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The intramyocardial aspect of the left ventricular summit (LVS) can be mapped by advancing a unipolar guidewire into septal perforator branches of the anterior interventricular vein.The purpose of this study was to differentiate between ventricular premature depolarizations (VPDs) with a basal superior intraseptal (SIS) site of origin and those originating from the epicardial LVS using septal intramyocardial mapping.A retrospective cohort of patients with suspected LVS VPDs who underwent SIS unipolar mapping were reviewed for their clinical characteristics, mapping findings, and procedural outcomes.SIS mapping was successful in 44 of 47 cases (93.6%). VPD origin was SIS (defined as earliest activation from the intraseptal wire) in 20 patients (45.5%; median 23 ms pre-QRS). Procedure success was similar in patients with (group 1) and without (group 2) SIS origin (84% vs 87.5%, respectively; P = .842). Of the 10 patients in group 1 without presystolic endocardial activation, 5 (11.3% of all 44 cases) were successfully ablated from the left ventricular endocardium by using an anatomical approach targeting the endocardium closest to the earliest intraseptal activation site.A significant proportion (45.5%) of VPDs that appear to arise from the left ventricular summit can be demonstrated to have a SIS origin using septal perforator venous mapping. A significant minority (11.3%) of these can be ablated from the endocardium by targeting from an anatomic vantage point closest to the earliest intraseptal activation site. The described strategy may help differentiate true LVS VPDs from those with SIS sites of origin.

Objectives This study describes the use of septal coronary venous mapping to facilitate substrate characterization and ablation of intramural septal ventricular arrhythmia (VA). Background Intramural septal VA represents a challenge for substrate definition and catheter ablation. Methods Between 2015 and 2018, 12 patients with structural heart disease, recurrent VA, and suspected intramural septal substrate underwent a septal coronary venous procedure in which mapping was performed by advancement of a wire into the septal perforator branches of the anterior interventricular vein. A total of 5 patients with idiopathic VA were also included as control subjects to compare substrate characteristics. Results Patients were 63 ± 14 years of age, and 11 (92%) were men. Most patients with structural heart disease had nonischemic cardiomyopathy (83%). Six patients underwent ablation for premature ventricular contractions (PVC) and 6 for ventricular tachycardia. All patients had larger septal unipolar voltage abnormalities than bipolar voltage abnormalities (mean area 35.3 ± 16.8 cm2 vs. 10.7 ± 8.4 cm2, respectively; p = 0.01), Patients with idiopathic VA had normal voltage. Septal coronary venous mapping revealed low-voltage, fractionated, and multicomponent electrograms in sinus rhythm in all patients with substrate compared to that in patients with idiopathic VA (amplitude 0.9 ± 0.9 mV vs. 4.4 ± 3.7 mV, respectively; p = 0.007; and duration 147 ± 48 ms vs. 92 ± 10 ms, respectively; p = 0.03). Ablation targeted early activation, pace map match, and/or good entrainment sites from intraseptal recording. Over a mean follow-up of 339 ± 240 days, the PVC and insertable cardioverter-defibrillator therapies burden were significantly reduced (from a mean of 22 ± 11% to 4 ± 8%; p = 0.005; and a mean 5 ± 2 to 1 ± 1; p = 0.001, respectively). Most patients (80%) with idiopathic VA remained arrhythmia free. Conclusions In patients with suspected intramural septal VA, mapping of the septal coronary veins may be helpful to characterize the arrhythmia substrate, identify ablation targets, and guide endocardial ablation.

Objective: To compare safety outcomes in patients at high-risk of thromboembolic events (TE) that underwent atrial fibrillation (AF) ablation with pre-procedural transesophageal echocardiography (TEE) versus intracardiac echocardiogram (ICE). Background: TEE is routinely performed in selected patients undergoing AF ablation, particularly in non-paroxysmal AF and high-risk of TE. Method: Patients at high-risk for TE (CHA2DS2 -VASc >2 and non-paroxysmal AF) were selected from the Montefiore Medical Center prospective AF ablation registry. Rates of left atrial and/or left atrial appendage (LA/LAA) thrombi or cerebrovascular accidents within 48 hours of the procedure and at 30 days follow-up were compared between patients that had LA/LAA screening with TEE vs. ICE. Results: A total of 231 patients [38 (16.5%) warfarin, 120 (59.1%) apixaban, 65 (28.1%) rivaroxaban, and 8 (3.5%) dabigatran] were enrolled. There were no differences between groups regarding baseline demographics. All patients had non-paroxysmal AF and the mean CHA2DS2-VASc was 4.0 {plus minus} 1.1 (TEE: 4.1 +/- 1.0; ICE: 3.9 +/- 1.1, p = 0.42). Forty patients (17.3%) had TEE prior to AF ablation. Of these patients, 14 (35%) had "smoke" and none (0%) had LA/LAA thrombus. In the ICE group (191 patients, 83%), none (0%) had LA/LAA thrombus or "smoke". There were no TE within 48 hours of AF ablation in either group. There was one TE (stroke) in the ICE group (p=0.32) during follow up. Conclusion: TEE may not be necessary when performing AF ablation in patients at high-risk of TE if appropriate peri-procedural anticoagulation and detailed LA/LAA evaluation with ICE is implemented.

The optimal ablation strategy for non-paroxysmal atrial fibrillation remains controversial. Non-PV triggers have been shown to have a major arrhythmogenic role in these patients. Common sources of non-PV triggers are: posterior wall, left atrial appendage, superior vena cava, coronary sinus, vein of Marshall, interatrial septum, crista terminalis/Eustachian ridge, and mitral and tricuspid valve annuli. These sites are targeted empirically in selected cases or if significant ectopy is noted (with or without a drug challenge), to improve outcomes in patients with non-paroxysmal atrial fibrillation. This article focuses on summarizing the current evidence and the approach to mapping and ablation of these frequent non-PV trigger sites.

Twelve-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge.The purpose of this study was to develop ECG criteria for accurate localization of LV PAP VAs using lead VConsecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007 to 2018 were reviewed (study group). The QRS morphology in lead VOne hundred eleven patients with LV PAP VAs (mean age 54 ± 16 years; 65% men) were identified, including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n = 21), outflow tract (n = 36), ostium (n = 37), inferobasal segment (n = 12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in lead VVAs originating from the LV PAPs manifest unique QRS morphologies in lead V

Background: Prone position is a valuable treatment strategy in acute respiratory distress syndrome (ARDS) and is frequently used in surgical scenarios. Nonetheless, prone position may hinder proper acquisition and interpretation of the 12-lead electrocardiogram (ECG) as there is a sparsity of data regarding standardization of lead position and interpretation. Objective: We aimed to analyze and compare ECGs in the supine and prone positions to provide guidance for adequate interpretation and clinical utility of the ECG in prone position. Methods: This was a multicenter prospective cohort study in which ECGs in the prone and supine position were compared, including patients with COVID-19 infection and healthy controls. The precordial leads for the prone ECGs were placed in the following fashion: V1 in the right paraspinal region at the level of the T7 vertebra, V2 in the left paraspinal region at the level of the T7 vertebra, V4 in the mid-scapular region at the level of the T8 vertebra (approximately bellow the tip of the scapula), V3 halfway between V3 and V4, V5 at the posterior axillary line at the level of the T8 vertebra, and V6 at the mid-axillary line at the level of T8 vertebra - same position as the V6 in the supine position. Results: A total of 45 patients with COVID-19 infection were compared with 40 healthy volunteers (48% of the patients were female, the mean age in the entire cohort was 48.8 years, and the mean BMI was 27.9). The mean heart rate, PR interval, QRS duration, QT and QTc interval, and QRS axis in the frontal plane were found to positively correlate in supine and prone ECGs. The main difference found was no correlation of the QRS amplitude between supine and prone ECGs in leads V1, V2, V3, and V4;but there was positive correlation in leads V5 and V6. Prominent Q waves were present in the anteroseptal leads (V1-V3) in the prone posterior position. In addition, T-wave inversions or flattening were observed in leads V1 and V2 were present in a majority of patients in the prone posterior position. Conclusion: ECGs performed in the prone position are an acceptable alternative to supine ECGs. Special attention and review of prior supine ECGs may be necessary for precise interpretation of the anteroseptal precordial leads which may be misleading (i.e, septal infarct).

Objective We carried out a meta-analysis summarizing the efficacy and safety of direct factor Xa inhibitor (DXI) in patients receiving guideline-based antiplatelet therapy (GBAT) after an acute coronary syndrome. Background Randomized-controlled trials have shown that the addition of a DXI to GBAT after acute coronary syndrome can reduce ischemic events, the trade-off being an increase in major bleeding complications. Methods PubMed, Central, Embase, The Cochrane Register, Google Scholar databases, and the scientific session abstracts were searched for eligible randomized trials from 1 January 1990 through 31 December 2016. Results Nine randomized-controlled trials were included in this meta-analysis enrolling a total of 45651 patients. There was a significant reduction in major adverse cardiovascular events with DXIs/GBAT compared with GBAT alone [odds ratio (OR): 0.88; 95% confidence interval (CI): 0.82-0.94, number needed to treat=52]. There were also significant reductions in two individual components of major adverse cardiovascular events: myocardial infarction (OR: 0.89; 95% CI: 0.81-0.98) and stent thrombosis (OR: 0.73; 95% CI: 0.59-0.90), favoring the DXI/GBAT group. There was an increased risk of major bleeding (OR: 2.51; 95% CI: 1.82-3.46) and intracranial hemorrhage (OR: 3.47; 95% CI: 1.76-6.86) compared with GBAT. Conclusion In acute coronary syndromes, the addition of a DXI to GBAT results in a significant reduction of major adverse cardiovascular events, myocardial infarction, and stent thrombosis, offset by an increased risk of bleeding.

BackgroundTo study trends in the clinical presentation, electrocardiograms, and diagnostic imaging in patients with pulmonary embolism presenting as ST segment elevation.MethodsWe performed a systematic literature search for all reported cases of pulmonary embolism mimicking ST-elevation myocardial infarction. Pre-specified data such as clinical presentation, electrocardiogram changes, transthoracic echocardiographic findings, cardiac biomarkers, diagnostic imaging, therapy, and outcomes were collected.ResultsWe identified a total of 34 case reports. There were 23 males. Mean age of the population was 56.5 ± 15.5 years. Patients presented with dyspnea (76.4%), chest pain (63.6%), and tachycardia (71.4%). All patients presented with ST-elevations, with the most common location being in the anterior-septal distribution, lead V3 (74%), V2 (71%), V1 (62%) and V4 (47%). ST-segment elevations in the inferior distribution were present in lead II (12%), III (18%), and aVF (21%). Presentation was least likely in the lateral distribution. Troponin was elevated in 78.9% of cases. Right ventricular strain was the most common echocardiographic finding. Over 80% of patients had findings consistent with elevated right ventricular pressure, with 50% reported RV dilatation and 20% RV hypokinesis. The most commonly used imaging modality was contrast-enhanced pulmonary angiography. There was a greater incidence of bilateral compared to unilateral pulmonary emboli (72.4% vs. 10%). About 65% patients received anticoagulation and 36.3% were treated with thrombolytics. Forty-six percent of patients required intensive care and 18.7% intubation. Overall mortality was 25.8%.ConclusionsA review of the literature reveals that in patients presenting with pulmonary embolism, electrocardiogram findings of ST-segment elevations will occur predominantly in the anterior-septal distribution.

Background Studies have shown that chronic total occlusion ( CTO ) in a noninfarct‐related artery in patients with ST‐segment–elevation myocardial infarction is linked to increased mortality. It remains unclear whether staged revascularization of a noninfarct‐related artery CTO in patients with ST‐segment–elevation myocardial infarction translates to improved outcomes. We performed a meta‐analysis to compare outcomes between patients presenting with ST‐segment–elevation myocardial infarction with concurrent CTO who underwent percutaneous coronary intervention of noninfarct‐related artery CTO versus those who did not. Method and Results We conducted an electronic database search of all published data. The primary end point was major adverse cardiovascular events. Secondary end points were all‐cause mortality, cardiovascular mortality, myocardial infarction, repeat revascularization with either percutaneous coronary intervention or coronary artery bypass grafting, stroke, and heart failure readmission. Odds ratios ( ORs ) and 95% confidence intervals ( CIs ) were computed. Random effects model was used and heterogeneity was considered if I 2 >25. Six studies (n=1253 patients) were included in the analysis. There was a significant difference in major adverse cardiovascular events ( OR , 0.54; 95% CI , 0.32–0.91), cardiovascular mortality ( OR , 0.43; 95% CI , 0.20–0.95), and heart failure readmissions ( OR , 0.57; 95% CI , 0.36–0.89), favoring the patients in the CTO percutaneous coronary intervention group. No significant differences were observed between the 2 groups for all‐cause mortality ( OR , 0.47; 95% CI , 0.22–1.00), myocardial infarction ( OR , 0.78; 95% CI , 0.41–1.46), repeat revascularization ( OR , 1.13; 95% CI , 0.56–2.27), and stroke ( OR , 0.51; 95% CI , 0.20–1.33). Conclusions In this meta‐analysis, CTO percutaneous coronary intervention of the noninfarct‐related artery in patients presenting with ST‐segment–elevation myocardial infarction was associated with a significant reduction in major adverse cardiovascular events, cardiovascular mortality, and heart failure readmissions.

Background— Nonvalvular atrial fibrillation is the most common arrhythmia. Patients with nonvalvular atrial fibrillation are at increased risk of stroke; therefore, we evaluated the efficacy and safety of different approaches to prevent this major complication. Methods and Results— We conducted electronic database searches of phase III randomized controlled trials. The groups were novel oral anticoagulants, Watchman left atrial appendage occlusion device (DEVICE), and warfarin. Efficacy outcomes were stroke or systemic embolism, and all-cause mortality. Safety outcome was major bleeding and procedure-related complications. A subgroup analysis of the elderly population was done. We used random-effects model to compare pooled outcomes and tested for heterogeneity. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed for each outcome. Seven randomized controlled trials (n=73 978) were included. There was a significant difference favoring novel oral anticoagulants for systemic embolism (OR, 0.84; 95% CI, 0.72–0.97; P =0.01), all-cause mortality (OR, 0.89; 95% CI, 0.84–0.94; P P =0.026) compared with warfarin. No difference was seen between DEVICE and warfarin for efficacy end points; however, DEVICE had more complications (OR, 1.85; 95% CI, 1.14–3.01; P =0.012). In the elderly (6 randomized controlled trials, n=30 699), systemic embolism was favored with novel oral anticoagulants over warfarin (OR, 0.77; 95% CI, 0.68–0.87; P ≤0.001). No evidence of significant publication bias was found. Conclusions— Novel oral anticoagulants is superior to warfarin for stroke prevention in nonvalvular atrial fibrillation. This benefit was also observed in the elderly population. DEVICE is a reasonable noninferior alternative to warfarin for stroke prevention, but cautious use is essential given safety concerns.

See Article by Cho et al Atrial fibrillation (AF) is a cause of significant morbidity and mortality, and the available therapies have evolved significantly during the past several decades. In particular, catheter ablation has developed into an increasingly safe and effective treatment option for controlling symptomatic AF. Multiple studies have shown that AF ablation improves quality of life in patients with symptomatic AF, including those with heart failure.1,2 AF ablation can also lead to improved outcomes in patients with heart failure,3 and the results of the CASTLE-AF trial (Catheter Ablation Versus Standard Conventional Treatment in Patients With Left Ventricular Dysfunction and Atrial Fibrillation) recently reported at the European Society of Cardiology Congress showed a mortality benefit in these patients, reporting a significantly lower incidence of death or hospitalization for heart failure in the catheter ablation group compared with optimal medical therapy (28.5% versus 44.6%; P =0.007; http://www.acc.org/latest-in-cardiology/clinical-trials/2017/08/26/01/51/castle-af). Nonetheless, ablation of AF certainly has limitations and is not as effective in patients with persistent AF. Antiarrhythmic drugs remain mainstays of symptomatic AF management, often as an alternative or adjunctive therapy to ablation. Dofetilide is a Vaughan Williams class III antiarrhythmic agent, which blocks the rapid component of the delayed rectifier potassium current ( I Kr): this increases the action potential duration primarily because of delayed repolarization in both atrial and ventricular myocardium. This prolongs the QT but also increases the atrial refractory period and, therefore, terminates reentrant tachyarrhythmias and prevents their reinduction (Tikosyn [dofetilide] capsules package insert; Pfizer, Inc). Dofetilide is important among the antiarrhythmics for multiple reasons. It is one of the most effective antiarrhythmic medications, with ≈60% likelihood of maintaining sinus rhythm for a year4 …

Supplemental Digital Content is available in the text, Background: The benefit of ≤6-month compared with 12-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement remains controversial. We performed a meta-analysis and meta-regression of ≤6-month versus 12-month DAPT in patients undergoing PCI with DES placement. Methods: We conducted electronic database searches of randomized controlled trials (RCTs) comparing DAPT durations after DES placement. For studies with longer follow-up, outcomes at 12 months were identified. Odds ratios and 95% confidence intervals were computed with the Mantel–Haenszel method. Fixed-effect models were used; if heterogeneity (I2) > 40 was identified, effects were obtained with random models. Results: Nine RCTs were included with total n = 19,224 patients. No significant differences were observed between ≤6-month compared with 12-month DAPT in all-cause mortality (OR 0.87; 95% confidence interval (CI): 0.69–1.11), cardiovascular (CV) mortality (OR 0.89; 95% CI: 0.66–1.21), non-CV mortality (OR 0.85; 95% 0.58–1.24), myocardial infarction (OR 1.10; 95% CI: 0.89–1.37), stroke (OR 0.97; 95% CI: 0.67–1.42), stent thrombosis (ST) (OR 1.37; 95% CI: 0.89–2.10), and target vessel revascularization (OR 0.95; 95% CI: 0.77–1.18). No significant difference in major bleeding (OR 0.72; 95% CI: 0.49–1.05) was observed, though the all-bleeding event rate was significantly lower in the ≤6-month DAPT group (OR 0.76; 95% CI: 0.59–0.96). In the meta-regression analysis, a significant association between bleeding events and non-CV mortality with 12-month DAPT was found, as well as between ST and mortality in addition to MI with ≤6-month DAPT. Conclusion: DAPT for ≤6 months is associated with similar mortality and ischemic outcomes but less bleeding events compared with 12-month DAPT after PCI with DES.

Long-term care facilities (LTCFs) are essential components of healthcare delivery to many patients. Unfortunately, LTCFs are also recognized as “reservoirs of antibiotic resistance” [1]. In the past 3 decades numerous outbreaks of multidrug-resistant gram-negative and gram-positive organisms have been described in LTCFs [2, 3]. The spread of antibiotic-resistant pathogens transmitted from LTCFs to wider healthcare delivery systems that serve a large region is now appreciated as a major challenge in the design of effective infection control and antibiotic utilization strategies in the care of the elderly [4]. Among gram-negative bacteria, Escherichia coli– and Klebsiella pneumoniae–producing extended-spectrum β-lactamases (ESBLs), as well as carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa, are the most significant threats in this setting [5–10]. Especially concerning has been the national and global spread of carbapenem-resistant K. pneumoniae harboring blaKPC, belonging to sequence type (ST) 258 [7, 11, 12]. Although not as well documented as in adult patients, antibiotic-resistant gram-negative organisms are present in healthcare settings serving children, including pediatric LTCFs [13–16]. In a surveillance study examining the antibiotic susceptibility of normal flora of children residing in an LTCF in Cleveland, Ohio, nearly 40% of subjects were colonized with resistant bacteria, and >60% of organisms were resistant to >2 antibiotics tested [14]. Invasive devices were found to be a significant risk factor for colonization by resistant gram-negative bacteria [14]. Little is known about the spread of blaKPC harboring strains or whether the same risk factors are present in children and adults. Unfortunately, the clinical detection of blaKPC is undermined by heterogeneous expression of carbapenem resistance. Ertapenem minimum inhibitory concentrations (MICs) are the most sensitive for detection of K. pneumoniae carbapenemase (KPC) but may lack specificity, and therefore additional phenotypic tests (ie, modified Hodge test and boronic acid disk) have been devised [17–20]. MICs of carbapenems are dependent not only on the presence and the level of expression of blaKPC but also on changes in outer membrane proteins [7, 21, 22]. In this study we describe the “silent dissemination” and earliest report of KPC-producing K. pneumoniae in an LTCF caring for children and young adults with neurodevelopmental impairments. As part of a study conducted in 2004 to determine the risk of stool colonization by extended-spectrum cephalosporin-resistant gram-negative bacteria, we identified 12 strains of K. pneumoniae that exhibited nonsusceptibility to extended-spectrum cephalosporins. Reassessment of carbapenem MICs using recently revised breakpoints uncovered carbapenem resistance. Genetic analysis revealed that a single sequence type not previously reported to contain blaKPC had disseminated as early as 2004 in Northeast Ohio in this LTCF. Introduction of blaKPC into our region occurred before the description of the spread of ST 258, recognition of Tn4401, the KQ element, or the mobile genetic elements harboring this carbapenemase gene [23, 24].

We report the emergence of a novel VIM variant (VIM-24) in a Klebsiella pneumoniae isolate in Colombia. The isolate displays MICs for carbapenems below the resistance breakpoints, posing a real challenge for its detection. The bla VIM-24 gene was located within a class 1 integron carried on a large plasmid. Further studies are needed to clarify its epidemiological and clinical impact.