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Objective Structured electrocardiography (ECG) analysis is used to screen athletes for high-risk cardiovascular conditions (HRCC) to prevent sudden cardiac death. ECG criteria have been specified and recommended for use in young athletes ≤ 35 years. However, it is unclear whether these ECG criteria can also be applied to master athletes >35 years. Aim The purpose of this study was to test whether the existing ECG criteria for detecting HRCC in young athletes can be applied to master athletes. Methods We conducted a cross-sectional study among athletes >35 years screened for HRCC between 2006 and 2010. We performed a blinded retrospective analysis of master athletes’ ECGs, separately applying European Society of Cardiology (ESC)-2005, Seattle, and International criteria. HRCC were defined using recommendations from the international cardiac societies American Heart Association and American College of Cardiology, and ESC, based on ECG screening and cardiovascular evaluation (CVE). Results We included 2578 master athletes in the study, of whom 494 had initial screening abnormalities mandating CVE. Atrial enlargement (109, 4.1%) and left ventricular hypertrophy (98, 3.8%) were the most common ECG abnormalities found using the ESC-2005 or Seattle criteria. Applying the International criteria, ST-segment deviation (66, 2.6%), and T-wave inversion (58, 2.2%) were most frequent. The ESC-2005 criteria detected more HRCC (46, 1.8%) compared with the Seattle (36, 1.4%) and International criteria (33, 1.3%). The most frequently detected HRCC was coronary artery disease (24, 0.9%). Conclusion ECG criteria recommended for use in young athletes can be applied to master athletes’ ECGs to detect HRCC. The ESC-2005 criteria had the highest sensitivity for detecting HRCC among master athletes.

We present the case of a patient with chest pain, palpitations, atrial fibrillation, left bundle branch block (LBBB) and occasional early narrow QRS complexes. An intracardiac study revealed rate-dependent LBBB with additional hidden rate-dependent slowing in the contralateral bundle branch, resulting in normalization of the early conducted QRS complexes. (c) 2020 Elsevier Inc. All rights reserved.

The recognition of the presence, location, and properties of unusual accessory pathways for atrioventricular conduction is an exciting, but frequently a difficult, challenge for the clinical cardiac arrhythmologist. In this third part of our series of reviews, we discuss the different steps required to come to the correct diagnosis and management decision in patients with nodofascicular, nodoventricular, and fasciculo-ventricular pathways. We also discuss the concealed accessory atrioventricular pathways with the properties of decremental retrograde conduction that are associated with the so-called permanent form of junctional reciprocating tachycardia. Careful analysis of the 12-lead electrocardiogram during sinus rhythm and tachycardias should always precede the investigation in the catheterization room. When using programmed electrical stimulation of the heart from different intracardiac locations, combined with activation mapping, it should be possible to localize both the proximal and distal ends of the accessory connections. This, in turn, should then permit the determination of their electrophysiologic properties, providing the answer to the question "are they incorporated in a tachycardia circuit?". It is this information that is essential for decision-making with regard to the need for catheter ablation, and if necessary, its appropriate site.

Background Sudden cardiac arrest (SCA) during sports can be the first symptom of yet undetected cardiovascular conditions. Immediate chest compressions and early defibrillation offer SCA victims the best chance of survival, which requires prompt bystander cardiopulmonary resuscitation (CPR). Aims To determine the effect of rapid bystander CPR to SCA during sports by searching for and analyzing videos of these SCA/SCD events from the internet. Methods We searched images.google.com, video.google.com, and YouTube.com, and included any camera-witnessed non-traumatic SCA during sports. The rapidity of starting bystander chest compressions and defibrillation was classified as < 3, 3–5, or > 5 min. Results We identified and included 29 victims of average age 27.6 ± 8.5 years. Twenty-eight were males, 23 performed at an elite level, and 18 participated in soccer. Bystander CPR < 3 min (7/29) or 3–5 min (1/29) and defibrillation < 3 min was associated with 100% survival. Not performing chest compressions and defibrillation was associated with death (14/29), and > 5 min delay of intervention with worse outcome (death 4/29, severe neurologic dysfunction 1/29). Conclusions Analysis of internet videos showed that immediate bystander CPR to non-traumatic SCA during sports was associated with improved survival. This suggests that immediate chest compressions and early defibrillation are crucially important in SCA during sport, as they are in other settings. Optimal use of both will most likely result in survival. Most videos showing recent events did not show an improvement in the proportion of athletes who received early resuscitation, suggesting that the problem of cardiac arrest during sports activity is poorly recognized.

Background: The randomized DAPA trial (Defibrillator After Primary Angioplasty) aimed to evaluate the survival benefit of prophylactic implantable cardioverter defibrillator (ICD) implantation in early selected high-risk patients after primary percutaneous coronary intervention for ST-segment–elevation myocardial infarction. Methods: A randomized, multicenter, controlled trial compared ICD versus conventional medical therapy in high-risk patients with primary percutaneous coronary intervention, based on one of the following factors: left ventricular ejection fraction Results: A total of 266 patients, 78.2% males, with a mean age of 60.8±11.3 years, were enrolled. One hundred thirty-one patients were randomized to the ICD arm and 135 patients to the control arm. All-cause mortality was significant lower in the ICD group (5% versus 13%, hazard ratio, 0.37 [95% CI, 0.15–0.95]) after 3 years follow-up. Appropriate ICD therapy occurred in 9 patients at 3 years follow-up (5 within the first 8 months after implantation). After a median long-term follow-up of 9 years (interquartile range, 3–11), total mortality (18% versus 38%; hazard ratio, 0.58 [95% CI, 0.37–0.91]), and cardiac mortality (hazard ratio, 0.52 [95% CI, 0.28–0.99]) was significant lower in the ICD group. Noncardiac death was not significantly different between groups. Left ventricular ejection fraction increased ≥10% in 46.5% of the patients during follow-up, and the extent of improvement was similar in both study groups. Conclusions: In this prematurely terminated and thus underpowered randomized trial, early prophylactic ICD implantation demonstrated lower total and cardiac mortality in patients with high-risk ST-segment–elevation myocardial infarction treated with primary percutaneous coronary intervention. Registration: URL: https://www.trialregister.nl ; Unique identifier: Trial NL74 (NTR105).

Background Sudden cardiac arrest (SCA) during sports can be the first symptom of yet undetected cardiovascular conditions. Immediate chest compressions and early defibrillation offer SCA victims the best chance of survival, which requires prompt bystander response.Aims To determine the effect of rapid bystander response to SCA during sports by searching for and analyzing videos of these SCA/SCD events from the internet.Methods We searched images.google.com, video.google.com and YouTube.com, and included any camera-witnessed non-traumatic SCA in athletes and other sports participants at any sports facility. The rapidity of starting bystander chest compressions and defibrillation was classified as 5 minutes. The year SCA occurred was allocated to 1990-2009, 2010-2014 or 2015 onwards, compatible with the current guidelines.ResultsWe identified and included 28 victims of average age 27.9 years (SD=9.8); 27 were males, 22 elite athletes, and 17 participated in soccer. Bystander response 5 minutes delay of intervention with worse outcome (death 4/28, severe neurologic dysfunction 1/28). Survival was highest between 2010-2014 (71.4%).ConclusionsAnalysis of internet videos showed that immediate bystander response to non-traumatic SCA during sports was associated with improved survival. This suggests that immediate chest compressions and early defibrillation are crucially important in SCA during sport, as they are in other settings. Optimal use of both will most likely result in survival. The observed bystander responses to SCA during sports do not show awareness of current guidelines.

We present a monomorphic ventricular tachycardia (VT) in a patient with a history of myocardial infarction and syncope. The ECG shows an acceleration-dependent peri-infarction block inferiorly. The authors suggest that this old (but forgotten) ECG-entity may serve as a marker for assessing the risk of post-infarction VT. (c) 2020 Elsevier Inc. All rights reserved.

The ECGs in Figure 1A and 1B are from a 72-year-old patient with a history of chronic recurrent sustained ventricular tachycardia (VT) and an inferior nonrevascularized ST-elevation myocardial infarction 10 years before his current admission in our hospital after a new episode of VT (Figure 1A). Because of hypotension and poor peripheral perfusion, the patient underwent a synchronized DC shock cardioversion. His left ventricle was remodeled with a current left ventricular (LV) ejection fraction of 30% and an inferior wall LV aneurysm. The ECG after cardioversion (Figure 1B) shows sinus bradycardia (the patient was chronically on amiodarone and betablockers), abnormal Q waves in leads II, III, and aVF, prolonged QT interval with prominent U waves (amiodarone), and an increased QRS voltage in lead V5 (35 mm). Figure 1. 12-lead ECG during VT and sinus rhythm. A , ECG of the broad QRS VT documented at admission. B , ECG in sinus rhythm after electric cardioversion. The high-pass filter was set at 0.05 Hz and the low-pass at 200 Hz. The morphology of the VT suggests an exit point at the left ventricular basal inferoposterior region. Is there anything unusual in the ECG during sinus …

Introduction Sudden cardiac arrest (SCA) in athletes is an unexpected life-threatening event, which is often not recognised early and cardiopulmonary resuscitation (CPR) is not always initiated immediately. We describe key features to rapidly recognise non-traumatic SCA in athletes during sports activity. Methods We reviewed videos and images of athletes suffering from non-traumatic SCA during sports activity. We searched Google images, Google videos and YouTube.com using the keywords ‘sudden cardiac death athlete’ and ‘resuscitation athlete’. We analysed (1) the athlete’s performance before syncope, (2) the athlete’s performance at the start of syncope, (3) the position of the body, and (4) the athlete’s facial expressions before CPR. We analysed our data by describing these four features to answer our research question. Results We analysed the sequence of events in six well-known soccer players in whom a camera-witnessed non-traumatic SCA occurred during their athletic activity. All six athletes showed no changes before syncope. Four became unstable while standing and unexpectedly collapsed falling on their back. Two suddenly ‘dropped dead’ and fell face down. All six had their eyes wide open with a fixed gaze and fixed pupils. Conclusions Sudden unexpected loss of consciousness in an athlete in action and a fixed gaze eye position are key features of SCA. Immediate cardiac massage should follow. The described features to immediately recognise SCA in athletes during sports activity should be taught to everyone involved in athletic activity leading to earlier recognition of SCA followed by earlier CPR.

Computerized interpretation of the electrocardiogram (CIE) was introduced to improve the correct interpretation of the electrocardiogram (ECG), facilitating health care decision making and reducing costs. Worldwide, millions of ECGs are recorded annually, with the majority automatically analyzed, followed by an immediate interpretation. Limitations in the diagnostic accuracy of CIE were soon recognized and still persist, despite ongoing improvement in ECG algorithms. Unfortunately, inexperienced physicians ordering the ECG may fail to recognize interpretation mistakes and accept the automated diagnosis without criticism. Clinical mismanagement may result, with the risk of exposing patients to useless investigations or potentially dangerous treatment. Consequently, CIE over-reading and confirmation by an experienced ECG reader are essential and are repeatedly recommended in published reports. Implementation of new ECG knowledge is also important. The current status of automated ECG interpretation is reviewed, with suggestions for improvement.

The term Mahaim conduction is conventionally used to describe decrementally conducting connections between the right atrium or the AV node and the right ventricle in or close to the right bundle branch. Although such pathways are rare, their unique properties make their diagnosis and treatment cumbersome. In this article we review the published evidence, and discuss the electrocardiographic and electrophysiological characteristics as well as the anatomy and origin of these fibres.

We present two cases with unexpected long sinus arrest resulting in syncope. There were no signs or symptoms of either sick sinus syndrome or increased vagal tone before the occurrence of pauses in these patients. The fact that these patients remained asymptomatic for quite long shows striking resemblance to paroxysmal sub-AV nodal block.We would therefore prefer to classify these cases as paroxysmal sinus arrest as a possible manifestation of the sick sinus syndrome. (C) 2019 Elsevier Inc. All rights reserved.

The famous quotation of Winston Churchill, made in his radio broadcast of 1939 regarding Russia's next move, specifically "A riddle wrapped up in a mystery, inside an enigma," perfectly fits the current understanding of unusual accessory atrioventricular pathways, including the variants producing ventricular pre-excitation. It was many decades after their original descriptions that we came better to begin to understand most of their structure-function relationships. Their mysterious pathophysiology was sometimes unveiled after invasive treatments, such as surgical ablation of the atrioventricular conduction axis instead of the accessory pathway itself. Speculations made on this basis have largely been validated by subsequent clinical experience. Most of the names suggested for description of the pathways have stood well the test of time. For some of them, however, this is not the case, with the initial names becoming confusing. In a series of reviews, we re-visit those accessory pathways producing ventricular pre-excitation other than classical Wolff-Parkinson-White syndrome. To set the scene, in this initial review, we describe the development and anatomy of the normal atrioventricular conduction axis, along with the insulating tissues of the atrioventricular junctions. We have sought to illustrate our explanations by using virtual dissection of computerized tomographic datasets, since they retain the intact heart within the setting of the body. These images illustrate well the value of attitudinally appropriate terminology. Thereafter, we discuss the electrophysiological manifestations of the abnormal anatomical pathways which provide the potential for both accessory atrioventricular and intraventricular conduction.

Background The differential diagnosis of a supraventricular tachycardia (SVT) is accomplished using a number of pacing maneuvers. The incidence and mechanism of a single ventricular premature beat (VPB) on initiation and termination of tachycardia were evaluated during programmed electrical stimulation (PES) of the heart in patients with the two most common regular SVTs: atrioventricular re-entrant tachycardia (AVNRT) and orthodromic atrioventricular tachycardia (AVRT). Methods Three hundred and thirty-seven consecutive patients aged above 18 years with an inducible sustained AVNRT or AVRT were prospectively enrolled. Patients with more than one tachyarrhythmia mechanism were excluded. Two hundred and seventeen patients (64.4%) had typical slow/fast AVNRT and 120 (35.6%) had an orthodromic AVRT using a rapidly conducting accessory pathway for V-A conduction. In this cross-sectional study, we specifically report the analysis of tachycardia induction and termination by a single VPB. Results Tachycardia induction with a single VPB during sinus rhythm was seen in 7 of 120 AVRT and in only one of the 217 patients with AVNRT, (5.8% vs. 0.3%, p

A Novel Familial Cardiac Arrhythmia Syndrome Five families were identified with a novel autosomal dominant syndrome characterized by marked ST-segment depression, the development of atrial fibrilla...

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Aims The clinical characteristics of atrial tachycardias (AT) ablated from the non-coronary aortic sinus (NCS) are thus far described only in small series. We aimed to outline, in a large cohort of patients, the clinical, electrocardiographic, electrophysiological characteristics of this tachycardia. Methods and results We analysed data pertaining to clinical, electrocardiographic, and electrophysiological characteristics of 43 consecutive patients from an overall cohort of 441 with AT who were successfully ablated from the NCS. The tachycardias ablated from the NCS were paroxysmal (98%) and adenosine sensitive (35/35). The patients were aged 54.6 ± 12.4 years, showing female preponderance (74%). No P wave pattern was predictive of the location of ablation. Electrophysiological findings suggested a possible micro-reentrant mechanism. During tachycardia, atrial electrograms recorded in the NCS preceded the A in the His region by 10.9 ± 7.4 ms. Fractionated atrial electrograms were noted at the site of ablation in 42 patients during the tachycardia. Radiofrequency ablation terminated the tachycardia within 5 s in 88%, with thermal automaticity seen only in 3 patients. The site of ablation at the base of the NCS was adjacent to the presumed site of the retroaortic node, a remnant of the initial atrio-ventricular canal musculature. Conclusions AT ablated from the NCS is a paroxysmal arrhythmia in middle-aged women, with distinct electrocardiographic and electrophysiological characteristics. We suspect the retroaortic node to be involved in the tachycardia circuit.

Aims: Establishing epicardial flow with percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is necessary but not sufficient to ensure nutritive myocardial reperfusion. We evaluated whether adding myocardial blush grade (MBG) and quantitative reperfusion ventricular arrhythmia “bursts” (VABs) surrogates provide a more informative biosignature of optimal reperfusion in patients with Thrombolysis in Myocardial Infarction (TIMI) 3 flow and ST-segment recovery (STR). Methods and results: Anterior STEMI patients with final TIMI 3 flow had protocol-blinded analyses of simultaneous MBG, continuous 12-lead electrocardiogram (ECG) STR, Holter VABs, and day 5–14 SPECT imaging infarct size (IS) assessments. Over 20 million cardiac cycles from >4500 h of continuous ECG monitoring in subjects with STR were obtained. IS and clinical outcomes were examined in patients stratified by MBG and VABs. VABs occurred in 51% (79/154) of subjects. Microcirculation (MBG 2/3) was restored in 75% (115/154) of subjects, of whom 53% (61/115) had VABs. No VABs were observed in subjects without microvascular flow (MBG of 0). Of 115 patients with TIMI 3 flow, STR, and MBG 2/3, those with VABs had significantly larger IS (median: 23.0% vs 6.0%, p=0.001). Multivariable analysis identified reperfusion VABs as a factor significantly associated with larger IS ( p=0.015). Conclusions: Despite restoration of normal epicardial flow, open microcirculation, and STR, concomitant VABs are associated with larger myocardial IS, possibly reflecting myocellular injury in reperfusion settings. Combining angiographic and ECG parameters of epicardial, microvascular, and cellular response to STEMI intervention provides a more predictive “biosignature” of optimal reperfusion than do single surrogate markers.

Objective: With the passing of Dr. Galen Wagner, an exceptional collaboration between Maastricht University Medical Center, The Netherlands, and Duke Clinical Research Institute, USA, has come to an end. This article focuses on the background of what Galen coined the Maastricht Duke bridge (MD-bridge), its merits, limitations and development throughout the years, and his special role.Methods: Between 2004 and 2015, 23 Maastricht University medical students and post-graduate students were enrolled in the 4-month research elective, mentored by Galen and the Maastricht co-mentor. They were asked to complete a survey about their MD-bridge experience.Results: Sixteen out of the 23 students responded. None but 1 participant had prior research experience. Following their MD bridge-program most participants published 1 or more manuscripts and/or presented their research in an international setting. They felt they had full responsibility as a leader of their project with all participants developing meaningful skills useful in their current job. Fourteen out of 16 would recommend the MD-bridge experience to others. Participants considered the program of great value for their personal growth and independence, giving a feeling of achievement. In addition, for some participants it led to careers in foreign countries including medical practice and research, or obtaining PhDs.Conclusions: With Galen's impressive career of mentoring students, including the 23 MD-bridge participants, he has left behind an amazing concept of self-development in research and personal life. The successes of the MD-bridge prove that it is possible for students to be young investigators during or just after medical school with the potential to contribute to developing meaningful skills and noteworthy careers. Collaborations between international universities, such as the MD-bridge, are feasible and should be embraced by other institutions. Published by Elsevier Inc.

Aims Unlike in the Wolff–Parkinson–White syndrome, there has been no systematic study on the role of the pre-excitation pattern in predicting the ablation site in patients with atriofascicular (AF) pathways. We assessed in a large cohort the value of the 12-lead electrocardiogram (ECG) during antidromic tachycardia (ADT) to predict the site of ablation. Methods and results Forty-five patients were studied, 23 males (51%), mean age of 27 ± 12 years with 46 AF pathways and 48 ADT using the AF pathway for A–V conduction. Inclusion required induction of a sustained ADT and successful ablation. Ablation site was assessed during LAO 45° projection and clockwise classified as hours in posteroseptal, posterolateral, lateral, anterolateral, and anteroseptal tricuspid annulus as follows: 05:00–07:00, >07:00–08:00, >08:00–09:00, >09:00–11:00, and >11:00–13:00 o'clock. The QRS axis was assessed during ADT and classified as normal (>+15°), horizontal (+15° to −30°), and superior (

unster, MGermany Background: We will focus our attention in this article in the ECG changes of classical Prinzmetal angina that occur during occlusive proximal coronary spasm usually in patients with normal or noncritical coronary stenosis. Results: The most important ECG change during a focal proximal coronary spasm is in around 50% of cases the appearance of peaked and symmetrical T wave that is followed, if the spasm persist, by progressive ST-segment elevation that last for a few minutes, and later progressively resolve. The most frequent ECG changes associated with ST-segment elevation are: (a) increased height of the R wave, (b) coincident S-wave diminution, (c) upsloping TQ in many cases, and (d) alternans of the elevated ST-segment and negative T wave deepness in 20% of cases. The presence of arrhythmias is very frequent during Prinzmetal angina crises, especially ventricular arrhythmias. The prevalence and importance of ventricular arrhythmias were related to: (a) duration of episodes, (b) degree of ST-segment elevation, (c) presence of ST-T wave alternans, and (d) the presence of >25% increase of the R wave. Conclusions: The incidence of Prinzmetal angina is much lower then 50 years ago for many reasons including treatment with calcium channel blocks to treat hypertension and ischemia heart disease and the decrease of smoking habits. Ann Noninvasive Electrocardiol 2014;19(5):442-453 electrocardiography; Prinzmethal angina; coronary spasm; ST elevation

Background For many years was considered that negative T wave in ischemic heart disease represents ischemia and for many authors located in subepicardial area. Methods We performed a review based in the literature and in the experience of the authors commenting the real significance of the presence of negative T wave in patients with ischemic heart disease. Results The negative T wave may be of primary or secondary type. Negative T wave observed in ischemic heart disease are of primary origin, therefore not a consequence of abnormal repolarization pattern. The negative T wave of ischemic origin presents the following characteristics: (1) are symmetrical and of variable deepness; (2) present mirror patterns; (3) starts in the second part of repolarization; and (4) may be accompanied by positive or negative U wave. The negative T wave of ischemic origin may be seen in the following clinical settings: (1) postmyocardial infarction due to a window effect of necrotic zone and (2) as a consequence of reperfusion in case of aborted MI when the artery has opened spontaneously, or after fibrinolysis, PCI, or coronary spasm. Conclusion Acute ongoing ischemia do not cause negative T wave. This pattern appears when the ongoing ischemia is vanishing or in the chronic phase. In all these cases the cause of negative T wave is not located in the subepicardial area. Furthermore, positive exercise testing is expressed by ST depression never by isolated negative T wave. There are many circumstances that may present negative T wave outside ischemic heart disease and that have been discussed in this paper.

Sudden cardiac death (SCD) remains a daunting problem. It is a major public health issue for several reasons: from its prevalence (20% of total mortality in the industrialized world) to the devastating psycho-social impact on society and on the families of victims often still in their prime, and it represents a challenge for medicine, and especially for cardiology. This text summarizes the discussions and opinions of a group of investigators with a long-standing interest in this field. We addressed the occurrence of SCD in individuals apparently healthy, in patients with heart disease and mild or severe cardiac dysfunction, and in those with genetically based arrhythmic diseases. Recognizing the need for more accurate registries of the global and regional distribution of SCD in these different categories, we focused on the assessment of risk for SCD in these four groups, looking at the significance of alterations in cardiac function, of signs of electrical instability identified by ECG abnormalities or by autonomic tests, and of the progressive impact of genetic screening. Special attention was given to the identification of areas of research more or less likely to provide useful information, and thereby more or less suitable for the investment of time and of research funds. ? The Author 2014. Published by Oxford University Press on behalf of the European Society of Cardiology.

A 30-year-old female patient was admitted for electrophy-siologic study and catheter ablation because of an 8-yearhistory of repeated tachycardia episodes in spite of anti-arrhythmic agents (beta and calcium channel blockers).Most tachycardia episodes had a left bundle branch block(LBBB)-like configuration except one showing a narrowQRS complex tachycardia. The patient did not have struc-tural heart disease.