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The aortic and pulmonary valve share a common developmental origin from the embryonic arterial trunk. Bicuspid aortic valve is the most common congenital anomaly and can occur isolated as well as in association with other congenital heart disease (CHD). Data on pulmonary valve morphology in these cases are scarce. In this study, we aimed to determine pulmonary valve morphology in hearts with BAV associated with CHD. In 83 post-mortem heart specimens with BAV and associated CHD, pulmonary valve morphology was studied and related to BAV morphology. In 14/83 (17%) hearts, the pulmonary valve was affected, bicuspid in 8/83 (10%), dome-shaped in 3/83 (4%) and atretic in 3/83 (4%). In specimens with a bicuspid pulmonary valve, 5/8 (63%) had a strictly bicuspid aortic valve (without raphe), 2/3 hearts (67%) with dome-shaped pulmonary valves and 2/3 hearts (67%) with atretic pulmonary valves had BAV without raphe. Six out of eight (75%) specimens with a bicuspid pulmonary valve had a perimembranous ventricular septal defect (VSD). 4/8 (50%) specimens with a bicuspid pulmonary valve were associated with chromosomal abnormalities: 3 (38%) had trisomy 18 and 1 (13%) had trisomy 13. In BAV with associated CHD, abnormal pulmonary valve morphology was observed in 17% of the hearts. The majority of hearts with abnormal pulmonary valve morphology had a Type B bicuspid aortic valve (without raphe). Bilateral semilunar valvular disease is associated with Type B BAVs and in many cases related to chromosomal abnormalities. As this study was performed in post-mortem specimens with high frequency of associated CHD, caution is warranted with application of these results to the general BAV population. [ABSTRACT FROM AUTHOR]

A 53‐year‐old man presented with symptomatic severe pulmonary valve regurgitation. He underwent a diagnostic catheterization. A heavily calcified pericardium and the pressure tracings illustrate typical features of constrictive pericarditis physiology, including the "square root sign." This condition is important to recognize given the progressive nature and poor prognosis if untreated. [ABSTRACT FROM AUTHOR]

'Multimodality' imaging--the side-by-side interpretation of data obtained from various noninvasive imaging techniques, such as echocardiography, radionuclide techniques, multidetector CT (MDCT), and MRI--allows anatomical, morphological, and functional data to be combined, increases diagnostic accuracy, and improves the efficacy of cardiovascular interventions and clinical outcomes. During the past decade, advances in software and hardware have allowed co-registration of various imaging modalities, resulting in cardiac 'hybrid' or 'fusion' imaging. In this Review, we discuss the roles of both multimodality and hybrid imaging in three broad areas of cardiology--coronary artery disease (CAD), heart failure, and valvular heart disease. In the evaluation of CAD, integration of either single-photon emission computed tomography (SPECT) or PET with CT coronary angiography provides both morphological and functional data in a single procedure. Accordingly, the functional consequences (myocardial hypoperfusion on SPECT or PET) of anatomical pathology (coronary anatomy on MDCT or MRI) can be assessed. Co-registration of PET and MRI data sets to provide cellular and molecular information on plaque composition and stability is now possible. Furthermore, novel imaging modalities have been implemented to guide electrophysiological and transcatheter-based procedures, such as cardiac resynchronization therapy (an established treatment for patients with heart failure), and transcatheter valve repair or replacement procedures. [ABSTRACT FROM AUTHOR]

The article discusses the effectiveness and adverse effects of antiarrhythmic drug, amiodarone. Introduced in the early 1960s, amiodarone was initially used for the treatment of angina pectoris. Later, amidarone became a widely used III antiarrhythmic agent. The drug is rich in iodine with strong structural qualities to the thyroid hormones.

Introduction: Patients with established arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) based on task force (TF) criteria and ventricular tachycardia (VT) are at risk of VT recurrence and sudden death. Data on patients with VT due to right ventricular (RV) scar not fulfilling TF criteria are lacking. The purpose of this study was to assess the long-term arrhythmia recurrence rate and outcome in patients with scar-related right VT with and without a diagnosis of ARVC/D. Methods: Sixty-four patients (age 43.5 ± 15 years, 49 males) presenting with nonischemic scar-related VT of RV origin were studied. Scar was identified by electroanatomical mapping, contrast echocardiography, and/or magnetic resonance imaging (MRI). Patients were evaluated and treated according to a standard institute protocol. Results: Twenty-nine (45%) patients were diagnosed with ARVC/D according to TF criteria (TF+) and 35 (55%) with RV scar of undetermined origin (TF–) at the end of follow-up (64 ± 42 months). Patients were treated with antiarrhythmic drugs, radiofrequency catheter ablation, and/or implantable cardioverter-defibrillator (ICD) implantation. VT recurrence-free survival for TF+ and TF– was 76% versus 74% at 1 year and 45% versus 50% at 4 years (P = ns). Patients with fast index VT (cycle length [CL]≤ 250 ms, n = 31) were more likely to experience a fast VT during follow-up than patients with a slow index VT (CL > 250 ms, n = 33) (61% vs 3%, P < 0.001). Conclusions: Scar-related RV VTs have a high recurrence rate in TF+ and TF– patients. Patients presenting with a fast index VT are at high risk for fast VT recurrence and may benefit most from ICD therapy. [ABSTRACT FROM AUTHOR]

Cardiac pacing is the only effective treatment for patients with sick sinus syndrome and atrioventricular conduction disorders. In cardiac pacing, the endocardial pacing lead is typically positioned at the right ventricular (RV) apex. At the same time, there is increasing indirect evidence, derived from large pacing mode selection trials and observational studies, that conventional RV apical pacing may have detrimental effects on cardiac structure and left ventricular function, which are associated with the development of heart failure. These detrimental effects may be related to the abnormal electrical and mechanical activation pattern of the ventricles (or ventricular dyssynchrony) caused by RV apical pacing. Still, it remains uncertain if the deterioration of left ventricular function as noted in a proportion of patients receiving RV apical pacing is directly related to acutely induced left ventricular dyssynchrony. The upgrade from RV pacing to cardiac resynchronization therapy may partially reverse the deleterious effects of RV pacing. It has even been suggested that selected patients with a conventional pacemaker indication should receive cardiac resynchronization therapy to avoid the deleterious effects. This review will provide a contemporary overview of the available evidence on the detrimental effects of RV apical pacing. Furthermore, the available alternatives for patients with a standard pacemaker indication will be discussed. In particular, the role of cardiac resynchronization therapy and alternative RV pacing sites in these patients will be reviewed. [Copyright &y& Elsevier]

The article examines the potential role of cardiac synchronization therapy (CRT) in the management of children with heart failure (HF) and congenital heart disease (CHD). Results from clinical trials reportedly showed that CRT improves symptoms of HF. However, it is noted that the technical aspects of CRT in patients with systemic right ventricle (RV) are challenging. The long-term benefits of CRT in CHD patients with left ventricular (LV) failure are also identified.

The article discusses troubleshooting implantable cardioverter-defibrillator (ICD) technology problems. Troubleshooting starts if a patient complained a possible device related problem or a regular technical follow-up shows a possible device deviation. The device will be interrogated extensively and the retrieved data will be analyzed. Evaluation methods include electrocardiography, Holter monitoring and others. ICD related problems include shocks, dizziness/fainting, palpitations, and alerts.

M-mode echocardiography (using the septal-to-posterior wall motion delay [SPWMD]) and color-coded tissue Doppler imaging (TDI; using the septal-to-lateral delay in peak systolic velocity) have been proposed for assessment of left ventricular (LV) dyssynchrony and prediction of response to cardiac resynchronization therapy (CRT). In this study, a head-to-head comparison between M-mode echocardiography and color-coded TDI was performed for assessment of LV dyssynchrony and prediction of response to CRT. Consecutive (n = 98) patients with severe heart failure (New York Heart Association class III/IV), LV ejection fraction ≤35%, and QRS duration >120 ms underwent CRT. Before pacemaker implantation, LV dyssynchrony was assessed by M-mode echocardiography (SPWMD) and color-coded TDI (septal-to-lateral delay). At baseline and 6 months after implantation, clinical and echocardiographic parameters were evaluated. SPWMD measurement was not feasible in 41% of patients due to akinesia of the septal and/or posterior walls or poor acoustic windows. Conversely, the septal-to-lateral delay could be assessed in 96% of patients. At 6-month follow-up, 75 patients (77%) were classified as responders to CRT (improvement ≥1 New York Heart Association class). The sensitivity and specificity of SPWMD were lower compared with those of septal-to-lateral delay (66% vs 90%, p <0.05; 50% vs 82%, p = NS, respectively). In conclusion, LV dyssynchrony assessment was feasible in 59% of patients with M-mode echocardiography compared with 96% (p <0.05) when color-coded TDI was used. Color-coded TDI was superior to M-mode echocardiography for prediction of response to CRT. [Copyright &y& Elsevier]

Abstract: Objective: The purpose of the study was to investigate the development of electrical transmission across human adult bone marrow-derived mesenchymal stem cells (hMSCs) during long-term co-incubation with cardiomyocytes (CMCs). Methods: Neonatal rat CMCs were cultured in multi-electrode array dishes. A conduction block was induced by creating a central acellular channel, yielding two asynchronously beating CMC fields. Enhanced green fluorescent protein (eGFP)-labeled hMSCs from ischemic heart disease patients (n =8), eGFP-labeled hMSCs having RNA interference-mediated connexin43 (Cx43) knockdown (n =6), 1,1′-dioctadecyl-3,3,3′,3′-tetramethylindocarbocyanine (Dil)-labeled CMCs (n =6), or no cells (n =9) were seeded in the channel. Assessment of conduction velocity (CV), Cx expression and localization, gap junctional coupling, and intracellular electrical recordings were performed for up to 14 days. Results: Resynchronization of the two CMC fields occurred within 24 h after seeding of hMSCs. CV across hMSCs increased from 1.4±0.4 cm/s at day 7 to 3.5±0.1 cm/s (p <0.05) at day 14. CV across seeded CMCs was 16.8±0.2 cm/s throughout this period. No resynchronization occurred in the absence of seeded cells. Knockdown of Cx43 in hMSCs abolished conduction across the channel completely. Time-dependent increase of CV across hMSCs was associated with increased Cx43 mRNA and protein expression resulting in increased gap junctional coupling. Intracellular recordings in coupled hMSCs showed increased conducted action potential (AP) amplitude, lower resting membrane potential, and decreased duration of conducted AP (p <0.05, day 14 versus day 1). Conclusions: CV across hMSCs increases progressively after 7 days of co-incubation with CMCs, most likely via improved electrotonic interaction. This is associated with increased Cx43 expression, increased functional gap junctional coupling, and enhanced intercellular electrical coupling between hMSCs and CMCs. [Copyright &y& Elsevier]

Objectives: This study was designed to assess the effects of long-term right ventricular (RV) pacing on left ventricular (LV) dyssynchrony, LV function, and heart failure symptoms. Background: Atrioventricular (AV) node ablation and subsequent long-term RV pacing is a well-established treatment option in patients with atrial fibrillation (AF). Methods: In 55 patients with drug-refractory AF, AV node ablation and implantation of a pacemaker was performed. At baseline and after a mean of 3.8 ± 1.7 years, LV dyssynchrony (by M-mode echocardiography and tissue Doppler imaging), LV function, and volumes and functional status were assessed. Results: After long-term RV pacing, 27 patients (49%) had developed LV dyssynchrony. Concomitantly, these patients worsened in heart failure symptoms (New York Heart Association functional class increased from 1.8 ± 0.6 to 2.2 ± 0.7, p < 0.05), with a decrease in LV ejection fraction (from 48 ± 7% to 43 ± 7%, p < 0.05) and an increase in LV end-diastolic volume (from 116 ± 39 ml to 130 ± 52 ml, p < 0.05). Conversely, patients without LV dyssynchrony did not deteriorate in heart failure symptoms, LV function, or LV volumes. Conclusions: Long-term RV pacing can induce LV dyssynchrony in almost 50% of patients treated with AV node ablation for chronic AF. The development of LV dyssynchrony was associated with deterioration in heart failure symptoms, systolic LV function, and LV dilatation. [Copyright &y& Elsevier]

Background: Focal atrial tachycardias (FAT) originate from areas with poor cell-to-cell coupling. Due to cellular uncoupling extracellular potentials become fractionated. The degree of fragmentation may be used to identify the site of origin of FAT prior to catheter ablation. We studied electrical fragmentation in relation to the distance to the site of earliest activity during FAT. Methods: Three-dimensional (3-D) electroanatomical activation/voltage maps obtained from patients (n = 15: 6 male, age 40 ± 14 (19–72) years) referred for catheter ablation of FAT were analyzed. Bipolar atrial potentials (BP) were categorized according to the number of deflections. The peak-to-peak amplitude and the time interval between the first and last deflection ( fractionation duration) of each BP were measured. Results: Eighteen different atrial tachycardias (AT) (CL 346 ± 109 [190–550]) msec were analyzed. The incidence of single potentials ranged from 30 to 81 (59 ± 16)%. The occurrence of double and fractionated potentials ≤2 cm of the site of earliest activity (“focal area”) was higher compared to the remainder of the atria (67 ± 22% vs 34 ± 14%, P < 0.001). Focal area potentials were characterized by a longer duration (49 ± 22 msec vs 34 ± 17 msec, P < 0.001) and a lower peak-to-peak amplitude (0.51 ± 0.43 [0.12–1.7] mV vs 0.94 ± 0.69 [0.22–2.58] mV, P = 0.03). Fractionation was not associated with FAT cycle length (r =−0.26, P = 0.29) or left atrial diameter (r = 0.47, P = 0.30). Conclusion: Significant differences in fractionation, fractionation duration, and peak-to-peak-amplitude of atrial potentials between the focal area and the remainder of the atria exist. Fractionation and voltage mapping can be used, besides activation mapping, to identify the site of origin of FAT during catheter ablation. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy (CRT) is beneficial in selected patients with moderate to severe heart failure (New York Heart Association [NYHA] classes III to IV). Patients with mildly symptomatic heart failure (NYHA class II) are currently not eligible for CRT and the potential beneficial effects in these patients have not been well studied. Fifty consecutive patients in NYHA class II heart failure and 50 consecutive patients in NYHA classes III to IV (control group) were prospectively included. All patients had left ventricular (LV) ejection fraction ≤35% and QRS duration >120 ms. The effects of CRT in NYHA class II patients were compared with the results obtained in both groups. The severity of baseline LV dyssynchrony (assessed with color-coded tissue Doppler imaging) was comparable between patients in NYHA class II versus those in NYHA classes III to IV (83 ± 49 vs 96 ± 51 ms, p = NS); resynchronization was achieved in all patients. NYHA class II patients showed a significant improvement in LV ejection fraction (from 25 ± 7% to 33 ± 10%, p <0.001) and reduction in LV end-systolic volume (from 168 ± 55 to 132 ± 51 ml, p <0.001) after CRT, similar to patients in NYHA classes III to IV. In addition, only 8% of NYHA class II patients had progression of heart failure symptoms. In conclusion, CRT had comparable effects in patients in NYHA class II and in NYHA classes III to IV heart failure in terms of LV resynchronization, improvement in LV ejection fraction, and LV reverse remodeling. [Copyright &y& Elsevier]

Objectives: The purpose of this research was to evaluate right ventricular (RV) remodeling after six months of cardiac resynchronization therapy (CRT). Background: Cardiac resynchronization therapy is beneficial in patients with end-stage heart failure. The effect of CRT on RV size is currently unknown. Accordingly, the effects of CRT on RV size, severity of tricuspid regurgitation, and pulmonary artery pressure were evaluated. Methods: Fifty-six consecutive patients with end-stage heart failure (52% ischemic cardiomyopathy), left ventricular (LV) ejection fraction (EF) ≤35%, QRS duration >120 ms, and left bundle branch block were included. Clinical parameters, LV volumes, LVEF, LV dyssynchrony, and RV chamber size were assessed at baseline and after six months of CRT; LV dyssynchrony was assessed using tissue Doppler imaging. Results: Clinical parameters improved significantly; LV dyssynchrony was acutely reduced after CRT and remained unchanged at six-month follow-up. Left ventricular EF improved significantly from 19 ± 6% to 26 ± 8% (p < 0.001), and LV end-diastolic volume decreased from 257 ± 98 ml to 227 ± 86 ml (p < 0.001). Right ventricular annulus decreased significantly from 37 ± 9 mm to 32 ± 10 mm, RV short-axis from 29 ± 11 mm to 26 ± 7 mm, and RV long-axis from 89 ± 11 mm to 82 ± 10 mm (all p < 0.001). Left ventricular and RV reverse remodeling were only observed in patients with substantial LV dyssynchrony at baseline. Finally, significant reductions in severity of tricuspid regurgitation and pulmonary artery pressure were observed. Conclusions: Cardiac resynchronization therapy results in significant reverse LV and RV remodeling after six months of CRT in patients with LV dyssynchrony. Moreover, CRT leads to a reduction of the severity of tricuspid regurgitation and a decrease in pulmonary artery pressure. [Copyright &y& Elsevier]

Background: Cardiac resynchronization therapy (CRT) has a beneficial effect on clinical symptoms, exercise capacity, and systolic left ventricular (LV) performance in patients with heart failure. The aim of the current study was to evaluate whether a gender difference exists in response to CRT. Methods: Consecutive patients with end-stage heart failure (New York Heart Association, NYHA, class III–IV), LV ejection fraction (LVEF) ≤35%, QRS duration >120 ms, and left bundle branch block configuration underwent CRT. At baseline and 6 months post-CRT, clinical and echocardiographic parameters were evaluated; follow-up was obtained up to 5 years. The effects of CRT were compared between women and men. Results: The study population comprised 137 men and 36 women (mean age 66 ± 11 years). No differences in baseline characteristics were observed except that nonischemic cardiomyopathy was more frequent in women than men (67% vs 38%, P < 0.05). In all patients, clinical and echocardiographic parameters improved significantly at 6-month follow-up. The magnitude of improvement in different parameters was similar between women and men, e.g., the improvement in NYHA Class was 0.9 ± 0.6 in women and 1.0 ± 0.7 in men (NS) and the increase in LVEF was 8 ± 8% in women as compared to 7 ± 9% in men (NS). The percentage of individual responders was not different between women and men (76% vs 80%, NS) and 2-year survival was comparable for women and men (84% vs 80%, NS). Conclusion: No gender differences were observed in response to CRT and long-term survival after CRT. [ABSTRACT FROM AUTHOR]

QRS Duration and LV Dyssynchrony. Introduction: Patients with end-stage heart failure and a wide QRS complex are considered candidates for cardiac resynchronization therapy (CRT). However, 20% to 30% of patients do not respond to CRT. Lack of left ventricular dyssynchrony may explain the nonresponse. Accordingly, we evaluated the presence of left ventricular dyssynchrony using tissue Doppler imaging (TDI) in 90 consecutive patients with heart failure. Methods and Results: Ninety patients with severe heart failure (left ventricular ejection fraction <35%, New York Heart Association class 111-IV) were prospectively evaluated. Based on QRS duration, 30 consecutive patients with a narrow QRS complex were included (QRS duration ≤120 ms), 30 patients with an intermediate QRS duration (120-150 ms), and 30 patients with a wide QRS complex (>150 ms). All patients underwent TDI to assess left ventricular dyssynchrony. Extensive left ventricular dyssynchrony was defined as an electromechanical delay on TDI between the septum and lateral wall, the so-called septal-to-lateral delay, of >60 ms. Severe dyssynchrony was observed in 27% of patients with narrow QRS complex, 60% with intermediate QRS duration, and 70% with wide QRS complex. No relation existed between QRS duration and septal-to-tateral delay. Conclusion: From 30% to 40% of heart failure patients with QRS duration >120 ms do not exhibit left ventricular dyssynchrony, which may explain the nonresponse to CRT. Alternatively, 27% of patients with heart failure and a narrow QRS complex show significant left ventricular dyssynchrony and may be candidates for CRT. [ABSTRACT FROM AUTHOR]

CCS-lacZ Expression in Conduction System Development. Introduction: The occurrence of arrhythmias in adult patients may arise preferentially in anatomic regions derived from the specialized cardiac conduction system. To examine this hypothesis, we performed a detailed analysis of the developing cardiac conduction system using the recently described CCS-lacZ transgenic mouse strain. Methods and Results: Transgenic embryos (E9.5–15.5) were stained for β-galactosidase activity and co-stained with the myocardial marker HHF35. Results were reconstructed three dimensionally. CCS-lacZ expression was observed in the sinoatrial node, left and right venous valves, septum spurium, right and left atrioventricular ring, His bundle, bundle branches, and right ventricular moderator band. Furthermore, lacZ-positive cells could be demonstrated for the first time in the left atrium, in the posterior wall surrounding the pulmonary venous orifice. and, in later stages, surrounding the pulmonary venous wall. These cells were continuous with the left venous valve in the right atrium. LacZ-positive tissue also could be identified in Bachmann's bundle, running retro-aortically between the right atrium and left atrium. Conclusion: Known arrhythmogenic areas including Bachmann's bundle, the pulmonary veins, and sinus venosus derived internodal structures, demonstrate lacZ expression. These data support the hypothesis that areas derived from the developing cardiac conduction system may contribute to the arrhythmogenic substrate in adult hearts. (J Cardiovasc Electrophysiol, Vol. 15, pp. 349-355, March 2004) [ABSTRACT FROM AUTHOR]

Background: Oxidation susceptibility of lipids in vitro is considered to reflect the exposure of lipids to oxidation stress in vivo which is related to cardiovascular morbidity. This study examined the effect of pravastatin therapy on serum oxidation susceptibility, particularly in relation to endothelial function of coronary arteries. Methods: The participants were recruited from the Pravastatin-Related Effects Following Angioplasty on Coronary Endothelium trial, a double-blinded, placebo-controlled, randomized, multi-center study designed to analyze the effect of parvastatin treatment on endothelial function in previously dilated and normal coronary arteries. Serial, graded, intra-coronary acetylcholine infusions were used to assess endothelial function. In vitro, copper-induced, serum oxidation parameters were determined at randomization and at time of coronary endothelial function assessment. Results: Oxidation parameters were determined in 45 patients (pravastatin 23, placebo 22). Pravastatin therapy significantly improved serum oxidation lag time (+8%, P<0.05), maximal diene formation rate (−22%, P<0.01) and total amount of dienes formed after 5 h (−16%, P<0.01). These parameters remained essentially unchanged in the placebo group. Acetylcholine-evoked responses were positively correlated to therapy-induced change in serum oxidation susceptibility in the dilated segment group (r2=0.56, P=0.006). Conclusion: Pravastatin''s beneficial effect on endothelial dysfunction of dilated coronary segments may be secondary to pravastatin''s improvement of oxidation susceptibility. [Copyright &y& Elsevier]

Background and objective Balance between benefit and burden of implantable cardioverter-defibrillator (ICD) therapy is more debatable in older patients, compared to younger patients. Of around 6000 yearly implanted ICDs in the Netherlands, 1:4 is received by patients ≥75 years. We aimed to evaluate the current clinical practice in the Netherlands for ICD implants and generator replacements, with a special focus on the older ICD patients. Research design and methods Cardiologists from all Dutch ICD implanting centres (n  = 28) were interviewed. Questions aimed to evaluate outpatient care, pre-operative patient assessment, end-of-life-care counselling, evaluation of social and cognitive wellbeing, clinical evaluation of all patients prior to ICD replacement, and the consideration of the option to downgrade or not replace a device. Results Implanting cardiologists from all 28 implanting centres were approached for an interview. Response rate was 86%. Management appeared diverse. An age ≥80 years was consistently reported as incentive for more extensive patient evaluation. Patients were invited for counselling prior to device replacements in only the minority (46%) of hospitals. Downgrade or non-replacement was performed in rare cases. End-of-life care discussions were not standard procedure in 67% of the hospitals. Evaluation of social and cognitive wellbeing of patients was based solely on the general clinical impression of the physician in 83%, or not at all assessed in 8% of the centres. Discussion and implication A structured framework for care and evaluation of cognitive and/or physical limitations is currently absent in most hospitals. At time of ICD (re-)evaluation, several factors may be considered before deciding on (continuation of) ICD therapy: patient preferences and comorbidity, the need for pacemaker therapy, primary vs. secondary prevention, procedural risks, and patient preferences. [ABSTRACT FROM AUTHOR]

The authors discuss the cardiac resynchronization therapy (CRT). The authors assert that CRT is considered as class I indication in heart failure patients. They reveal that various studies have related the success of CRT to left ventricular (LV) lead position and site of latest mechanical activation. They cite that various results of the studies raise the question whether positioning of the LV pacing lead in CRT should be guided by echocardiography.

The article reflects on whether multislice computed tomography (MSCT) is significant before performing atrial fibrillation ablation. It talks about anatomical studies which focuses on pulmonary veins (PVs) and the use of image integration systems in the fusion of MSCT images and electroanatomical maps.

In large cardiac resynchronization therapy (CRT) trials, approximately 20–30% of patients did not respond to CRT. Recent studies indicated that left ventricular (LV) dyssynchrony is needed for response to CRT. However, the presence of LV dyssynchrony may not be the only determinant of response, because some patients with LV dyssynchrony do not benefit from CRT. In the current case report, we present a patient with ischemic cardiomyopathy, NYHA class III heart failure symptoms, and substantial LV dyssynchrony on tissue Doppler imaging who underwent CRT implantation but did not respond. Following CRT, LV dyssynchrony was not reduced and the patient did not improve in clinical symptoms or LV function. The lack of LV resynchronization was explained by the presence of extensive scar tissue in the region of the tip of the LV pacing lead resulting in ineffective LV pacing. In patients with ischemic cardiomyopathy and history of previous infarction, assessment of scar tissue should be considered before CRT implantation. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy (CRT) has been proposed to improve hemodynamics in patients with heart failure and left bundle branch block (LBBB) by resynchronization of left ventricular (LV) dyssynchrony. The current report concerns a patient with narrow QRS complex without LV dyssynchrony who experienced an acute exacerbation of heart failure following exercise. Careful analysis revealed that an increase of heart rate induced acceleration-dependent LBBB with severe LV dyssynchrony and mitral regurgitation followed by acute heart failure and hemodynamic collapse. CRT prevented these adverse reactions. Accordingly, optimal evaluation for CRT may include testing for LV dyssynchrony during exercise. [ABSTRACT FROM AUTHOR]

In the present study, the effects of cardiac resynchronization therapy (CRT) in elderly patients were evaluated. The study included 170 consecutive patients whose clinical and echocardiographic improvements were evaluated after 6 months of follow-up. Survival was evaluated up to 2 years. The effects of CRT in elderly patients (age ≥70 years) were compared with those in younger patients (age &#60;70 years). [Copyright &y& Elsevier]

Cardiac resynchronization therapy (CRT) is considered a major advance in the treatment of patients with heart failure. The presence of left ventricular (LV) dyssynchrony seems mandatory for a positive response to CRT. Currently, only patients with wide QRS complexes are considered for CRT, although patients with narrow QRS complexes may also have LV dyssynchrony. In the present study, the incidence of LV dyssynchrony was prospectively evaluated in 64 patients with heart failure and narrow QRS complexes using tissue Doppler imaging. [Copyright &y& Elsevier]

Simple Summary: This study compares the presence of coronary artery calcium on coronary computed tomography angiography in relation to cardiovascular events between Hodgkin lymphoma (HL) survivors treated with thoracic radiotherapy and a matched non-cancer control group. HL survivors have a higher prevalence of coronary artery calcium more than ten years after irradiation. However, HL patients with a coronary artery calcium score of zero still have an increased risk of future cardiovascular events, possibly due to rapid progression of atherosclerosis in the coronary arteries following irradiation. Timely treatment with statins should be considered to prevent rapid acceleration of pre-existing atherosclerosis. Background: Thoracic radiotherapy is one of the corner stones of HL treatment, but it is associated with increased risk of cardiovascular events. As HL is often diagnosed at a young age, long-term follow-up including screening for coronary artery disease (CAD) is recommended. Objectives: This study aims to evaluate the presence of coronary artery calcium score (CACS) in relation to cardiovascular events in HL patients treated with thoracic radiotherapy compared to a non-cancer control group. Methods: Consecutive HL patients who underwent evaluation for asymptomatic CAD with coronary computed tomography angiography > 10 years after thoracic irradiation were included. The study population consisted of 97 HL patients matched to 97 non-cancer patients on gender, age, cardiovascular risk factors, and statin use. Results: Mean age during CT scan in the HL population was 45.5 ± 9.9 and in the non-cancer population 45.5 ± 10.3 years. CACS was elevated (defined as >0) in 49 (50.5%) HL patients and 30 (30.9%) control patients. HL survivors had an odds ratio of 2.28 [95% CI: 1.22–4.28] for having a CACS > 0 compared to the matched population (p = 0.006). Prevalence of CACS > 90th percentile differed significantly: 17.1% in HL survivors vs. 4.6% in the matched population (p = 0.009). Non-obstructive coronary artery stenosis was more prevalent in the HL population than in the control population (45.7% vs. 28.4%, respectively, p = 0.01). During follow-up of 8.5 [5.3; 9.9] years, nine HL patients experienced an event including two patients with a CACS of zero. No events occurred in the control population. Conclusion: In a matched study population, HL survivors have a higher prevalence of a CACS > 0 and an increased risk of cardiovascular events after thoracic irradiation compared to a matched non-cancer control group. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the efficacy and safety of the stepwise mechanical transvenous lead extraction approach in a patient population with chronically implanted transvenous leads with a long dwell time. From January 2014 till December 2018, all lead extractions with lead dwell time ≥5 years performed at our tertiary centre were retrospectively analysed. A total of 173 leads, from 78 patients (median age 68 years; 81% male) with a median dwell time of 9 years (interquartile range [IQR] 5) were extracted, with three or more leads in 42% of the patients. Right atrial leads: 41%; right ventricular pacing leads: 16%; implantable cardioverter‐defibrillator (ICD) leads: 31% (72% dual coil); coronary sinus leads: 12%. The majority (75%) of the leads had an active fixation. Most frequent indication for extraction was pocket infection/erosion (76%). Overall clinical success was 97%, and complete procedural success was 93%. Venous patency, assessed with venous angiography, was well preserved in 93% of the cases. The overall procedural complication rate was 3.8% (2.6% major and 1.3% minor). Despite the complexity of the population and a very long dwell time (median 9 years), a clinical success rate of 97% was achieved with the stepwise mechanical approach. Analysis of impeding progression of pectoral extraction suggests that dense fibrosis and sharp lead curvature in the transvenous trajectory pose a challenge. Complication rate was low, and acute venous patency was generally well preserved. [ABSTRACT FROM AUTHOR]

Implantable cardioverter defibrillators (ICDs) significantly contribute to the prevention of sudden cardiac death in selected patients. However, it is essential to identify those who are likely to not have benefit from an ICD and to defer a pulse generator exchange. Easily implementable guidelines for individual risk stratification and decision making are lacking. This study investigates the 1-year mortality of patients who underwent an ICD or cardiac resynchronization therapy with defibrillator function (CRT-D) pulse generator replacement in a contemporary real-world tertiary hospital setting. The cause of death and patient- and procedure-related factors are stratified, and predictive values for 1-year mortality are evaluated. Patients with a follow-up of ≥365 days (or prior mortality) after an ICD or CRT-D exchange at the Leiden University Medical Center from 1 January 2018 until 31 December 2021 were eligible. In total, 588 patients were included (77% male, 69 [60–76] years old, 59% primary prevention, 46% ischemic cardiomyopathy and 37% mildly reduced left ventricular ejection fraction (LVEF)). Patients undergoing a CRT-D replacement or upgrade had a significantly higher 1-year all-cause mortality (10.7% and 11.9%, respectively) compared to patients undergoing ICD (2.8%) exchange (p = 0.002). LVEF ≤ 30%, New York Heart Association class ≥ 3, estimated glomerular filtration rate ≤ 30 mL/min/m2 and haemoglobin ≤ 7 mmol/L were independently associated with mortality within 1 year after pulse generator replacement. There is a growing need for prospectively validated risk scores to weight individualized risk of mortality with the expected ICD therapy benefit and to support a well-informed, shared decision-making process. [ABSTRACT FROM AUTHOR]

Introduction: Increasing survival of adult congenital heart disease (ACHD) patients comes at the price of a range of late complications—arrhythmias, heart failure, and valvular dysfunction. Transcatheter valve interventions have become a legitimate alternative to conventional surgical treatment in selected acquired heart disease patients. However, literature on technical aspects, hemodynamic effects, and clinical outcomes of percutaneous atrioventricular (AV) valve interventions in ACHD patients is scarce. Method: This is a descriptive cohort from CAHAL (Center of Congenital Heart Disease Amsterdam-Leiden). ACHD patients with severe AV valve regurgitation who underwent a transcatheter intervention in the period 2020–2022 were included. Demographic, clinical, procedural, and follow-up data were collected from patient records. Results: Five ACHD patients with severe or torrential AV valve regurgitation are described. Two patients underwent a transcatheter edge-to-edge repair (TEER), one patient underwent a valve-in-valve procedure, one patient received a Cardioband system, and one patient received both a Cardioband system and TEER. No periprocedural complications occurred. Post-procedural AV valve regurgitation as well as NYHA functional class improved in all patients. The median post-procedural NYHA functional class improved from 3.0 (IQR [2.5–4.0]) to 2.0 (IQR [1.5–2.5]). One patient died 9 months after the procedure due to advanced heart failure with multiorgan dysfunction. Conclusion: Transcatheter valve repair is feasible and safe in selected complex ACHD patients. A dedicated heart team is essential for determining an individualized treatment strategy as well as pre- and periprocedural imaging to address the underlying mechanism(s) of AV regurgitation and guide the transcatheter intervention. Long-term follow-up is essential to evaluate the clinical outcomes of transcatheter AV valve repair in ACHD patients. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Association of Atrial Tissue Fibrosis Identified by Delayed Enhancement MRI and Atrial Fibrillation Catheter Ablation: The DECAAF Study," by N. F. Marrouche et al that was published in a 2014 issue.

Aims Ventricular tachyarrhythmias (VTs) are common in the pathologically remodelled heart. These arrhythmias can be lethal, necessitating acute treatment like electrical cardioversion to restore normal rhythm. Recently, it has been proposed that cardioversion may also be realized via optically controlled generation of bioelectricity by the arrhythmic heart itself through optogenetics and therefore without the need of traumatizing high-voltage shocks. However, crucial mechanistic and translational aspects of this strategy have remained largely unaddressed. Therefore, we investigated optogenetic termination of VTs (i) in the pathologically remodelled heart using an (ii) implantable multi-LED device for (iii) in vivo closed-chest, local illumination. Methods and results In order to mimic a clinically relevant sequence of events, transverse aortic constriction (TAC) was applied to adult male Wistar rats before optogenetic modification. This modification took place 3 weeks later by intravenous delivery of adeno-associated virus vectors encoding red-activatable channelrhodopsin or Citrine for control experiments. At 8–10 weeks after TAC, VTs were induced ex vivo and in vivo , followed by programmed local illumination of the ventricular apex by a custom-made implanted multi-LED device. This resulted in effective and repetitive VT termination in the remodelled adult rat heart after optogenetic modification, leading to sustained restoration of sinus rhythm in the intact animal. Mechanistically, studies on the single cell and tissue level revealed collectively that, despite the cardiac remodelling, there were no significant differences in bioelectricity generation and subsequent transmembrane voltage responses between diseased and control animals, thereby providing insight into the observed robustness of optogenetic VT termination. Conclusion Our results show that implant-based optical cardioversion of VTs is feasible in the pathologically remodelled heart in vivo after local optogenetic targeting because of preserved optical control over bioelectricity generation. These findings add novel mechanistic and translational insight into optical ventricular cardioversion. [ABSTRACT FROM AUTHOR]

Simple Summary: Radiotherapeutic treatment in classic Hodgkin lymphoma (CHL) survivors contributes to long-term survival but is associated with lifetime increased risk of cardiovascular events. Echocardiographic screening for left ventricular (LV) dysfunction usually assesses left ventricular ejection fraction (LVEF). Global longitudinal strain (GLS) can detect early subclinical LV dysfunction. The aim of this study was to evaluate the association of conventional echocardiographic parameters and GLS in relation to cardiovascular events in CHL survivors treated with thoracic radiotherapy. Impaired GLS was associated with increased risk of cardiovascular events. In addition, conventional echocardiographic parameters, including LVEF and diastolic dysfunction also showed a significant association with cardiovascular events and cardiac death. Assessing LV strain by echocardiography can contribute to early detection of subclinical LV dysfunction and identifying CHL patients at increased risk for cardiovascular events. Background: Treatment with thoracic irradiation for classic Hodgkin lymphoma (CHL) leads to improved survival but also increases the risk of cardiovascular events. Left ventricular (LV) dysfunction is usually assessed by echocardiographic left ventricular ejection fraction (LVEF), whereas global longitudinal strain (GLS) can detect early subclinical LV dysfunction. The purpose of this study was to evaluate if conventional echocardiographic parameters and GLS are associated with cardiovascular events during long-term follow-up. Methods: 161 consecutive CHL patients treated with radiotherapy who underwent echocardiography > 10 years after diagnosis were assessed for eligibility. Multivariable cause-specific Cox regression was performed for a composite outcome of cardiac death and cardiovascular events and the competing outcome of noncardiac death. Results: 129 patients (61.2% female, N = 79) with a mean age of 46.3 ± 11.0 years at index visit were eligible for analysis. GLS was impaired in 51 patients (39.5%) and 10.9% had a LVEF of< 50%. The median E/e' was 9.2 [7.2;12.7]. Adjusted for confounders, GLS > −16% showed a significant association with a near four-fold risk of the composite endpoint (HR = 3.95, 95% CI: 1.83–8.52, p < 0.001). LVEF < 50% (HR = 2.99, p = 0.016) and E/e' (HR = 1.16, p < 0.001) also showed a significant relationship with the outcome. None of the aforementioned parameters were associated with the competing outcome. Conclusions: This study shows that LV dysfunction including impaired GLS in CHL survivors is associated with cardiovascular events and cardiac death. [ABSTRACT FROM AUTHOR]

Aims Atrial fibrillation (AF) is the most common cardiac arrhythmia and often involves reentrant electrical activation (e.g. spiral waves). Drug therapy for AF can have serious side effects including proarrhythmia, while electrical shock therapy is associated with discomfort and tissue damage. Hypothetically, forced expression and subsequent activation of light-gated cation channels in cardiomyocytes might deliver a depolarizing force sufficient for defibrillation, thereby circumventing the aforementioned drawbacks. We therefore investigated the feasibility of light-induced spiral wave termination through cardiac optogenetics. Methods and results Neonatal rat atrial cardiomyocyte monolayers were transduced with lentiviral vectors encoding light-activated Ca2+-translocating channelrhodopsin (CatCh; LV.CatCh∼eYFP↑) or eYFP (LV.eYFP↑) as control, and burst-paced to induce spiral waves rotating around functional cores. Effects of CatCh activation on reentry were investigated by optical and multi-electrode array (MEA) mapping. Western blot analyses and immunocytology confirmed transgene expression. Brief blue light pulses (10 ms/470 nm) triggered action potentials only in LV.CatCh∼eYFP↑-transduced cultures, confirming functional CatCh-mediated current. Prolonged light pulses (500 ms) resulted in reentry termination in 100% of LV.CatCh∼eYFP↑-transduced cultures (n = 31) vs. 0% of LV.eYFP↑-transduced cultures (n = 11). Here, CatCh activation caused uniform depolarization, thereby decreasing overall excitability (MEA peak-to-peak amplitude decreased 251.3 ± 217.1 vs. 9.2 ± 9.5 μV in controls). Consequently, functional coresize increased and phase singularities (PSs) drifted, leading to reentry termination by PS–PS or PS–boundary collisions. Conclusion This study shows that spiral waves in atrial cardiomyocyte monolayers can be terminated effectively by a light-induced depolarizing current, produced by the arrhythmogenic substrate itself, upon optogenetic engineering. These results provide proof-of-concept for shockless defibrillation. [ABSTRACT FROM PUBLISHER]

Introduction: It is unknown how long-term prognosis after ST-elevation myocardial infarction (STEMI) in patients with a prior cancer diagnosis is impacted by cancer-related factors as diagnosis, stage, and treatment. We aimed to assess long-term survival trends after STEMI in this population to evaluate both cardiovascular and cancer-related drivers of prognosis over a follow-up period of 5 years. Methods: In this retrospective single-center cohort study, patients with a prior cancer diagnosis admitted with STEMI between 2004 and 2014 and treated with primary percutaneous coronary intervention (PCI) were recruited from the STEMI clinical registry of our institution. Results: In the 211 included patients, the cumulative incidence of all-cause death after 5 years of follow-up was 38.1% (N = 60). The cause of death was predominantly malignancy-related (N = 29, 48.3% of deaths) and nine patients (15.0%) died of a cardiovascular cause. After correcting for age and sex, a recent cancer diagnosis (< 1 year relative to > 10 years, HRadj 2.98 [95% CI: 1.39–6.41], p = 0.005) and distant metastasis at presentation (HRadj 4.02 [1.70–9.53], p = 0.002) were significant predictors of long-term mortality. While maximum levels of cardiac troponin-T and creatinine kinase showed significant association with mortality (resp. HRadj 1.34 [1.08–1.66], p = 0.008; HRadj 1.36 [1.05–1.76], p = 0.019), other known determinants of prognosis after STEMI, e.g., hypertension and renal insufficiency, were not significantly associated with survival. Conclusions: Patients with a prior cancer diagnosis admitted with STEMI have a poor survival rate. However, when the STEMI is optimally treated with primary PCI and medication, cardiac mortality is low, and prognosis is mainly determined by factors related to cancer stage. [ABSTRACT FROM AUTHOR]

Aims Sustained ventricular fibrillation (VF) is maintained by multiple stable rotors. Destabilization of sustained VF could be beneficial by affecting VF complexity (defined by the number of rotors). However, underlying mechanisms affecting VF stability are poorly understood. Therefore, the aim of this study was to correlate changes in arrhythmia complexity with changes in specific electrophysiological parameters, allowing a search for novel factors and underlying mechanisms affecting stability of sustained VF. Methods and results Neonatal rat ventricular cardiomyocyte monolayers and Langendorff-perfused adult rat hearts were exposed to increasing dosages of the gap junctional uncoupler 2-aminoethoxydiphenyl borate (2-APB) to induce arrhythmias. Ion channel blockers/openers were added to study effects on VF stability. Electrophysiological parameters were assessed by optical mapping and patch-clamp techniques. Arrhythmia complexity in cardiomyocyte cultures increased with increasing dosages of 2-APB (n > 38), leading to sustained VF: 0.0 ± 0.1 phase singularities/cm2 in controls vs. 0.0 ± 0.1, 1.0 ± 0.9, 3.3 ± 3.2, 11.0 ± 10.1, and 54.3 ± 21.7 in 5, 10, 15, 20, and 25 µmol/L 2-APB, respectively. Arrhythmia complexity inversely correlated with wavelength. Lengthening of wavelength during fibrillation could only be induced by agents (BaCl2/BayK8644) increasing the action potential duration (APD) at maximal activation frequencies (minimal APD); 123 ± 32%/117 ± 24% of control. Minimal APD prolongation led to transient VF destabilization, shown by critical wavefront collision leading to rotor termination, followed by significant decreases in VF complexity and activation frequency (52%/37%). These key findings were reproduced ex vivo in rat hearts (n = 6 per group). Conclusion These results show that stability of sustained fibrillation is regulated by minimal APD. Minimal APD prolongation leads to transient destabilization of fibrillation, ultimately decreasing VF complexity, thereby providing novel insights into anti-fibrillatory mechanisms. [ABSTRACT FROM PUBLISHER]

Aims Cardiac hypertrophy and fibrosis are associated with potentially lethal arrhythmias. As these substrates often occur simultaneously in one patient, distinguishing between pro-arrhythmic mechanisms is difficult. This hampers understanding of underlying pro-arrhythmic mechanisms and optimal treatment. This study investigates and compares arrhythmogeneity and underlying pro-arrhythmic mechanisms of either cardiac hypertrophy or fibrosis in in vitro models. Methods and results Fibrosis was mimicked by free myofibroblast (MFB) proliferation in neonatal rat ventricular monolayers. Cultures with inhibited MFB proliferation were used as control or exposed to phenylephrine to induce hypertrophy. At Day 9, cultures were studied with patch-clamp and optical-mapping techniques and assessed for protein expression. In hypertrophic (n = 111) and fibrotic cultures (n = 107), conduction and repolarization were slowed. Triggered activity was commonly found in these substrates and led to high incidences of spontaneous re-entrant arrhythmias [67.5% hypertrophic, 78.5% fibrotic vs. 2.9% in controls (n = 102)] or focal arrhythmias (39.1, 51.7 vs. 8.8%, respectively). Kv4.3 and Cx43 protein expression levels were decreased in hypertrophy but unaffected in fibrosis. Depolarization of cardiomyocytes (CMCs) was only found in fibrotic cultures (−48 ± 7 vs. −66 ± 7 mV in control, P < 0.001). L-type calcium-channel blockade prevented arrhythmias in hypertrophy, but caused conduction block in fibrosis. Targeting heterocellular coupling by low doses of gap-junction uncouplers prevented arrhythmias by accelerating repolarization only in fibrotic cultures. Conclusion Cultured hypertrophic or fibrotic myocardial tissues generated similar focal and re-entrant arrhythmias. These models revealed electrical remodelling of CMCs as a pro-arrhythmic mechanism of hypertrophy and MFB-induced depolarization of CMCs as a pro-arrhythmic mechanism of fibrosis. These findings provide novel mechanistic insight into substrate-specific arrhythmicity. [ABSTRACT FROM PUBLISHER]

The article discusses the causation and treatment of the degenerative aortic stenosis and focuses on the significance of Transcatheter aortic valve implantation (TAVI) technique as an alternative to surgical aortic valve replacement for the treatment of the valvular heart disease. As mentioned, there are two types of TAVI prostheses named as Medtronic Core Valve system and the Edwards-SAPIEN prosthesis. Statistics are also presented which shows the impact and efficacy of different prostheses. INSETS: Transcatheter aortic valve implantation (TAVI) for…;Preprocedural evaluation of patients who are candidates…;You can get CPD/CME credits for Education in Heart.

Aims Cardiac fibrosis is associated with increased incidence of cardiac arrhythmias, but the underlying proarrhythmic mechanisms remain incompletely understood and antiarrhythmic therapies are still suboptimal. This study tests the hypothesis that myofibroblast (MFB) proliferation leads to tachyarrhythmias by altering the excitability of cardiomyocytes (CMCs) and that inhibition of MFB proliferation would thus lower the incidence of such arrhythmias. Methods and results Endogenous MFBs in neonatal rat CMC cultures proliferated freely or under control of different dosages of antiproliferative agents (mitomycin-C and paclitaxel). At Days 4 and 9, arrhythmogeneity of these cultures was studied by optical and multi-electrode mapping. Cultures were also studied for protein expression and electrophysiological properties. MFB proliferation slowed conduction from 15.3 ± 3.5 cm/s (Day 4) to 8.8 ± 0.3 cm/s (Day 9) (n = 75, P < 0.01), whereas MFB numbers increased to 37.4 ± 1.7 and 62.0 ± 2%. At Day 9, 81.3% of these cultures showed sustained spontaneous reentrant arrhythmias. However, only 2.6% of mitomycin-C-treated cultures (n = 76, P < 0.0001) showed tachyarrhythmias, and ectopic activity was decreased. Arrhythmia incidence was drug–dose dependent and strongly related to MFB proliferation. Paclitaxel treatment yielded similar results. CMCs were functionally coupled to MFBs and more depolarized in cultures with ongoing MFB proliferation in which only L-type Ca2+-channel blockade terminated 100% of reentrant arrhythmias, in contrast to Na+ blockade (36%, n = 12). Conclusion Proliferation of MFBs in myocardial cultures gives rise to spontaneous, sustained reentrant tachyarrhythmias. Antiproliferative treatment of such cultures prevents the occurrence of arrhythmias by limiting MFB-induced depolarization, conduction slowing, and ectopic activity. This study could provide a rationale for a new treatment option for cardiac arrhythmias. [ABSTRACT FROM PUBLISHER]

Cardiac resynchronization therapy (CRT) is an effective treatment for patients with drug-refractory, chronic heart failure. Multiple single-center and multicenter studies have shown significant reductions in left ventricular (LV) volumes and an increase in LV systolic function. More importantly, CRT reduces mortality and morbidity during long-term follow-up. Current guidelines consider CRT as a Class I indication for heart failure patients in New York Heart Association (NYHA) functional class III to IV with depressed LV ejection fraction ≤35% and a wide QRS complex (≥120 ms). However, the benefits of this therapy could possibly be extended to selected subgroups of patients who do not fulfill these criteria. These subgroups include patients with mildly symptomatic heart failure and patients with a narrow QRS complex (<120 ms). Results from recent multicenter controlled clinical trials including heart failure patients in NYHA functional class I to II or with a narrow QRS complex are equivocal. Although expanding CRT to patients with a narrow QRS complex seems currently not likely, the benefits of CRT in mildly symptomatic patients are more evident. Perhaps attenuation of disease progression will prove to be a successful new treatment strategy in heart failure patients in the future. In addition, multimodality cardiac imaging will allow optimizing responder rate in patients undergoing CRT according to current guidelines. [ABSTRACT FROM AUTHOR]

Background Improvement of left ventricular ejection fraction (LVEF) after radiofrequency catheter ablation (RFCA) of frequent premature ventricular contractions (PVCs) has been reported. However, most patients with frequent PVCs have a normal LVEF. In these patients subtle and early forms of PVC-induced left and right ventricular (RV) impairment may not be detected by standard echocardiographic techniques. Objective To assess the effect of frequent PVCs on ventricular function in patients with preserved LVEF. Methods 49 patients (30 male, 49±16 years) with recent-onset (median 1.2 years), frequent PVCs (burden 26±13%) and 25 healthy controls were studied. Thirty-four patients with PVCs underwent successful RFCA. Two-dimensional echocardiography was performed at baseline and follow-up. LV volumes and LVEF were calculated by Simpson's rule. Tricuspid annulus plane systolic excursion and fractional area change were calculated to assess RV function. Multidirectional LV strain (radial, circumferential, longitudinal) and RV free-wall longitudinal strain were calculated by two-dimensional speckle tracking imaging. At baseline LVEF, volumes and RV dimensions were normal in patients and controls. Results Speckle tracking imaging demonstrated reduced LV and RV strain in patients with PVC as compared with controls. At follow-up there were no changes in LVEF, LV volumes and RV dimensions and function in patients successfully treated by RFCA and untreated patients. However, radial, circumferential and longitudinal strain improved significantly in patients after RFCA but remained unchanged in untreated patients. Conclusions Frequent PVCs can induce subtle cardiac dysfunction detected by speckle tracking imaging analysis in patients without apparent cardiomyopathy. RFCA can successfully eliminate PVCs and improve cardiac function. [ABSTRACT FROM AUTHOR]

The left atrium (LA) anterior—posterior diameter was one of the first standardised echocardiographic parameters. However, the clinical importance of LA size assessment has been neglected for some time. Recent population-based studies have demonstrated the prognostic value of LA size for long-term outcome. Furthermore, with new dedicated techniques such as tissue Doppler imaging, it has become feasible to assess (regional) LA function. In addition, the introduction of catheter ablation procedures has changed the treatment of patients with drug-refractory atrial fibrillation (AF) dramatically. New image integration systems have become available for these catheter ablation procedures. With the use of image integration systems, a real anatomical ‘roadmap’ of the LA is provided for catheter ablation procedures. All these factors may explain the renewed interest in LA anatomy. In this article, the importance of assessment of LA size and LA anatomy is discussed. Furthermore, the various imaging modalities that are available for the non-invasive visualisation of the LA will be reviewed. In addition, the role of these imaging techniques in catheter ablation procedures for AF will be discussed. [ABSTRACT FROM AUTHOR]

Objectives: Impaired cardiovascular function has been associated with cognitive deterioration; however, to what extent cardiovascular dysfunction plays a role in structural cerebral changes remains unclear. We studied whether vascular and left ventricular (LV) functions are associated with measures of cerebral small vessel disease (cSVD) in the middle-aged general population. Methods: In this cross-sectional analysis of the UK Biobank, 4366 participants (54% female, mean age 61 years) underwent magnetic resonance imaging to assess LV function (ejection fraction [EF] and cardiac index [CI]) and cSVD measures (total brain volume, grey and white matter volumes, hippocampal volume and white matter hyperintensities [WMH]). Augmentation index (AIx) was used as a measure of arterial stiffness. Linear and non-linear associations were evaluated using cardiovascular function measures as determinants and cSVD measures as outcomes. Results: EF was non-linearly associated with total brain volume and grey matter volume, with the largest brain volume for an EF between 55 and 60% (both p < 0.001). EF showed a negative linear association with WMH (- 0.23% [- 0.44; - 0.02], p = 0.03), yet no associations were found with white matter or hippocampal volume. CI showed a positive linear association with white matter (β 3194 mm3 [760; 5627], p = 0.01) and hippocampal volume (β 72.5 mm3 [23.0; 122.0], p = 0.004). No associations were found for CI with total brain volume, grey matter volume or WMH. No significant associations were found between AIx and cSVD measures. Conclusions: This study provides novel insights into the complex associations between the heart and the brain, which could potentially guide early interventions aimed at improving cardiovascular function and the prevention of cSVD. Key Points: • Ejection fraction is non-linearly and cardiac index is linearly associated with MRI-derived measures of cerebral small vessel disease. • No associations were found for arterial stiffness with cSVD measures. [ABSTRACT FROM AUTHOR]

Rationale: The impact of prophylactic implantable cardioverter-defibrillator (ICD) implantation on the psychological well-being of patients on dialysis is unknown. Objective: We aimed to identify the effect of primary ICD implantation on quality of life (QoL), mood and dispositional optimism in patients undergoing dialysis. Methods and results: We performed a prespecified subanalysis of the randomized controlled ICD2 trial. In total, 177 patients on chronic dialysis, with an age of 55–81 years, and a left ventricular ejection fraction of ≥ 35%, were included in the per-protocol analysis. Eighty patients received an ICD for primary prevention, and 91 patients received standard care. The Short Form-36 (SF-36), Geriatric Depression Scale-15 (GDS-15), Revised Life Orientation Test (LOT-R) questionnaires were administered prior to ICD implantation (T0), and at 1-year follow-up (T1) to assess QoL, depression and optimism, respectively. The patients were predominantly male (76.0%), with a median age of 67 years. Hemodialysis was the predominant mode of dialysis (70.2%). The GDS-15 score difference (T1 − T0) was 0.5 (2.1) in the ICD group compared with 0.3 (2.2) in the control group (mean difference − 0.3; 95% CI − 1.1 to 0.6; P = 0.58). The LOT-R score difference was − 0.2 (4.1) in the ICD group compared with − 1.5 (4.0) in the control group (mean difference − 1.1 (0.8); 95% CI − 2.6 to 0.4; P = 0.17). The mean difference scores of all subscales of the SF-36 were not significantly different between randomization groups. Conclusions: In our population of patients on dialysis, ICD implantation did not affect QoL, mood or dispositional optimism significantly during 1-year follow-up. Clinical Trial Registration: Unique identifier: ISRCTN20479861. http://www.controlled-trials.com. [ABSTRACT FROM AUTHOR]

Background: Aortic stiffness, assessed through pulse wave velocity (PWV), is an independent predictor for cardiovascular disease risk. However, the scarce availability of normal and reference values for cardiovascular magnetic resonance imaging (CMR) based PWV is limiting clinical implementation. The aim of this study was to determine normal and reference values for CMR assessed PWV in the general population. Methods: From the 2,484 participants of the Netherlands Epidemiology of Obesity (NEO) study that have available CMR-PWV data, 1,394 participants free from cardiovasculard disease, smokers or treatment for diabetes, hypertension or dyslipidaemia were selected (45–65 years, 51% female). Participants were divided into sex, age and blood pressure (BP) subgroups. Normal values were specified for participants with a BP < 130/80 mmHg and reference values for elevated BP subgroups (≥ 130/80 and < 140/90 mmHg; and ≥ 140/90 mmHg). Differences between groups were tested with independent samples t-test or ANOVA. Due to an oversampling of obese individuals in this study, PWV values are based on a weighted analysis making them representative of the general population. Results: Normal mean PWV was 6.0 m/s [95% CI 5.8–6.1]. PWV increased with advancing age and BP categories (both p < 0.001). There was no difference between sex in normal PWV, however in the BP > 140/90 mmHg women had a higher PWV (p = 0.005). The interpercentile ranges were smaller for participants < 55 years old compared to participants ≥ 55 years, indicating an increasing variability of PWV with age. PWV upper limits were particularly elevated in participants ≥ 55 years old in the high blood pressure subgroups. Conclusion: This study provides normal and reference values for CMR-assessed PWV per sex, age and blood pressure category in the general population. [ABSTRACT FROM AUTHOR]

Background: J‐waves and fragmented QRS (fQRS) on surface ECGs have been associated with the occurrence of ventricular tachyarrhythmias. Whether these non‐invasive parameters can also predict ventricular tachycardia (VT) recurrence after radiofrequency catheter ablation (RFCA) is unknown. Of interest, patients with a wide QRS‐complex have been excluded from clinical studies on J‐waves, although a J‐wave like pattern has been described for wide QRS. Methods: We retrospectively included 168 patients (67 ± 10 years; 146 men) who underwent RFCA of post‐infarct VT. J‐wave pattern were defined as J‐point elevation ≥ 0.1 mV in at least two leads irrespective of QRS width. fQRS was defined as various RSR' pattern in patients with narrow QRS and more than two R wave in those with wide QRS. The primary endpoint was VT recurrence after RFCA up to 24 months. Results: J‐wave pattern and fQRS were present in 27 and 28 patients, respectively. Overlap of J‐wave pattern and fQRS was observed in nine. During a median follow‐up of 20 (interquartile range 9–24) months, 46 (27%) patients had VT recurrence. Kaplan–Meier curves revealed that both J‐wave pattern and fQRS were associated with VT recurrence. Multivariate Cox regression analysis demonstrated that the presence of J‐wave pattern (hazard ratio [HR] 2.84; 95% confidence interval [CI] 1.45–5.58; P =.002) and greater number of induced VT (HR 1.29; 95% CI 1.15–1.45; P <.001) were the independent predictors of VT recurrence. Conclusions: A J‐wave pattern—but not fQRS—is independently associated with an increased risk of post‐infarct VT recurrence after RFCA irrespective of QRS width. This simple non‐invasive parameter may identify patients who require additional treatment. [ABSTRACT FROM AUTHOR]

To evaluate immediate success and 6-month restenosis rate, 70 Micro Stents II were implanted for 65 stenoses in 63 patients (age 59+/-9 years). Stable angina pectoris was present in 47% of the patients (38% class I to III; 9% class IV), whereas 32% had postinfarction angina and 21% had unstable angina. Indications for stent implantation were elective in 62% and semi-elective in 38% of the patients. Sixty-two percent of the patients received ticlopidin and acetylsalicylic acid for 28 days, whereas 38% of the patients received only acetylsalicylic acid. All stents were deployed successfully at the target site. Subacute closure occurred in 2 patients (3%), both of whom were not treated with ticlopidin. Two other patients (3%) developed non-Q-wave infarction after side branch occlusion during the procedure. The minimum lumen diameter increased from 1.0+/-0.5 mm to 2.8+/-0.4 mm after stent implantation. At follow-up the loss in diameter was 0.9+/-0.6 mm, indicating a net gain of 0.9+/-0.8 mm. Late clinical events (4 weeks to 6 months) were coronary angioplasty of a stented segment (3%), coronary angioplasty of a nonstented segment (10%), and coronary artery bypass grafting (2%). No deaths or myocardial infarction occurred. The procedural success rate was 94% and the event-free survival at 6-month follow-up was 79%. Micro Stent II implantation can be done with a high rate of immediate success and good 6-month outcome. The Micro Stent II has proven to be a versatile device that can also be used in patients with less favorable coronary anatomy or lesion characteristics. [ABSTRACT FROM AUTHOR]