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This case report describes eight years of follow-up in a young adult with arrhythmogenic right ventricular dysplasia (ARVD). He presented with exertional palpitations, symmetric T wave inversions and possible epsilon waves in the right precordial leads on electrocardiogram (EKG), raising suspicion for ARVD. Transthoracic echocardiography revealed a dilated and excessively trabeculated right ventricle (RV), and cardiac magnetic resonance imaging showed fatty infiltration of the RV myocardium. These findings established the diagnosis of ARVD, and given his palpitations, a defibrillator was implanted. Over the next years, he had several episodes of ventricular tachycardia requiring therapy from his device, despite escalating medical therapy. He therefore underwent radiofrequency catheter ablation for the VT, which successfully controlled the VT.

Diana Aurora Bordejevic,1 Tudor Pârvănescu,2 Lucian Petrescu,1 Cristian Mornoș,1 Ioan Olariu,1 Simina Crișan,1 Cristina Văcărescu,1 Mihai Lazăr,1 Vlad Ioan Morariu,2 Ioana Mihaela Citu,2 Mirela Cleopatra Tomescu,2 Dragoș Cozma1 1Cardiology Department, Institute of Cardiovascular Diseases, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania; 2Cardiology Department, City Hospital, Victor Babes University of Medicine and Pharmacy, Timisoara, RomaniaCorrespondence: Tudor Pârvănescu; Ioana Mihaela CituVictor Babes University of Medicine and Pharmacy, 2nd Eftimie Murgu Square, Timișoara 300041, RomaniaTel +40 724 369729; +40 723 280 623Fax +40 256 220636Email tudorparvanescu@gmail.com; ioanamihaela2010@gmail.comBackground: Patients with acute myocardial infarction (AMI) are at high risk for left ventricular (LV) remodeling and heart failure. We aimed to study whether LV strains (S) and strain rates (SR) could predict cardiac remodeling in patients with AMI having a midrange or preserved LV ejection fraction (EF) following a percutaneous coronary intervention (PCI) within the first 12 hours from the onset of symptoms.Patients and Methods: This is a case-control observational study including patients admitted for their first AMI, either with ST-segment elevation (STEMI) or without ST elevation (NSTEMI), with an LVEF > 40% after a successful PCI. Echocardiography was repeated after 6 months, and the patients were divided into two groups, according to whether LV remodeling was determined on echocardiography.Results: Of the 253 AMI patients (mean 66 aged ± 13 years), including 185 males (73%), 61 (24%) presented signs of LV remodeling. In univariate logistic regression analysis, age, male sex, smoking history, hypertension, hypercholesterolemia, Killip class, renal function, peak creatine phosphokinase - MB level, 2- and 3-vessel coronary artery disease (CAD), and several echocardiographic parameters were significantly associated with LV remodeling (P< 0.05). In multivariate logistic regression analysis harmed (H) LS and SR, Killip class, 3-vessel CAD, and LV end-diastolic volume were outlined as independent predictors for LV remodeling. Receiver operating characteristic curve analyses showed that HLS and HLSR were the most powerful independent predictors for LV remodeling (P< 0.001), with an area under the curve (AUC) of 0.85 (sensitivity 83%; specificity 84%; p < 0.001) and 0.77 (sensitivity 93; specificity 61%; p < 0.001), respectively. The identified cut-off values for predictor variables were HLS< − 11%, and HLSR< − 0.65s− 1.Conclusion: We concluded that 2D-STE was the best method to evaluate LV remodeling in patients with AMI and midrange or preserved LVEF following myocardial revascularization by a PCI.Keywords: AMI, PCI, preserved LVEF, midrange LVEF, 2D speckle tracking echocardiography, LV remodeling

Purpose: Left ventricle (LV)-only pacing is non-inferior to biventricular pacing but permanent fusion pacing is needed to ensure cardiac resynchronization therapy (CRT) responsiveness. The role of systematic exercise testing (ET) in these patients has not been established. This study was designed to assess clinical and therapeutic implications (device programming/drugs) of systematic ET in patients requiring fusion-pacing CRT without an right ventricle (RV) lead. Methods: Consecutive patients with a right atrium/LV-only dual-chamber (DDD) pacing system were included. Prospective data were obtained: device interrogation, ET, and echocardiography at every 6-month follow-up visit. CRT assessment during ET included maximal heart rate, beat-to-beat echocardiography analysis of LV fusion pacing, LV loss of capture, and improvement in exercise capacity. If LV loss of capture or unsatisfactory LV fusion pacing occurred, reprogramming was individualized for each patient and ET redone. Results: A total of 55 patients (29 male) aged 62±11 years were included. During follow-up (39±18 months), a total of 235 ETs were performed, with mean exercise load 6.4±1.3 metabolic equivalents of task (118±35 W, maximal heart rate 119±17 beats/min). Twenty patients (36%) had inadequate pacing or loss of LV capture during ET, due to exceeding the maximum tracking rate (11%), chronotropic incompetence (7%), and LV pacing outside the fusion-pacing band (18%), caused by physiological shortening of the PR interval or exagerated LV preexcitation during maximum exercise. Post-ET CRT-device optimization included reprogramming of rate-adaptive atrioventricular interval (total decrease 23±8 ms), individualized programming of maximum tracking rate, or rate-response function. Drug optimization was performed in 32% of patients, and ET redone in 36%. Conclusion: In one of three ETs, an intervention in device and medication optimization was done to ensure a better outcome. Routine ET should be a standard approach to maximize fusion-pacing CRT response during follow-up.

This study assessed the value of heart rate recovery index (HRRI), a new parameter of an exercise test, as the predictor of response to cardiac resynchronization therapy (CRT). Methods: Consecutive patients receiving a CRT device were followed up after implantation and every 6 months. An effort test (ET) was quantified by minimum heart rate/maximum heart rate, as well as acceleration and deceleration times. HRRI was calculated as the ratio between acceleration and deceleration time (AT/DT) and compared to outcome. We used logistic regression to assess the predictive value of HRRI for responders and non-responders to CRT. The area under the curve (AUC) was computed to distinguish between positive and negative outcomes. Results: A total of 109 patients (74 men, mean age 63.3 &plusmn, 9.8 years) were analyzed, permanent long-term fusion CRT pacing was possible in 65 patients. Patients were assigned to two groups: responders and non-responders (98/11 patients). During a mean follow-up of 36 months, 545 ETs were performed. HRRI was significantly higher in responders versus non-responders (3.16 &plusmn, 2 vs. 1.4 &plusmn, 0.5, p &lt, 0.001). The optimal cutoff value for HRRI as a predictor of CRT response was 1.51 (area under the receiver operating characteristic (ROC) curve = 0.844). Responders had significant left-ventricular (LV) reverse remodeling (LV end-diastolic volume = 240 &plusmn, 90 mL vs. 217 &plusmn, 89 mL, p &lt, 0.001) and higher LV ejection fraction (26 &plusmn, 5.8% vs. 35 &plusmn, 8.7%, p &lt, 0.001). Conclusions: HRRI computation during routine ET is useful for the evaluation of responsiveness to CRT.

Background: The aim of our study was to assess the real life cardiac resynchronization therapy (CRT) fusion left ventricular (LV) only pacing in patients with normal AV conduction (NAVc) without right ventricular (RV) lead. Methods: Consecutive NAVc patients with CRT indication were implanted with a right atrium RA/LV DDD pacing system. Complete follow-up at 1, 3 and every 6 months thereafter included echocardiography and stress testing. Results: We analysed 55 patients (62 &plusmn, 11 years). All patients were responders with significant LV reverse remodelling (LV end-diastolic volume 193.7 &plusmn, 81 vs. 243.2 &plusmn, 82 mL at baseline, p &lt, 0.002) and increased LV ejection fraction (38 &plusmn, 7.9% vs. 27 &plusmn, 5.2% at baseline, p &lt, 0.001). Mitral regurgitation decreased in 38 patients (69%). During follow-up (35 &plusmn, 18 months), 20 patients (36%) needed reprogramming sensed/paced AV delay or maximum tracking rate (MTR) because of inadequate or lost LV capture at exercise test, personalized programming to achieve up to 100% fusion pacing was used in all patients. One patient developed Mobitz II second degree AV block and triple chamber CRT-P upgrade was performed, defibrillator upgrade was not necessary. Conclusions: LV only pacing CRT-P without RV lead showed a positive outcome in carefully selected patients.

Background and aim: To assess the safety of dabigatran in converting persistent atrial fibrillation (PAF) and atrial flutter (AFL) to sinus rhythm (SR) without transoesophageal echocardiography (TEE) evaluation. Methods: Consecutive patients with PAF or AFL were included between 2012 and 2015. Dabigatran was used for three weeks before and six months after cardioversion. Left atrium area (LAA) and left atrium volume (LAV) were assessed in all patients. Follow-up visits for major cardiac events occurred at 1, 3, 6, and 12 months. Results: The study included 82 patients (56 male, mean age 63.1 ± 10.4 years), of which 45 had PAF and 37 AFL. In patients with PAF, mean LAA was 30.3 ± 5.3 cm2 and LAV 114.4 ± 31.5 mL; in those with AFL mean LAA was 26.5 ± 4.2 cm2 and LAV 97 ± 24.9 mL at baseline. Forty-nine patients underwent uncomplicated electric cardioversion (38 with PAF and 11 with AFL), 11 patients were pharmacologically converted to SR (7 with PAF and 4 with AFL), and 22 patients with AFL underwent successful radiofrequency ablation. The mean CHA2DS2-VASc score was 2.96 ± 1.39 (score > 3, 58.6%). No major cardiac events occurred during the follow-up period of 19.4 ± 9.5 months. Conclusions: Safe cardioversion using dabigatran was achieved in this small group of patients without the need for TEE.