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Low voltage areas (LVAs) on left atrial (LA) bipolar voltage mapping correlate with areas of fibrosis. LVAs guided substrate modification was hypothesized to improve the success rate of atrial fibrillation (AF) ablation particularly in non-paroxysmal AF population. However, randomized controlled trials (RCTs) and observational studies yielded mixed results.The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to August 2022. Relevant studies comparing LVA guided substrate modification (LVA ablation) versus conventional AF ablation (non LVA ablation) in patients with non-paroxysmal AF were identified and a meta-analysis was performed (Graphical Abstract image). The efficacy endpoints of interest were recurrence of AF and the need for repeat ablation at 1-year. The safety endpoint of interest was adverse events for both groups. Procedure related endpoints included total procedure time and fluoroscopy time.A total of 11 studies with 1597 patients were included. A significant reduction in AF recurrence at 1-year was observed in LVA ablation versus non LVA ablation group [RR 0.63 (27% vs 36%),95% CI 0.48-0.62, P0.001]. Also, redo ablation was significantly lower in LVA ablation group [RR 0.52 (18% vs 26.7%),95% CI 0.38-0.69, P0.00133]. No difference was found in the overall adverse event [RR 0.7 (4.3% vs 5.4), 95% CI 0.36-1.35, P= 0.29].LVA guided substrate modification provides significant reduction in recurrence of all atrial arrhythmias at 1-year compared with non LVA approaches in persistent and longstanding persistent AF population without increase in adverse events. This article is protected by copyright. All rights reserved.

This review highlights the current evidence on racial, ethnic, and socioeconomic disparities in cardiac arrest outcomes within the United States. Several studies demonstrate that patients from Black, Hispanic, or lower socioeconomic status backgrounds suffer the most from disparities at multiple levels of the resuscitation pathway, including in the provision of bystander cardiopulmonary resuscitation, defibrillator usage, and postresuscitation therapies. These gaps in care may altogether lead to lower survival rates and worse neurological outcomes for these patients. A multisystem, culturally sensitive approach to improving cardiac arrest outcomes is suggested in this article.

We present the case of an 18-year-old man, with a history of subarachnoid hemorrhage, who is found to have the spiked helmet sign on electrocardiogram during a hospital admission for severe respiratory infection. The spiked helmet sign is a poorly understood electrocardiographic finding that mimics other electrocardiographic pathologies, and is associated with critical illness and high mortality. (Level of Difficulty: Beginner.), Central Illustration

Telemedicine has been in existence for years with little traction for global mainstream medicine. COVID19 has exposed the importance of providing continued care for patients while minimizing the risk of exposure during pandemics. There has been robust growth in the use of telemedicine since the pandemic began rendering care possible while providing safety to patients and healthcare workers. Various digital applications are available to facilitate telehealth. Even in the absence of a pandemic, telemedicine allows the care of patients who may live in remote areas, or those who have issues with transportation or comorbidities prohibiting ambulation. This study is based on a questionnaire of providers who have been exposed to telemedicine during COVID19. A survey was shared in social media forums involving groups of physicians, and nurse practitioners who were willing to take the survey. Telemedicine is one of the best approaches to handling situations like pandemics or disease surges. In these circumstances, a virtual visit is beneficial for social distancing if a laptop, smartphone, or tablet is available, along with an internet or cellular coverage. Based on this survey conducted for healthcare workers from a variety of specialties, there was a considerable impetus for the continued benefit from telemedicine as an alternative to in-person visits for selected patients. Ongoing improvements in quality of applications/tools, education, and the cost are essential to maintain the benefits of telemedicine. There is also an ongoing necessity for vast improvements in healthcare policies and reimbursements.

Myocardial Infarction in the absence of obstructive coronary artery disease [MINOCA] is seen in 5-6% of the patients presenting with myocardial infarction. While patients with MINOCA can present with either ST segment elevation or non-ST segment elevation myocardial infarction, they are less likely to have ST segment deviation on electrocardiography and have less of cardiac biomarker elevation compared to their obstructive coronary artery disease counterparts. Patients with MINOCA are usually younger and with lower prevalence of traditional cardiovascular risk factors compared with patients presenting with obstructive coronary artery disease. A variety of atherosclerotic and non-atherosclerotic mechanisms can lead to MINOCA. A diagnosis of MINOCA can only be made in patients whose clinical presentation is attributed to an ischemic event after excluding obstructive coronary artery disease and alternate causes for troponin elevation. A systematic approach to diagnosing the underlying causes is warranted to optimally treat patients presenting with MINOCA.

PurposeThe aim of this study is to investigate the effect of foreign institutional investors (FII) on the contribution of cash and dividend to firm's value in the context of Japan.Design/methodology/approachThis study used a sample of 1,929 nonfinancial firms listed in Tokyo Stock Exchange in the period from 2002 to 2016. For data analysis, pooled OLS regression with firm and year fixed effect is applied. Further, the p-value of difference is used to test the null hypothesis of equal coefficients.FindingsThe findings depict that cash holdings contribute more to firm's value when ownership by FII is high. Contrarily, dividends contribute more to firm's value when ownership by FII is low. The results remain consistent after using excess cash holdings instead of cash holdings and after re-estimating the main regression model in the presence of top 30% and bottom 30% ownership level.Research limitations/implicationsThis study is limited to Japanese nonfinancial sector. The results implied that firms where the probability of managerial agency cost and expropriation of cash is high, the presence of FII mitigates the agency cost and positively influences the contribution of cash to firm's value. Overall, this research highlighted the disciplinary and monitoring role of FII in Japan.Originality/valueThis study provides new insights on the monitoring and governance role of foreign institutions, showing that FII promote better cash management and utilization, which significantly affects the contribution of cash holdings to firm's value.

Disparities in overall outcomes for atrial fibrillation (AF) across racial and ethnic groups have been demonstrated in prior studies. We aim to evaluate in-hospital outcomes and resource utilization across 3 racial/ethnic groups with AF using contemporary data. We identified patients admitted with AF in the National Inpatient Sample registry from 2015 to 2018. ICD-10-CM codes were used to identify variables of interest. The primary outcomes were in-hospital complications and resource utilization. There were 1,250,075 AF admissions. Our sample was made up of 85.49% White, 8.12% Black, and 6.38% Hispanic patients. Black patients were younger but had a higher burden of cardiovascular comorbidities including obesity, hypertension, and chronic kidney disease. Social determinants were also less favorable in Black patients, with a higher percentage of Medicaid insurance and a high proportion of patients being in the lowest percentile for household income. Total hospital charge was highest in Hispanic patients. Despite higher rates of gastrointestinal bleed, Black patients were least likely to undergo left atrial appendage occlusion device implantation. Black and Hispanic patients were less like to undergo catheter ablation therapy. Black race was an independent predictor of mortality, stroke, mechanical ventilation, acute kidney injury, hemodynamic shock, need for vasopressor, upper gastrointestinal bleed, need for blood transfusion, total hospital charges, and length of stay when compared to other groups. Disparities exist in the risk of AF, and its management among racial and ethnic groups. Health care costs and inpatient outcomes disproportionately impact minorities in the United States.

Lyme disease can have cardiac involvement and can subsequently present with various types of atrio ventricular (AV) block. Sinus node dysfunction (SND) and accelerated junctional rhythm are highlighted in this case as an uncommon presentation for Lyme Carditis. This case highlights the importance of having a high index of suspicion for cardiac involvement with Lyme disease when atypical arrhythmias are present.

The number of patients with implantable electronic cardiac devices is continuously increasing. As more pacemakers and implantable cardioverter-defibrillators (ICDs) are being placed, a basic understanding of some troubleshooting for devices is becoming essential. Loss of capture can be an emergent presentation for an unstable patient and can be encountered intermittently in hospitalized patients. There are many causes for a loss of capture, with the timing of the implant having a high correlation with certain causes over others. The most common acute cause just after the insertion procedure is lead dislodgement or malposition. In comparison, an increase in the required threshold promoting a loss of capture can happen after months to years of insertion of the pacemaker or ICD. This change can be due to a cardiomyopathy, fibrosis medications, metabolic imbalance, lead fracture, or an exit block. Loss of capture can also occur from external electrical stimuli and inappropriate pacemaker or ICD settings. Further, there are also potential noncardiac causes, such as medications, electrolyte imbalance, and acidemia. A knowledge of these factors is essential for health care providers, given the morbidity and mortality that can potentially be associated with device-related issues, especially in patients who are dependent on the included pacing function.

Background and objective QT prolongation is associated with an increased risk of ventricular arrhythmias. Since some patients on contact or droplet precautions require QT-prolonging medications, monitoring the QT interval may become imperative to prevent fatal arrhythmias. To limit the exposure of staff to patients during and even after the coronavirus disease 2019 (COVID-19) pandemic and judiciously use personal protective equipment (PPE), it is important to find alternatives to frequent 12-lead electrocardiograms (ECG). The objective of this study was to compare QT intervals measured on telemetry to those measured on 12-lead ECG to determine whether telemetry QT interval measurements could be used in place of 12-lead measurements. Methods Simultaneous telemetry recordings via a Philips telemetry monitoring system (Philips Healthcare, Eindhoven, Netherlands) and 12-lead ECGs were obtained from 50 patients. Patients were from cardiac telemetry and cardiac intensive care units. QT interval from the telemetry system was compared to the QT interval on the 12-lead ECG. QT intervals on two telemetry strips were uninterpretable as the termination of the T-wave could not be defined appropriately; therefore, these patients were excluded. Results In 33 of 48 patients (69%), QT intervals from the telemetry studies matched the QT intervals measured by 12-lead ECG. The intraclass correlation coefficient (ICC) between telemetry QT and 12-lead ECG QT was 0.887 (95% CI: 0.809-0.934; p

Telemedicine has been in existence for decades with little traction for global mainstream medicine. However, COVID-19 has exposed the importance of providing continued care for patients while minimizing the risk of exposure during pandemics. There has been robust growth in the use of telemedicine since the pandemic began, rendering safety in care provided by minimizing exposure to patients and healthcare workers. There has been tremendous growth and innovation in various digital applications that facilitate telehealth as the platforms continue to improve. Even in the absence of a pandemic, telemedicine allows for care of patients who may live in remote areas or have issues with transportation and comorbidities prohibiting ambulation. This study is based on a questionnaire for healthcare providers who have been exposed to telemedicine during COVID-19. A survey was shared in social media forums involving groups of physicians and nurse practitioners who were willing to take the survey. Telemedicine is one of the best approaches to handling situations like pandemics or disease surges. In these circumstances, a virtual visit is beneficial for social distancing if a laptop, smartphone, or tablet is available, along with internet or cellular coverage. This survey was conducted among healthcare workers of various specialties and it was found out that there was a considerable impetus for the continued benefit from telemedicine as an alternative to in-person visits for selected patients. Ongoing improvements in the quality of applications/tools, education, and cost are essential to maintain telemedicine. There is also a constant necessity for vast improvements in healthcare policies and reimbursements to allow for telemedicine to evolve.

Introduction: QT prolongation is associated with increased risk of ventricular arrhythmias.As many patients with COVID19 may be started on QT prolonging drugs, measuring and monitoring QT is imperative to prevent fatal ventricular arrhythmias. However, we need to limit exposure of staff to patients with confirmed COVID19 and judiciously use personal protective equipment. Thus, it is important to find alternatives to doing frequent 12-lead ECGs. Hypothesis: We hypothesize that the QT interval measured from telemetry is similar to the QT interval on 12-lead ECG. Methods: Telemetry recordings and 12-lead ECGs were obtained from 15 patients at the same time and identical heart rates. Patients were from two different inpatient units with the same telemetry monitoring service. QT intervals were measured manually using calipers with the tangent method, excluding U waves. Telemetry recordings included lead I and II or a precordial lead. QT from telemetry was compared to the corresponding leads and to the longest QT on the 12-lead ECG. In cases of atrial fibrillation (AF), the QT from all the complexes was averaged. Results: Of 15 patients, 2 were in AF and 2 had RBBB. One patient had abnormal T-wave morphology and QT prolongation (abnormal repolarization). In all patients, QT intervals from the same leads as telemetry matched the QT measured from 12-lead. In 14 of 15 patients, telemetry QT matched the longest QT on the 12-lead ECG. However, in the patient with abnormal repolarization, maximum QT on 12-lead ECG was substantially longer than telemetry QT (Figure 1). Conclusion: When using the same lead, QT intervals were identical on telemetry and 12-lead ECG. However, in the patient with abnormal repolarization, the longest QT on 12-lead ECG was not represented on telemetry. In patients with abnormal repolarization on 12-lead ECG, we recommend serial 12-lead ECGs while on QT-prolonging drugs. Telemetry may suffice as a surrogate for 12-lead ECG to follow QT intervals in most patients.

Leadless pacemakers are evolving as a new technologic alternative to conventional transvenous pacemakers, though potential short-term and long-term complications have been recognized. The two currently available right ventricular leadless pacing systems are the Nanostim™ Leadless Cardiac Pacemaker (Abbott Laboratories, Chicago, IL, USA) and the Micra™ Transcatheter Pacing System (Medtronic, Minneapolis, MN, USA). This review aims to highlight the safety and efficacy of leadless pacemakers using these two devices as exemplars.

Vasovagal syncope (VVS) or neurocardiogenic syncope is defined by transient loss of consciousness with spontaneous and rapid recovery. Recently, a closed loop stimulation (CLS) pacing system has emerged as a new strategy which appears superior to conventional pacing for patients with refractory syncope. However, its efficacy remains of considerable debate and large randomized controlled clinical trials are needed. Between 2002 and 2017, 12 total studies evaluated the use of CLS pacing in patients with refractory VVS, and are summarized in this article.

Karachi (Pakistan) has recently been subject to violent incidents targeted primarily at civilians. These incidents are problematic for commuters who use the public bus system and who often fail to reach their work organisations due to consequent bus strikes. This series of events leads to considerable financial losses for the transport industry. This study proposes and implements safe and fast around the road (SAFAR) which is an intelligent transport Android application developed in collaboration with the local transport authority of Karachi. SAFAR provides run-time information to bus commuters regarding recent violent activities farther up from the current location of the commuters on their route. SAFAR employs live Twitter feeds to classify the manner, location, and casualty information of the violence. The authors investigate SAFAR's performance offline with three named entity recognition (NER) approaches, namely, supervised, dictionary-based, and integrated (hybrid), and show that the integrated approach has the best performance with a precision of 85%. Furthermore, SAFAR recommends alternate routes to commuters if violence is detected farther up through the A-star (A*) algorithm. An online evaluation of SAFAR with 50 real users gave a precision of ∼85% to identify violence locations. Finally, a subjective evaluation showed that SAFAR's performance is satisfactory.

During pregnancy, there are several physiologic changes that are regulated through hormonal, hemodynamic, and autonomic alterations. It is common for women during pregnancy to experience some form of palpitations, fortunately the majority of which are benign. A large retrospective study showed that 0.17% of hospital admissions during pregnancy are related to arrhythmias including supraventricular tachycardia (SVT), atrial fibrillation, ventricular tachycardia or fibrillation, and atrioventricular block (Li et al., 2008). The literature is not clear as to whether new onset arrhythmias such as SVT are more likely during pregnancy, but an increase in episodes in women with preexistent arrhythmias is more common. However, a woman with asymptomatic Wolff–Parkinson–White syndrome may experience her first episode of SVT during pregnancy (Tawam et al., 1993; Kounis et al., 1995). In this chapter, we will explore the hormonal and autonomic electrophysiologic effects of pregnancy, which can lead to cardiac arrhythmias.

Vasovagal syncope (VVS) or neurocardiogenic syncope is defined by transient loss of consciousness with spontaneous and rapid recovery. Recently, a closed loop stimulation (CLS) pacing system has emerged as a new strategy which appears superior to conventional pacing for patients with refractory syncope. However, its efficacy remains of considerable debate and large randomized controlled clinical trials are needed. Between 2002 and 2017, 12 total studies evaluated the use of CLS pacing in patients with refractory VVS, and are summarized in this article.

Background Inappropriate Sinus Tachycardia (IST) is a clinical syndrome characterized by a sinus heart rate inexplicably higher than one hundred beats per minute at rest that is associated with symptoms like palpitations, dyspnea or dizziness in the absence of primary causes of tachycardia. The diagnosis requires exclusion of other causes of tachycardia including medications/substances (such as anti-cholinergic, beta-blocker withdrawal, caffeine, and alcohol) or medical conditions (such as panic attacks, pulmonary embolism, fever, hyperthyroidism, hypovolemia, anemia, and pain). Methods Work up should include an EKG to differentiate other causes of tachycardia, 24 hour- Holter monitor if indicated, serum thyroid levels, hemoglobin levels and toxicology screen. Electrophysiological studies are not routinely recommended, but should be considered in certain patients in whom concurrent supraventricular tachycardia is suspected. Conclusion The underlying pathology in IST is yet to be completely understood. However, it is thought that the causes of IST can be broadly classified into two groups; either as an intrinsic increase in sinus node automaticity or an extrinsic cause. Among extrinsic causes, there is evolving evidence that IgG anti-β receptor antibodies are found in IST causing tachycardia. Managing patients with IST includes lifestyle modification, non-pharmacological and pharmacological interventions. Ivabradine has recently emerged as an effective treatment of IST and was shown to be superior to beta-blockers.

There is scant data about outcomes in patients with left ventricular epicardial (LVE) leads who develop endocarditis or device-related infection. This retrospective study evaluated mortality and recurrence of infection among patients with LVE leads in comparison to patients with endovascular coronary sinus (CS) leads after the development of endocarditis or device-related infection. Patients with cardiac resynchronization therapy (CRT) devices who developed endocarditis or pocket infection over 5 years at Cleveland Clinic were included in the study. The groups were all patients with LVE leads versus CRT devices without epicardial leads that developed endocarditis or pocket infection. Mortality was assessed using the Social Security Death Index and re-infection was assessed by reviews of the medical record. Prospective extraction of the CRT device and leads occurred among all 50 patients with CS leads and 8 of the 14 patients with LVE leads. The survival rate was 92.9 versus 92 % and freedom from re-infection rate was 64.3 versus 80 % in the patients with LVE leads versus CS leads, respectively, over 1 year (P value = 0.918 and 0.226, respectively). At 3 years, the survival rate in LVE lead group was 92.9 % and freedom from re-infection rate was 64.3 % in comparison to survival rate of 90 % and freedom from re-infection rate of 68 % in the CS group (P value = 0.751 and 0.798, respectively). After development of endocarditis or pocket infection, no statistically significant differences were seen in mortality, or recurrent infection between patients with LVE leads and those with CS leads.

In this paper, we present an intelligent, state-of-the-art, mobile-based transportation system called SAFAR (Safe and Fast around the Road), which provides dynamic information to Karachi bus commuters concerning any type of violence incident which has occurred farther ahead from their current location on the current bus route. Using named entity recognition techniques, we have trained SAFAR to recognize the location and method of violence incident along with the casualty information (if available) from live Twitter news feeds. Using the well-known A* heuristic search algorithm, SAFAR also recommends alternative routes to reach the destination in case of any violence up ahead. SAFAR has a competitive violence detection accuracy of 80% on a test corpus as well as in an online evaluation with real users. Finally, a subjective evaluation of these users reveals satisfactory performance of SAFAR across several dimensions.

Little literature exists on the risk of performing coronary intervention (PCI) on patients who have had recent gastrointestinal bleeding (GIB), although bleeding after PCI has been identified as a risk factor for long-term mortality.Patients within the Cleveland Clinic PCI database who had acute GIB within 30 days preceding PCI during the same hospitalization (n = 79) were retrospectively compared to those who had PCI without recent GIB (n = 10 979) for mortality and need for revascularization. Baseline characteristics, laboratory values, procedures, morbidities, and mortality were compared using chi-square test for categorical variables and using Wilcoxon rank sum test for continuous variables. Mortality data was obtained using Social Security Death Index and demonstrated using Kaplan-Meier method.The GIB group had more prevalent history of peptic ulcer disease, GIB, gastrointestinal or liver disease (P0.0001), transient ischemic accident (P = 0.017), peripheral vascular disease (P = 0.0002), significant carotid artery occlusion (P = 0.023), and myocardial infarction (P0.0001). 47% of patients had upper GIB with 20% needing endoscopic intervention. This group had more anemia (P0.0001), heart failure (P = 0.0001), cardiogenic shock (10% versus 1.4%, P0.001), cardiac arrest (7.6% versus 1%, P0.001). GIB group had worse in-hospital mortality (P0.0001), long-term mortality (P0.001), and a 7.6% re-bleeding incidence.Overall, the patients who had GIB preceding PCI had higher in-hospital mortality and long-term mortality compared with those without GIB before PCI.

Background The best periprocedural anticoagulation strategy at the time of pulmonary vein isolation (PVI) is not known. Most centers stop administering warfarin (Coumadin) and use bridging with heparin or enoxaparin. Objective The purpose of this study was to evaluate the efficacy and safety of PVI under therapeutic international normalized ratio (INR). Methods Between January 2005 and December 2008, PVI was performed in 3,052 patients with therapeutic INR (≥1.8) at the time of ablation. All patients were evaluated for ischemic strokes and bleeding complications. Results Mean INR was 2.53 ± 0.62. Only 3 (0.098%) patients had ischemic strokes. One patient had a hemorrhagic stroke on the third day postablation but recovered completely by 1-week follow-up. Bleeding complications occurred in 34 (1.11%) patients; most were minor (0.79%). Major hemorrhagic complications occurred in 10 (0.33%) patients (tamponade in 5, hematomas requiring intervention in 2, transfusion necessary in 3). Conclusion In a large patient population, continuation of Coumadin at a therapeutic INR at the time of PVI without use of heparin or enoxaparin for bridging is a safe and efficacious periprocedural anticoagulation strategy. It is an acceptable and potentially better alternative to strategies that use bridging with heparin or enoxaparin.

A 64-year-old male with Budd–Chiari syndrome (BCS) due to inferior vena cava (IVC) occlusion after liver transplant presented with massive ascites and lower extremity edema. He was found to have chronic total occlusion of the supra-hepatic IVC with thrombosis in the infra-hepatic IVC, hepatic, renal, and iliac veins. Attempts to recanalize the occlusion by multiple operators failed. He was not a surgical candidate. The patient underwent venography of the IVC, and placement of a McNamara catheter for catheter-directed thrombolysis on the first day. The second day, he underwent right internal jugular access with contrast injections to mark the superior aspect of the occlusion via a Multipurpose catheter. An adult transseptal needle (Bard Electrophysiology Division C. R. Bard, Inc., Lowell, MA, USA) was used to create a tract through a 6French Raabe Sheath and traverse the occlusion. A 10-mm Snare (Cook, Bloomington, IN, USA) cranially retracted the guidewire. Intravascular ultrasound was performed to further delineate the diameter of the IVC at the lesion before dilation with a 6.0mm×40mm PTA balloon and a 10mm×29mm Palmaz Stent (Cordis Corporation, Bridgewater, NJ, USA) deployment. The patient lost 24.6kg in 2 weeks with resolution of ascites and pedal edema. Learning objective: This case provides a unique approach to percutaneous intervention of inferior vena cava chronic total occlusion in the setting of Budd–Chiari syndrome post-liver transplant. There was use of an inferior and superior marker followed by use of transseptal needle to transverse the occlusion followed by balloon dilation and stent placement. While the disease and intervention have been described, the use of dual cranial/caudal markers and use of transseptal needle is unique to this particular case.>

A 14-year-old boy presented with exertional chest pain and was found to have rising cardiac biomarkers. The electrocardiogram revealed ST-segment elevation and T-wave inversion in the anterolateral leads. Coronary arteriograms and coronary computed tomography (CCT) showed an anomalous left main coronary artery originating from the right coronary sinus of Valsalva and coursing intramurally within the wall of the aorta between the aorta and the pulmonary trunk. The proximal left main was narrow with normal distal left main, left anterior descending, and left circumflex coronary arteries. The patient underwent surgical de-roofing of the intramural course of the left main artery with relief of his symptoms. Coronary artery anomalies have been found in 1.3% of the patients in a large arteriographic study. These anomalies are classified on the basis of the origin of the coronary arteries, as well as their course and distribution. Many of these variations are discovered incidentally at arteriography or autopsy. However, some of the anomalies cause symptoms, and a few of them can cause sudden cardiac death, even at a young age.

In patients with cardiomyopathy (CM) and an implantable cardioverter-defibrillator (ICD), the relationship between positron emission tomography (PET) stress myocardial blood flow (sMBF) and adverse cardiac events including ventricular arrhythmia (VT/VF) is unknown. Patients with CM with an ICD in