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Background: The ventricular ectopic QRS interval (VEQSI) has been shown to identify structural heart disease and predict mortality. In arrhythmogenic right ventricular cardiomyopathy (ARVC), early diagnosis is difficult using current methods, and life-threatening arrhythmias are common and difficult to predict.Objective: The purpose of this study was to assess the utility of ventricular ectopic indices including VEQSI in ARVC diagnosis.Methods: We studied 70 patients with ARVC [30 with definite disease (age 47 ± 12 years; 60% male), 40 with incomplete disease expression (age 44 ± 18 years; 44% male)], 116 healthy controls (age 40 ± 15 years; 56% male), and 26 patients with normal heart right ventricular outflow tract (RVOT) ectopy (age 46 ± 17 years; 27% male). The duration of the broadest ventricular ectopic beat during 12-lead Holter monitoring was recorded as VEQSI max.Results: VEQSI max was associated with age and gender, but not with conducted QRS duration. Adjusted VEQSI max was greater in ARVC patients than in control groups. In healthy males (44.5 years), estimated VEQSI max was 163 ms (95% confidence interval [CI] 159-167 ms); in definite ARVC 212 ms (95% CI 206-217 ms); in incompletely expressed ARVC 204 ms (95% CI 199-210 ms); and in normal heart RVOT ectopy 171 ms (95% CI 165-178 ms). VEQSI max >180 ms had 98% sensitivity and specificity for diagnosis of ARVC (area under the curve 0.99, 95% CI 0.980-0.998). In our incompletely expressed ARVC patients, VEQSI max >180 ms identified 88% as affected.Conclusion: VEQSI max distinguishes ARVC patients, including those with incomplete disease expression, from healthy controls and patients with normal heart RVOT ectopy. [ABSTRACT FROM AUTHOR]

Background: We have described the use of femoral access followed by pull through of the lead to a pectoral position to circumvent difficulty in implanting a left ventricular (LV) lead by standard methods.Objective: The purpose of this study was to establish the effect of femoral implantation and pull through on the overall rate of success in percutaneous implantation of LV leads.Methods: We collected data prospectively in all attempts at LV lead implantation from the time that we envisioned the femoral pull-through approach.Results: In the 6 years to September 30, 2014, our group attempted to implant a new LV lead in 736 patients, including 16 who previously had failed attempts by other groups. A standard superior approach was successful in 726 of 731 patients (99.3%) in whom it was attempted. In 5 patients (0.7%), we failed to deliver a lead from a superior approach; in 5 of 16 patients, with previous failed attemtps (31%), we judged that those attempts had been exhaustive. In all 10 cases, LV lead placement was achieved from a femoral approach, with the procedure time being 186 ± 65 minutes. In the first case attempted, the pull through failed; the lead was tunneled to the pectoral generator. In 1 case, the coronary sinus was found to be occluded at the ostium: a transseptal approach was used with the subsequent pull through. No complication occurred. At 22.3 ± 18.5 months after the implantation, all systems implanted by a femoral approach continued to function.Conclusion: Used as an adjunct to standard methods, the femoral access and pull through method allows percutaneous LV lead placement in virtually all cases. [ABSTRACT FROM AUTHOR]

Abstract: Background: The prevalence of the Brugada-type ECG and its natural history are still unclear. The recently proposed diagnostic criteria have not been systematically applied in a European general population. Methods: We retrospectively analyzed ECGs and clinical data of 12,012 apparently healthy individuals who had undergone medical examination for occupational reasons. We sought follow-up information on the subjects with at least one ECG fulfilling the criteria for the Brugada pattern. Results: A Brugada-type ECG was found in 23 subjects (0.19%; 95% confidence interval 0.12–0.27%) on the first ECG recorded in that subject. In a further 8 cases, the Brugada pattern was present in a subsequent ECG, so that it was present at some time in 31 subjects (0.26%, 95% confidence interval 0.18–0.37%), all male. Only 2 patients displayed the classical type 1 Brugada ECG pattern. In 29 patients (94%), clinical information was available subsequent to the first Brugada pattern ECG recorded. The mean follow-up was 10.1±5.5 years. A sudden death occurred in a 27-year-old man with Brugada type 2 ECG pattern. No sudden death or symptomatic ventricular arrhythmia occurred among the other 28 patients. The annual rate of sudden death associated with Brugada ECG pattern was 0.3% per patient-year of follow-up. Conclusion: The Brugada-type ECG pattern, as currently defined, is uncommon in a young healthy male European population and confers a moderately elevated risk of sudden death. Our findings underscore the need to study risk predictors in asymptomatic patients with a Brugada-type ECG. [Copyright &y& Elsevier]

Abstract: Background: Existing guidelines for electrical cardioversion (ECV) of atrial arrhythmias suggest starting at a low energy setting on the grounds that shocks of high energy might damage the myocardium or trigger more serious arrhythmias. We hypothesised that more powerful shocks would exceed the upper limit of vulnerability for inducing ventricular fibrillation. The initial use of higher energy could therefore reduce arrhythmic complications. Methods: We collected data on the sequence of shocks delivered and the resulting changes in cardiac rhythm in 1896 patients who underwent transthoracic ECV. Rhythm strips derived from 200 consecutive ECV attempts were studied to verify the accuracy of the synchronisation of the shocks delivered. Results: In 2522 attempts at transthoracic ECV, 6398 shocks were delivered, 1243 in atrial flutter or atrial tachycardia, the others in AF. Ventricular fibrillation was significantly more common after shocks of <200 J (5 of 2959 vs. 0 of 3439 shocks, p <0.05, Fischer''s exact test). Conversion of atrial flutter or atrial tachycardia to AF was also more common at <200 J (20 of 930 shocks vs. 1 of 313 shocks at ≥200 J, p <0.05, χ 2 test). Sinus bradycardia or sinus arrest complicated 0.95% of cardioversion attempts, but none required emergency pacing. The incidence of bradycardia was not related to the energy used. Conclusions: Shocks of >200 J are associated with fewer tachyarrhythmic complications, and do not increase the risk of other serious complications. Bradycardia after cardioversion is very rarely of clinical importance. [Copyright &y& Elsevier]

: ObjectivesThe goal of this study was to identify the factors responsible for embolic complications of direct current (DC) cardioversion of atrial arrhythmias.: BackgroundDirect current cardioversion of atrial fibrillation (AF) carries a risk of thromboembolism, which is reduced, but not eliminated, by anticoagulation. The risk of embolism after conversion of atrial flutter is believed to be lower. No series to date has included enough patients receiving anticoagulants or enough patients with atrial flutter to estimate the risk in these groups.: MethodsWe reviewed the case records of 1,950 patients who underwent 2,639 attempts at DC cardioversion.: ResultsCardioversion was performed within two days of the apparent onset of the arrhythmia in 443 episodes, 352 without subsequent prolonged anticoagulation with one embolic complication. Cardioversion was preceded by warfarin therapy for ≥3 weeks in 1,932 instances. No embolic complication occurred in 779 attempts performed with an international normalized ratio (INR) of ≥2.5 (95% confidence limits 0% to 0.48%). Of 756 cases in which the INR was <2.5 or was not measured before conversion, nine were complicated by thromboembolism. Embolism was significantly more common at an INR of 1.5 to 2.4 than at an INR ≥2.5 (0.93% vs. 0%, p = 0.012). The incidence of embolism after conversion of atrial flutter or tachycardia was similar to that after cardioversion of AF (0.72% vs. 0.46%, p = NS).: ConclusionsThe INR should be ≥2.5 at the time of cardioversion if the duration of AF is uncertain or >2 days. Cardioversion of atrial flutter presents similar risks and requires similar anticoagulation. [Copyright &y& Elsevier]

Abstract: Background: Risk stratification after myocardial infarction (MI) remains expensive and disappointing. We designed a prognostic indicator using demographic information to select patients at risk of dying after MI. Method and results: We combined individual patient data from the placebo arms of EMIAT, CAMIAT, TRACE and DIAMOND-MI with LVEF ≤40% or ventricular arrhythmias (i.e. >10 ventricular premature beats/hour or a run of ventricular tachycardia). Risk factors for mortality beginning at day 45 post-MI up to 2 years were examined using Cox regression analysis. Risk scores were derived from the equation of a Cox regression model containing only significant variables. The prognostic index was the sum of the individual contribution from the risk factors. 2707 patients were pooled (age: 66 (23–92) years, 78.8% M) with 480 deaths at 2-years (44% arrhythmic and 35.6% non-arrhythmic cardiac deaths). Variables predicting mortality were age, sex, previous MI or angina, hypertension, diabetes, systolic blood pressure, heart rate, NYHA functional class and non-Q wave infarct on electrocardiogram. Distinct survival curves were obtained for 3 risk groups based on the median and inter-quartile range for the prognostic index. In the high-risk group, up to 40% of patients died (all-cause mortality), 19.1% died of arrhythmic and 18.2% died of non-arrhythmic cardiac causes at 2-years. Conclusion: In post-MI patients with LVEF ≤40% or frequent ventricular premature beats, the additional use of a simple prognostic indicator based on demographic information was able to provide clinically meaningful risk stratification on patients that were at high risk of dying and may be used to identify patients for prophylactic implantable cardioverter-defibrillator therapy. [Copyright &y& Elsevier]

Evaluates the potential prognostic value of the circadian variation of QT intervals in predicting sudden cardiac death in patients after myocardial infarction (MI). Dynamic changes in ventricular repolarization; Complementary prognostic information for risk stratification of patients after acute MI.