diagnostic performance (gross) increased with progressively longer AF episodes: 88.0% for ≥1 h, 97.3% for 6 h, and 100% for 24 h. The main source of FP during tachycardia was T‐wave oversensing (54.2%), while in non‐tachycardic episodes it was predominantly ectopy (71.2%). The AF burden precision was excellent (93.3%). Conclusion: The Confirm Rx™ ICM diagnostic performance was modest for all AF episodes (75%), with accuracy increasing for longer AF episodes. [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]

Aim: To study the safety profile and effectiveness of Anti Snake venom (ASV) in western India Methods: This retrospective study gathered safety, and clinicoepidemiologicaldata on 157 patients admitted at Shri Sainath Hospital, Dharampur, Gujarat, from July 2022 to February 2023. Results: Majority were bitten between August and November. There were 88 males, 5 to70 yrs. (mean 39.14), 69 females, 2 to 70 years (mean 40.32). 6 of these were children ranging from 2 to 12 years.134 were agricultural labourers. 120 cases were analysable. 17 had neurotoxicity and 103 had haemotoxicity. Mean (SD) number of vials used was 10.1(6.2), time to discontinue ASV was 3.0(5.2) hours, and duration of hospital stay was 4.5(2.6) days. Patients bitten by saw scaled vipers were discharged early. In Russel’s Viper bites, number of vials used, was higher if the bite to needle time was less than 6 hours 9 patients suffered 24 adverse events, with two possible cases of anaphylaxis. One case had urticaria, itching and tachycardia as a triad. The remaining were isolated events of mild urticaria, itching, tachycardia, hypotension, cough, rigor. Conclusion: 10.1 vials were needed on average for control of envenomation with no fatalities or severe comorbidities. Adverse events were reported in 5.7% cases. The ASV brand used was well tolerated. Patients who were brought late suffered more renal complications [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]

When an injured patient arrives in the Emergency Department (ED), timely and appropriate care is crucial. Shock Index Pediatric Age-Adjusted (SIPA) has been shown to accurately identify pediatric patients in need of emergency interventions. However, no study has evaluated SIPA against age-adjusted tachycardia (AT). This study aims to compare SIPA with AT in predicting outcomes such as mortality, severe injury, and the need for emergent intervention in pediatric trauma patients. This is a retrospective cross-sectional analysis of patient data abstracted from the Trauma Quality Improvement Program Participant Use Files (TQIP PUFs) for years 2013–2020. Patients aged 4–16 with blunt mechanism of injury and injury severity score (ISS) > 15 were included. 36,517 children met this criteria. Sensitivity, specificity, overtriage, and undertriage rates were calculated to compare the effectiveness of AT and elevated SIPA as predictors of severe injuries and need for emergent intervention. Emergent interventions included craniotomy, endotracheal intubation, thoracotomy, laparotomy, or chest tube placement within 24 h of arrival. AT classified 59% of patients as "high risk," while elevated SIPA identified 26%. Compared to AT patients, a greater proportion of patients with elevated SIPA required a blood transfusion within 24 h (22% vs. 12%, respectively; p < 0.001). In-hospital mortality was higher for the elevated SIPA group than AT (10% vs. 5%, respectively; p < 0.001) as well as the need for emergent operative interventions (43% vs. 32% respectively; p < 0.001). Grade 3 or higher liver/spleen lacerations requiring blood transfusion were also more common among elevated SIPA patients than AT patients (8% vs. 4%, respectively; p < 0.001). AT demonstrated greater sensitivity but lower specificity compared to SIPA across all outcomes. AT showed improved overtriage and undertriage rates compared to SIPA, but this is attributed to identifying a large proportion of the sample as "high risk." AT outperforms SIPA in sensitivity for mortality, injury severity and emergent interventions in pediatric trauma patients while the specificity of SIPA is high across these outcomes. [ABSTRACT FROM AUTHOR]

• The study describes management of post-COVID sub-syndromes encountered in our clinic. • Most frequent sub-syndromes: COVID ILD and COVID dyspnea-tachycardia syndrome [DTS]. • COVID ILD received mycophenolate mofetil+prednisone, DTS patients received metoprolol. COVID patients continue to experience unremitting symptoms that extend far beyond the initial illness. While there is rapid accumulation of data on acute COVID treatment in hospitalized patients, little is known regarding post-COVID management. To describe our center's experience treating post-COVID sub-syndromes encountered in Post-COVID Lung Clinic. We retrospectively reviewed data on 98 post-COVID patients evaluated in our clinic between 07/01/2020–12/31/2022. We encountered three distinct post-COVID subtypes: 1) respiratory complaints associated with increased O2 requirements and abnormal CT findings (post-COVID interstitial lung disease [ILD]), 2) respiratory complaints associated with tachycardia (post-COVID dyspnea-tachycardia syndrome [DTS]). Post-COVID ILD patients (n = 28) received steroids in combination with cell cycle inhibitor (mycophenolate mofetil-MMF). Post-COVID DTS patients (n = 16) were treated with metoprolol. 3) A third, undifferentiated group presented with mild respiratory complaints and normal spirometry (n = 17) and was followed in clinic without initiation of a specific treatment. In treated post-COVID ILD patients, mean oxygen requirements at rest (1.96 ± 1.79 L/NC) decreased to 0.89 ± 1.29 L/NC at 6 months follow-up, p = 0.005. In patients with post-COVID DTS, mean heart rate at rest decreased (98 ± 15 bpm to 79 ± 11 bpm) at 6 months follow-up, p = 0.023. 60 % of patients reported an improvement in exertional dyspnea. Our descriptive study presents a single center outpatient COVID-19 clinic experience. We encountered 3 post-COVID sub-syndromes and describe their treatments: post-COVID interstitial lung disease [ILD] treated with a novel regimen of MMF and steroids, post COVID dyspnea-tachycardia syndrome [DTS] treated with metoprolol, and a third subgroup with mild undifferentiated symptoms without specific treatment. [ABSTRACT FROM AUTHOR]

BACKGROUND: Differentiating wide complex tachycardias (WCTs) into ventricular tachycardia (VT) and supraventricular wide tachycardia via 12-lead ECG interpretation is a crucial but difficult task. Automated algorithms show promise as alternatives to manual ECG interpretation, but direct comparison of their diagnostic performance has not been undertaken. METHODS: Two electrophysiologists applied 3 manual WCT differentiation approaches (ie, Brugada, Vereckei aVR, and VT score). Simultaneously, computerized data from paired WCT and baseline ECGs were processed by 5 automated WCT differentiation algorithms (WCT Formula, WCT Formula II, VT Prediction Model, Solo Model, and Paired Model). The diagnostic performance of automated algorithms was compared with manual ECG interpretation approaches. RESULTS: A total of 212 WCTs (111 VT and 101 supraventricular wide tachycardia) from 104 patients were analyzed. WCT Formula demonstrated superior accuracy (85.8%) and specificity (87.1%) compared with Brugada (75.2% and 57.4%, respectively) and Vereckei aVR (65.3% and 36.4%, respectively). WCT Formula II achieved higher accuracy (89.6%) and specificity (85.1%) against Brugada and Vereckei aVR. Performance metrics of the WCT Formula (accuracy 85.8%, sensitivity 84.7%, and specificity 87.1%) and WCT Formula II (accuracy 89.8%, sensitivity 89.6%, and specificity 85.1%) were similar to the VT score (accuracy 84.4%, sensitivity 93.8%, and specificity 74.2%). Paired Model was superior to Brugada in accuracy (89.6% versus 75.2%), specificity (97.0% versus 57.4%), and F1 score (0.89 versus 0.80). Paired Model surpassed Vereckei aVR in accuracy (89.6% versus 65.3%), specificity (97.0% versus 75.2%), and F1 score (0.89 versus 0.74). Paired Model demonstrated similar accuracy (89.6% versus 84.4%), inferior sensitivity (79.3% versus 93.8%), but superior specificity (97.0% versus 74.2%) to the VT score. Solo Model and VT Prediction Model accuracy (82.5% and 77.4%, respectively) was superior to the Vereckei aVR (65.3%) but similar to Brugada (75.2%) and the VT score (84.4%). CONCLUSIONS: Automated WCT differentiation algorithms demonstrated favorable diagnostic performance compared with traditional manual ECG interpretation approaches. [ABSTRACT FROM AUTHOR]

BACKGROUND: During pulsed field ablation (PFA), relationships between ablation parameters (contact force [CF], number of burst pulses, impedance decrease, and electrode temperature) and lesion size in beating hearts have not been well validated. METHODS: A 7.5F-catheter with a 3.5-mm ablation electrode and CF sensor (ThermoCool SmartTouch SF-Dual-Energy, Biosense Webster, Inc, Irwindale, CA) was connected to a PFA system (TRUPULSE2, Biosense Webster, Inc). In 11 closedchest swine, biphasic PFA current was delivered between the ablation electrode and the skin patch at 219 sites in left ventricle and right ventricle using 12, 18, and 24 burst pulses with 4 different levels of CF: (1) low (n=57; CF, 4--15g; median, 10g); (2) moderate (n=60; CF, 16--30g; median, 22.5g); (3) high (n=68; CF, 32--65g; median, 40g); and (4) no electrode contact (n=34), 2 mm away from the endocardium. Swine were euthanized 2 hours after ablation, and lesion size was measured using triphenyl tetrazolium chloride staining. RESULTS: All PFA lesions with electrode-myocardium contact were well demarcated with triphenyl tetrazolium chloride staining, demonstrating (1) pale central zone (contraction band necrosis with minimal coagulation necrosis), (2) dark brown zone (contraction band necrosis with hemorrhage), and (3) hyperstained red zone by triphenyl tetrazolium chloride (unaffected normal myocardium with preserved mitochondrial activity, consistent with reversible zone). Lesion depth increased significantly with increasing CF and the number of PFA burst pulses. An exponential/logarithmic formula combined with CF and the number of PFA burst pulses correlated lesion depth with high accuracy: R=0.809, P<0.0001, ±1.0-mm accuracy in 128 of 163 (79%) lesions, and ±1.5-mm accuracy in 153 of 163 (94%) lesions. Impedance decrease and electrode temperature were poor predictors of lesion size. There were no detectable lesions resulting from ablation without electrode contact. CONCLUSIONS: Acute PFA ventricular lesions demonstrate irreversible and reversible lesion boundaries. Electrode-tissue contact is required for effective lesion formation. Lesion depth increases significantly with increasing CF and PFA burst pulses. A new exponential/logarithmic formula combined with CF and the number of PFA burst pulses correlates lesion depth with high accuracy. [ABSTRACT FROM AUTHOR]

In the field of cardiac electrophysiology, there is a universal desire: the discovery of a flawless diagnostic maneuver for supraventricular tachycardias (SVTs). This is not merely a wish but a shared odyssey. To improve diagnostic accuracy and achieve sufficient sensitivity and specificity, numerous diagnostic maneuvers have been proposed. However, each has its limitations and prompts a search for new diagnostic techniques. This continuous cycle of discovery and refinement, which we titled "SVT Quest" is reviewed in chronological sequence. This adventure in diagnosing narrow QRS tachycardia unfolds in 3 steps: Step 1 involves differentiating atrial tachycardia from other SVTs based on the observations such as V‐A‐V or V‐A‐A‐V response, ΔAA interval, VA linking, the last entrainment sequence, and response to the atrial extrastimulus. Step 2 focuses on differentiating orthodromic reciprocating tachycardia from atrioventricular nodal reentrant tachycardia based on the observations such as tachycardia reset upon the premature ventricular contraction during His refractoriness, uncorrected/corrected postpacing interval, differential ventricular entrainment, orthodromic His capture, transition zone analysis, and total pacing prematurity. Step 3 characterizes the concealed nodoventricular/nodofascicular pathway and His‐ventricular pathway‐related tachycardia based on observations such as V‐V‐A response, ΔatrioHis interval, and paradoxical reset phenomenon. There is no single diagnostic maneuver that fits all scenarios. Therefore, the ability to apply multiple maneuvers in a case allows the operator to accumulate evidence to make a likely diagnosis. Let's embark on this adventure! [ABSTRACT FROM AUTHOR]

BACKGROUND: In the PARTITA trial (Does Timing of Ventricular Tachycardia Ablation Affect Prognosis in Patients With an Implantable Cardioverter Defibrillator?), antitachycardia pacing (ATP) predicted the occurrence of implantable cardioverter defibrillator (ICD) shocks. Catheter ablation of ventricular tachycardia after the first shock reduced the risk of death or worsening heart failure. A threshold of ATPs that might warrant an ablation procedure before ICD shocks is unknown. Our aim was to identify a threshold of ATPs and clinical features that predict the occurrence of shocks and cardiovascular events. METHODS: We analyzed data from 517 patients in phase A of the PARTITA study. We used classification and regression tree analysis to develop and test a risk stratification model based on arrhythmia patterns and clinical data to predict ICD shocks. Secondary end points were worsening heart failure and cardiovascular hospitalization. RESULTS: Classification and regression tree classified patients into 6 leaves by increasing shock probability. Patients treated with ≥5 ATPs in 6 months (active arrhythmia pattern) had the highest risk of ICD shocks (93% and 86%, training and testing samples, respectively). Patients without ATPs had the lowest (1% and 2%). Other predictors included left ventricle ejection fraction<35%, age of <60 years, and obesity. Survival analysis revealed a higher risk of worsening heart failure (hazard ratio, 5.45 [95% CI, 1.62-18.4]; P=0.006) and cardiovascular hospitalization (hazard ratio, 7.29 [95% CI, 3.66-14.5]; P<0.001) for patients with an active arrhythmia pattern compared with those without ATPs. CONCLUSIONS: Patients with an active arrhythmia pattern (≥5 ATPs in 6 months) are associated with an increased risk of ICD shocks, as well as heart failure hospitalization and cardiovascular hospitalization. These data suggest that additional treatments may be helpful to this high-risk group as a preventive strategy to reduce the incidence of major events. Further prospective randomized trials are needed to confirm the benefits of early ventricular tachycardia ablation in this setting. [ABSTRACT FROM AUTHOR]

BACKGROUND: Endocardial catheter-based pulsed field ablation (PFA) of the ventricular myocardium is promising. However, little is known about PFA's ability to target intracavitary structures, epicardium, and ways to achieve transmural lesions across thick ventricular tissue. METHODS: A lattice-tip catheter was used to deliver biphasic monopolar PFA to swine ventricles under general anesthesia, with electroanatomical mapping, fluoroscopy and intracardiac echocardiography guidance. We conducted experiments to assess the feasibility and safety of repetitive monopolar PFA applications to ablate (1) intracavitary papillary muscles and moderator bands, (2) epicardial targets, and (3) bipolar PFA for midmyocardial targets in the interventricular septum and left ventricular free wall. RESULTS: (1) Papillary muscles (n=13) were successfully ablated and then evaluated at 2, 7, and 21 days. Nine lesions with stable contact measured 18.3±2.4 mm long, 15.3±1.5 mm wide, and 5.8±1.0 mm deep at 2 days. Chronic lesions demonstrated preserved chordae without mitral regurgitation. Two targeted moderator bands were transmurally ablated without structural disruption. (2) Transatrial saline/carbon dioxide assisted epicardial access was obtained successfully and epicardial monopolar lesions had a mean length, width, and depth of 30.4±4.2, 23.5±4.1, and 9.1±1.9 mm, respectively. (3) Bipolar PFA lesions were delivered across the septum (n=11) and the left ventricular free wall (n=7). Twelve completed bipolar lesions had a mean length, width, and depth of 29.6±5.5, 21.0±7.3, and 14.3±4.7 mm, respectively. Chronically, these lesions demonstrated uniform fibrotic changes without tissue disruption. Bipolar lesions were significantly deeper than the monopolar epicardial lesions. CONCLUSIONS: This in vivo evaluation demonstrates that PFA can successfully ablate intracavitary structures and create deep epicardial lesions and transmural left ventricular lesions. [ABSTRACT FROM AUTHOR]

The article discusses a prospective observational study on tachyarrhythmia-induced cardiomyopathy, highlighting the frequency of recovery post-rhythm correction and identifying early diagnostic markers, such as left ventricular (LV) end-diastolic diameter, predictive of response. Topics include the study's methodology, the high incidence of tachyarrhythmia-induced cardiomyopathy, and the significance of LV end-diastolic diameter in predicting response to treatment.

Introduction: During ventricular pacing, a fusion of atrial activation may occur owing to the simultaneous retrograde conduction of the atrioventricular (AV) node and accessory pathway (AP), potentially leading to an inaccurate mapping of the atrial AP insertion site. Objective: We tested the hypothesis that landiolol, an ultra‐short‐acting intravenous β1‐blocker, could dissociate a fusion of atrial activation. Methods: We conducted a prospective before‐and‐after study to investigate the effect of landiolol on retrograde conduction via the AV node and AP. We enrolled 21 consecutive patients with orthodromic AV reciprocating tachycardia who underwent electrophysiological studies at our hospital between January 1, 2018, and August 31, 2020. Results: Six patients exhibited a fusion of atrial activation. After landiolol administration (10 μg/kg/min), the effective refractory period was unchanged in AP (280 [240–290] ms vs. 280 [245–295] ms, p =.91), whereas that of the AV node was prolonged (275 [215–380] ms vs. 332 [278–445] ms, p =.03). The Wenckebach pacing rate via retrograde AV node decreased after landiolol administration (180 [140–200] beats per minute [bpm] vs. 140 [120–180] bpm, p =.02). Thus, landiolol decreased the minimum ventricular pacing rate required to dissociate a fusion of atrial activation (180 [160–200] bpm vs. 140 [128–155] bpm, p =.007). Radiofrequency catheter ablation under landiolol administration successfully eliminated AP in all patients during ventricular pacing without complications or recurrence. Conclusion: Landiolol inhibited the AV node without affecting the AP and helped dissociate a fusion of atrial activation at a lower ventricular pacing rate. [ABSTRACT FROM AUTHOR]

Aim: Culture-negative sepsis (CNS) is a common but understudied entity. The objective of this study was to compare the incidence, characteristics, and outcomes of CNS with culture-positive sepsis (CPS). Methods: This was a prospective observational study of patients admitted to the medical intensive care unit (ICU) of a tertiary hospital from January to December 2015 with clinical suspicion of severe sepsis as defined by Consensus Conference Criteria 2001. Results: Patients with severe sepsis (n = 122) were studied of whom 66 (54%) were CPS and 56 (46%) were CNS. Patients with CNS had fewer comorbidities (0.7 ± 0.70 vs. 2 ± 0.8, P < 0.01). At presentation, CNS patients had less tachycardia (heart rate 92.5 ± 10.5 vs. 105.9 ± 13.2, P < 0.01), lower white blood cell counts (11859 ± 4791 vs. 14224 ± 3898, P = 0.003), lower need for vasopressors (38% vs. 68%, P < 0.01), and mechanical ventilation (23% vs. 53%, P < 0.01) compared to patients with CPS. The number of antibiotics on admission was similar between the groups (1.5 ± 0.6 vs. 1.6 ± 0.6, P = 0.36) but the duration of antibiotics was less in CNS (7.6 ± 1.7 days vs. 10.4 ± 2.6 days, P < 0.01). CNS had lower duration of ICU stay (6 ± 2.1 days vs. 7.8 ± 3.7 days, P < 0.01) and lower ICU mortality (7.1% vs. 22.7%, P = 0.02). Conclusion: CNS is very common in ICU. CNS patients compared to CPS tend to be less sick at presentation utilizing less resources but were initiated on a similar number of antibiotics on admission although for a shorter duration. Patients with CNS had a lower mortality in comparison to those with CPS. [ABSTRACT FROM AUTHOR]

Torsades de Pointes (TdP) is a potentially lethal ventricular tachydysrhythmia. Prolonged heartrate corrected QT interval (QTc) predicts TdP; however, with poor specificity. We performed this study to identify other predictors of TdP among patients with prolonged QTc. We performed a retrospective case control study with 2:1 matching at an urban academic hospital. We searched our hospital electrocardiogram (ECG) database for tracings with heartrate ≤ 60, QTc ≥ 500, and QRS < 120, followed by a natural language search for electronic records with "Torsades," "polymorphic VT," or similar to identify TdP cases from 2005 to 19. We identified controls from a similar ECG database search matching for QTc, heartrate, age, and sex. We compared cardiologic and historical factors, medications, laboratory values, and ECG measurements including ectopy using univariate statistics. For those cases with saved telemetry strips that included preceding beats or TdP onset, we compared ectopy and TdP onset characteristics between the ECG and telemetry strips using mixed linear modeling. Seventy-five cases including 50 with telemetry strips and 150 controls were included. Historical, pharmacologic, laboratory, and cardiologic testing results were similar between cases and controls. The proportion of telemetry tracings with premature ventricular contractions (PVC's) preceding TdP was 0.78 compared to 0.16 for case ECG's (difference 0.62(95%CI 0.44–0.75)) and 0.10 for control ECGs (difference 0.68(95%CI 0.56–0.80)). Average telemetry heartrate was 72 and QTc 549 immediately preceding TdP, similar to the ECG values. Clinical factors don't differentiate patients with long QTc who develop TdP, however, an increase in PVC's in patients with prolonged QTc may usefully predict imminent TdP. [Display omitted] • History or meds don't differ between long QTc patients who do or don't suffer TdP. • Serum chemistries don't differ between long QTc patients who do or don't suffer TdP. • Increased ventricular ectopy commonly precedes TdP. • Increased ventricular ectopy and its characteristics could be used to predict TdP TdP = Torsades de Pointes. [ABSTRACT FROM AUTHOR]

Background: Compatibility of DiamondTemp (DT) radiofrequency (RF) catheter with the Rhythmia mapping system has not been manufacturer‐reported nor its tracking accuracy reported. Methods: Consecutive patients undergoing macroreentrant atrial tachycardia ablation guided by Rhythmia and ablated using DT were prospectively enrolled. Following catheter configuration, ablation lines were performed and remapped to measure the RF tag to effective‐ablation‐line‐center (RFT‐ALC) distance. Results: Among 20 consecutive patients (54 maps), 40 ablation lines were evaluated. Overall, the RFT‐ALC distance was 3.88 ± 2.95 mm, and the operator assessment of accuracy was high. No complications occurred. Conclusion: The use of DT catheter guided by the Rhythmia mapping system is feasible and accurate. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether atrial fibrillation (AF) burden varies by pacing site in patients with reactive atrial antitachycardia pacing (rATP). We aimed to compare AF burden in patients with high atrial septal pacing (HASp) via delivery catheter and right atrial appendage pacing (RAAp) in patients with sick sinus syndrome (SSS). Methods: We retrospectively identified 109 patients with a history of paroxysmal AF and SSS who had received dual‐chamber pacemaker implantation between January 2017 and December 2019, of whom 39 and 70 patients had HASp and RAAp, respectively. rATP was initiated after a 1‐month post‐implantation run‐in period. Results: Patients with HASp had a significantly shorter P‐wave duration during atrial pacing than those with RAAp (99.3 ± 10.4 vs. 116.0 ± 14.3 ms, p <.001). During the 3‐year follow‐up period, the incidence of an AF lasting longer than 1 or 7 days was significantly lower (hazard ratio [HR], 0.45; p =.016; HR, 0.24; p =.004) than in those with RAAp. The median time of AF/AT per day in the follow‐up periods was significantly shorter in the HASp group than in the RAAp group (10 vs. 18 min/day, p =.018). Atrial lead division did not occur in the HASp group during the follow‐up period. Conclusions: HASp via delivery catheter is as safe as RAAp, and HASp combined with rATP is effective for reducing AF burden in patients with SSS and paroxysmal AF. [ABSTRACT FROM AUTHOR]

Accelerated junctional rhythm (AJR) and junctional ectopic tachycardia (JET) are common postoperative arrhythmias associated with morbidity/mortality. Studies suggest that pre- or intraoperative treatment may improve outcomes, but patient selection remains a challenge. The purpose of this study was to describe contemporary outcomes of postoperative AJR/JET and develop a risk prediction score to identify patients at highest risk. This was a retrospective cohort study of children aged 0–18 years undergoing cardiac surgery (2011–2018). AJR was defined as usual complex tachycardia with ≥1:1 ventricular–atrial association and junctional rate >25th percentile of sinus rate for age but <170 bpm, whereas JET was defined as a rate >170 bpm. A risk prediction score was developed using random forest analysis and logistic regression. Among 6364 surgeries, AJR occurred in 215 (3.4%) and JET in 59 (0.9%). Age, heterotaxy syndrome, aortic cross-clamp time, ventricular septal defect closure, and atrioventricular canal repair were independent predictors of AJR/JET on multivariate analysis and included in the risk prediction score. The model accurately predicted the risk of AJR/JET with a C-index of 0.72 (95% confidence interval 0.70–0.75). Postoperative AJR and JET were associated with prolonged intensive care unit and hospital length of stay, but not with early mortality. We describe a novel risk prediction score to estimate the risk of postoperative AJR/JET permitting early identification of at-risk patients who may benefit from prophylactic treatment. [ABSTRACT FROM AUTHOR]

Phaeochromocytomas are rare tumours of the adrenal medulla that can be associated with various presentations. Many of the better characterized clinical signs, including weakness, tachycardia and tachypnoea, are attributable to excessive and unregulated catecholamine secretion from functional tumours. In addition to catecholamine-induced cardiomyopathy and vasospasm, the invasive nature of phaeochromocytomas can lead to occlusion of the caudal vena cava contributing to systemic cardiovascular compromise. In humans, leukocytoclastic vasculitis is a rarely reported manifestation of catecholamine excess associated with phaeochromocytomas. We now describe a dog that had an invasive unilateral phaeochromocytoma with histological evidence of myocardial damage, consistent with catecholamine-induced cardiomyopathy, and leukocytoclastic vasculitis of small vessels in a range of tissues. We conclude that catecholamine excess may have played a role in the pathogenesis of vasculitis in this case. To the best of our knowledge, this is the first documented association between phaeochromocytoma and leukocytoclastic vasculitis in a non-human species. [ABSTRACT FROM AUTHOR]

Background: Modulating atrial fibrillation (AF) drivers has been proposed as one of the effective ablation strategies for non‐paroxysmal AF (non‐PAF). However, the optimal non‐PAF ablation strategy is still under debate because the exact mechanisms of AF persistence including focal activity and/or rotational activity, are not well‐understood. Recently, spatiotemporal electrogram dispersion (STED) assumed to indicate rotors in the form of rotational activity is proposed as an effective target for non‐PAF ablation. We aimed to clarify the effectiveness of STED ablation for modulating AF drivers. Methods: STED ablation plus pulmonary vein isolation was applied in 161 consecutive non‐PAF patients not undergoing previous ablation. STED areas within the entire left and right atria were identified and ablated during AF. After the procedures, the STED ablation's acute and long‐term outcomes were investigated. Results: (1) Despite a more effective acute outcome of the STED ablation for both AF termination and non‐inducibility of atrial tachyarrhythmias (ATAs), Kaplan–Meier curves showed that the 24‐month freedom ratio from ATAs was 49%, which resulted from the higher recurrence ratio of atrial tachycardia (AT) rather than AF. (2) A multivariate analysis showed that the determinant of ATA recurrences was only a non‐elderly age, not long‐standing persistent AF, and an enlarged left atrium, which were conventionally considered as key factors. Conclusions: STED ablation targeting rotors was effective in elderly non‐PAF patients. Therefore, the main mechanism of AF persistency and the component of the fibrillatory conduction might vary between elders and non‐elders. However, we should be careful about post‐ablation ATs following substrate modification. [ABSTRACT FROM AUTHOR]

Background: Ablation strategies and modalities for atrial fibrillation (AF) have transitioned over the past decade, but their impact on post‐ablation medication and clinical outcomes remains to be fully investigated. Methods: We divided 682 patients who had undergone AF ablation in 2014–2019 (420 paroxysmal AFs [PAF], 262 persistent AFs [PerAF]) into three groups according to the period, that is, the 2014–2015 (n = 139), 2016–2017 (n = 244), and 2018–2019 groups (n = 299), respectively. Results: Persistent AF became more prevalent and the left atrial (LA) diameter larger over the 6 years. Extra‐pulmonary vein (PV)‐LA ablation was more frequently performed in the 2014–2015 group than in the 2016–2017 and 2018–2019 groups (41.1% vs. 9.1% and 8.1%; p <.001). The 2‐year freedom rate from AF/atrial tachycardias for PAF was similar among the three groups (84.0% vs. 83.1% vs. 86.7%; p =.98) but lowest in the 2014–2015 group for PerAF (63.9% vs. 82.7% and 86.3%; p =.025) despite the highest post‐ablation antiarrhythmic drug use. Cardiac tamponade was significantly decreased in the 2018–2019 group (3.6% vs. 2.0% vs. 0.33%; p = 0.021). There was no difference in the 2‐year clinically relevant events among the three groups. Conclusion: Although ablation was performed in a more diseased LA and extra‐PV‐LA ablation was less frequent in recent years, the complication rate decreased, and AF recurrences for PAF remained unchanged, but that for PerAF decreased. Clinically relevant events remained unchanged over the recent 6 years, suggesting that the impact of the recent ablation modalities and strategies on remote clinically relevant events may be small during this study period. [ABSTRACT FROM AUTHOR]

Laryngeal dystonia is a chronic neurologic disorder characterized by intention-induced spasms of the vocal folds driven by aberrant central motor processing. The use of in-office transcervical botulinum toxin injection for the treatment of laryngeal disorders, such as laryngeal dystonia, has been deemed safe and efficacious. There is, however, no available data outlining the hemodynamic changes experienced by patients undergoing this frequently performed procedure. One hundred and one patients diagnosed with laryngeal dystonia were enrolled in this prospective study. These patients underwent transcervical laryngeal botulinum toxin injection to address their dysphonia. Vital signs where acquired prior to, and at the time of injection. Alterations in these parameters were then evaluated for statistical significance. Statistically significant increases in mean heart rate (5.8 ± 10.8 bpm, P < 0.0001), systolic blood pressure and diastolic blood pressure (7.0 ± 9.5 mm Hg, P < 0.0001; 8.7 ± 14.7 mm Hg, P < 0.0001) were discovered. No statistically significant difference in oxygen saturation was noted and no patients in the study faced major adverse outcomes. Though these findings may not have related to clinically significant complication, our study demonstrates the importance of understanding potential stressors in a procedure routinely performed by laryngologists. This may result in more careful patient selection, alterations in procedure, and improved safety by acting in a timely fashion if alarming changes in hemodynamic parameters are noted. [ABSTRACT FROM AUTHOR]

Background: Oxidative stress is associated with atrial fibrillation recurrence following catheter ablation. Urinary isoxanthopterin (U‐IXP) is one of the noninvasive markers which reflect the reactive oxygen species; however, its ability to predict atrial tachyarrhythmias (ATAs) occurrence following catheter ablation remains uncertain. Methods: Among the patients who received scheduled catheter ablation for atrial fibrillation, baseline U‐IXP levels were measured just before the procedure. The prognostic impact of baseline U‐IXP upon postprocedural ATAs occurrence was investigated. Results: Among 107 patients (71 years old, 68% men), baseline U‐IXP level was 0.33 nmol/gCr on the median. During a mean of 603 days of follow‐up, 32 patients had ATAs. Baseline higher U‐IXP was independently associated with the occurrence of ATAs following catheter ablation with a hazard ratio of 4.69 (95% confidence interval: 1.82–12.37, p =.001) adjusted for the left atrial diameter, a persistent type, and hypertension which were potential confounders, with a cutoff of 0.46 nmol/gCr, which stratified cumulative incidence of ATAs occurrence (p <.001). Conclusion: U‐IXP can be used as the noninvasive predictive biomarker for ATAs following catheter ablation for atrial fibrillation. [ABSTRACT FROM AUTHOR]

Thyroid storm (TS) is an uncommon but severe manifestation of hyperthyroidism and an endocrine emergency, as it is fatal if it goes unrecognized. In pediatrics, the current literature is limited to case reports and case series. Current knowledge is extrapolated from adult data. This systematic review aims to present the epidemiology, most common etiologies, clinical presentation, and most accepted standard of care of TS in children. We aim to raise awareness of hyperthyroidism in the pediatric community. The databases used were PubMed, google scholar, and LILACS, with the search terms "thyroid storm" AND "pediatrics". Studies included case reports and case series in English and Spanish from patients between the ages of 0–21 years with clinical features consistent with a diagnosis of TS based on ATA 2016, with or without reported scale scores, published between 2000 and 2022. Variables such as ethnicity, etiology, possible triggers, clinical features, and management components were analyzed and presented. We analyzed data from 45 patients. Their mean age was 11.25 years. The majority of them were from Asia (26%). The most common clinical features were sinus tachycardia (86.7%) and fever (64%), followed by altered mental status (46%) and diarrhea (31%). Graves' disease was the most common underlying condition, and infection the most common precipitant. Thirty one percent of patients received treatment with four components; however morbidity and mortality were not clinically significant with those who did not. TS has a heterogeneous presentation with multisystemic involvement. The most common symptoms in this review were fever, tachycardia, diarrhea, and altered mental status. Further studies may be needed to best standardize the diagnosis and management of TS in children. Qualitative studies are needed to best assess the delay in diagnosis of hyperthyroidism and how this may impact prognosis in case patients were to develop TS. [ABSTRACT FROM AUTHOR]