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Background: In addition to increased cardiovascular risk, patients with primary aldosteronism (PA) also suffer from impaired health-related qual ity of life (HRQoL) and psychological symptoms. We assessed for changes in HRQoL and de pressive symptoms in a cohort of Asian patients with PA, after surgical and medical therapy. Methods: Thirty-four patients with PA were prospectively recruited and completed questionnaires from 2017 to 2020. HRQoL was assessed using RAND -36 and EQ-5D-3L, and depressive symptoms were assessed using Beck Depression Inventory (BDI-II) at baseline, 6 months, and 1 year post-treatment. Results: At 1 year post-treatment, significant improvement was observed in both physical and mental summative scores of RAND-36, +3.65, P = 0.023, and +3.41, P = 0.033, respectively, as well as four subscale domains (physical functioning, bodily pain, role emotional, and mental health). Significant improvemen t was also seen in EQ-5D dimension of anxiety/depression at 1 year post-treatment. Patients treated with surgery (n = 21) had significant improvement in EQ-5D index score post-treat ment and better EQ-5D outcomes compared to the medical group (n = 13) at 1 year post-treatment. 37.9, 41.6 and 58.6% of patients had symptoms in the cognitive, affective and somatic domains of BDI-II, respectively. There was a significant improve ment in the affective domain of BDI-II at 1 year post-treatment. Conclusion: Both surgical and medical therapy improve HRQoL and psychologi cal symptoms in patients with PA, with surgery providing better outcomes. This highlights the importance of early diagnosis, accurate subtyping and appropriate treatment of PA.

Modeling is regarded as a suitable tool to improve biomass pyrolysis in terms of efficiency, product yield, and controllability. However, it is crucial to develop advanced models to estimate products' yield and composition as functions of biomass type/characteristics and process conditions. Despite many developed models, most of them suffer from insufficient validation due to the complexity in determining the chemical compounds and their quantity. To this end, the present paper reviewed the modeling and verification of products derived from biomass pyrolysis. Besides, the possible solutions towards more accurate modeling of biomass pyrolysis were discussed. First of all, the paper commenced reviewing current models and validating methods of biomass pyrolysis. Afterward, the influences of biomass characteristics, particle size, and heat transfer on biomass pyrolysis, particle motion, reaction kinetics, product prediction, experimental validation, current gas sensors, and potential applications were reviewed and discussed comprehensively. There are some difficulties with using current pyrolysis gas chromatography and mass spectrometry (Py-GC/MS) for modeling and validation purposes due to its bulkiness, fragility, slow detection, and high cost. On account of this, the applications of Py-GC/MS in industries are limited, particularly for online product yield and composition measurements. In the final stage, a recommendation was provided to utilize high-temperature sensors with high potentials to precisely validate the models for product yield and composition (especially CO, CO2, and H2) during biomass pyrolysis.

Bimetallic nanoparticles comprised of iron and nickel were synthesized, characterized, and evaluated to optimize the ideal metal ratio for azo dye removal from water systems. Results show that changing the molar ratio of nickel to iron caused different removal rates, as well as the extent of overall elimination of azo dye from water. Lower molar ratios, from Ni1Fe10 to Ni2.5Fe10, exhibited a higher removal efficiency of 80-99%. Higher concentrations of Ni in the catalyst, from Ni3Fe10 to Ni5Fe10, resulted in 70-90% removal. The lower molar ratios of Ni exhibited a consistent removal rate of 0.11 g/L/min, while the higher molar ratios of Ni displayed varying removal rates of 0.1-0.05 g/L/min. A second order kinetic model was fit to the first twenty minutes of the reaction for all nickel to iron compositions, where there is a decrease in rate constant with an increase in molar ratio. During the last forty minutes of reaction, azo dye removal fit a zero order kinetic model. All as-synthesized nanoparticle samples were found to be structurally disordered based on the lack of distinct peaks in XRD spectra. Post-reaction samples were found to have Fe2O3 and FeOOH cubic peaks.

Background: Among patients with structural heart disease with ventricular tachycardia (VT) refractory to medical therapy and catheter ablation, cardiac stereotactic body radiotherapy (SBRT) is a paradigm-changing treatment option., Aims: To assess the efficacy of cardiac SBRT in refractory VT by comparing the rates of VT episodes, anti-tachycardia pacing (ATP) therapies, and implantable cardioverter-defibrillator (ICD) shocks post-SBRT with pre-SBRT., Methods: We performed a comprehensive literature search and included all clinical studies reporting outcomes on cardiac SBRT for VT. Treatment efficacy was evaluated as random-effects pooled rate-ratios of VT episodes, ATP therapies and ICD shocks post-SBRT (after 6-week blanking) and pre-SBRT, with patients serving as their own controls. Post-SBRT overall survival was assessed using Kaplan-Meier method., Results: We included 23 studies published 2017-2024 reporting on 225 patients who received cardiac SBRT, with median follow-up 5.8-28 months. There was significant heterogeneity among the studies for all 3 efficacy endpoints (p<0.00001). The random-effects pooled rate-ratios of VT episodes, ATP therapies and ICD shocks post- versus pre-SBRT were 0.10 (95% CI 0.06, 0.16), 0.09 (0.05, 0.15), and 0.09 (0.05, 0.17), respectively (all p<0.00001). The most common reported complications included pericardial (8.0%, including 0.9% late gastroesophageo-pericardial fistula) and pulmonary (5.8%). There was no change in left ventricular ejection fraction post-SBRT (p=0.3) but some studies reported an increase in mitral regurgitation. The combined 3-, 12- and 24-month overall patient survival was 0.86 (0.80, 0.90), 0.72 (0.65, 0.78) and 0.57 (0.47, 0.67) respectively., Conclusion: Among patients with refractory VT in context of structural heart disease, VT burden and ICD shocks are dramatically reduced following cardiac SBRT. The overall mortality in this population with heart failure and refractory VT receiving palliative cardiac SBRT remains high., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: The use of ultrasound (US)-guided venous puncture for cardiac pacing/defibrillation lead placement may minimize the risk of periprocedural complications and radiation exposure. However, none of the published studies have been sufficiently powered to recommend this approach as the standard of care. We compare the safety and efficacy of ultrasound-guided axillary venous puncture (US-AVP) vs. fluoroscopy-guided access for cardiac implantable electronic devices (CIEDs) by performing an individual patient data meta-analysis based on previously published studies., Methods and Results: We conducted a thorough literature search encompassing longitudinal investigations (five randomized and one prospective studies) reporting data on X-ray-guided and US-AVP for CIED procedures. The primary endpoint was to compare the safety of the two techniques. Secondary endpoints included the success rate of each technique, the necessity of switching to alternative methods, the time needed to obtain venous access, X-ray exposure, and the occurrence of periprocedural complications. Six longitudinal eligible studies were identified including 700 patients (mean age 74.9 ± 12.1 years, 68.4% males). The two approaches for venous cannulation showed a similar success rate. The use of an X-ray-guided approach significantly increased the risk of inadvertent arterial punctures (OR: 2.15, 95% CI: 2.10-2.21, P = 0.003), after adjustment for potential confounders. Conversely, a US-AVP approach reduces time to vascular access, radiation exposure, and the number of attempts to vascular access., Conclusion: The US-AVP enhances safety by reducing radiation exposure and time to vascular access while maintaining a low rate of major complications compared to the X-ray-guided approach., Clinical Trial Registration: PROSPERO identifier: CRD42024539623., Competing Interests: Conflict of interest: F.V., M.Z., Mi.M., M.B., P.C., Ma.M., S.F., F.M., J.J.-D., F.H.S., S.H.S., and A.M.C. have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article. A.P.T. has received speaking fees from Biotronik, Boston Scientific, and Meril Life. A.N.K. is a Proctor for Medtronic., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The utility of standard published electrocardiographic (ECG) criteria for left ventricular hypertrophy (LVH) in patients with left bundle branch block (LBBB) is not established. We have previously shown that in ECGs demonstrating LBBB, QRS duration outperforms vectorcardiographic X, Y, Z lead and root-mean-squared (3D) amplitudes and voltage-time-integrals in diagnosing LVH and dilation. We sought to evaluate diagnostic yields of published LVH criteria versus QRS duration for ECG based diagnosis of LVH and dilation in presence of LBBB., Methods: We included adult patients with typical LBBB having ECG and transthoracic echocardiogram performed within 3 months of each other in 2010-2020. We obtained area under receiver-operator characteristic curve (AUC) for QRS duration and each of the published ECG LVH criteria to predict increased LV mass indexed (↑LVMi, women >95 g/m 2 , men >115 g/m 2 ) and LV end diastolic volume indexed (↑LVEDVi, women >61 mL/m 2 , men >74 mL/m 2 )., Results: Among 413 adults (53 % women, age 73 ± 12 yr) with LBBB, the traditional LVH criteria performed poorly to detect ↑LVMi or ↑LVEDVi. Cornell voltage-duration product had the highest AUCs (↑LVMi 0.634, ↑LVEDVi 0.580). QRS duration had a higher AUC for diagnosing ↑LVMi (women 0.657, men 0.703) and ↑LVEDVi (women 0.668, men 0.699) compared to any other criteria., Conclusions: In patients with LBBB, prolonged QRS duration (women ≥150 ms, men ≥160 ms) is a superior predictor of LVH and dilation than traditional ECG-based LVH criteria., Competing Interests: Declaration of competing interest None. AUTHOR STATEMENT. Ashley DeBauge: Conceptualization, Methodology, Formal analysis, Investigation, Data Curation, Writing - Original Draft. Christopher J. Harvey: Methodology, Software, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft. Amulya Gupta: Methodology, Formal analysis, Tyan Fairbank: Investigation, Data Curation. Sagar Ranka: Investigation, Data Curation. Sania Jiwani: Investigation, Data Curation. Madhu Reddy: Supervision, Writing - Review & Editing. Seth H. Sheldon: Supervision, Writing - Review & Editing. Amit Noheria: Conceptualization, Methodology, Validation, Formal analysis, Resources, Writing - Review & Editing, Supervision., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation (AF) leads to impaired left atrial appendage contractility, increasing the risk of thromboembolic stroke. The left atrial appendage emptying velocity (LAAev) measured on transesophageal echocardiogram (TEE) is a marker of increased thromboembolic risk., Objectives: The purpose of this study was to evaluate predictors of reduced LAAev for identifying individuals at increased risk for cardioembolic stroke., Methods: This was a single-center retrospective review of TEEs and clinical charts. Predictors of LAAev <30 cm/s were identified using logistic regression. A risk prediction model was created using stepwise selection in a derivation set (n = 695) and separately tested in a validated set (n = 300)., Results: We included TEEs on 995 patients (age 71.3±12.7 years; female 38.1%; history of AF 82.1%; in AF at evaluation 27.7%; CHA 2 DS 2 -VASc score 4.1 ± 1.9; LAAev 41.6 ± 21.0 cm/s). Significant multivariable predictors of LAAev <30 cm/s in derivation set were used to create the CHIRP 3 M -1 score containing 8 variables: Coronary artery disease (1), congestive Heart failure (1), Increased left atrial volume index ≥42 mL/m 2 (1), current Rhythm AF (1), Paroxysmal AF (2), Persistent AF (3), longstanding Persistent/permanent AF (4), and greater than moderate Mitral regurgitation (-1). In the validation set, as compared to intermediate scores (3-4), those with low scores (≤2) and high scores (≥5) had odds ratios for LAAev <30 cm/s of 0.41 (0.21, 0.78, P = .007) and 2.58 (95% confidence interval 1.45-4.61, P = .001), respectively., Conclusion: We developed and validated a novel risk stratification system to predict reduced LAAev using clinical and echocardiographic variables. This may help refine the stratification of cardioembolic stroke risk., Competing Interests: Disclosures The authors have no conflicts to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Pulsed-field ablation (PFA) is a novel technology for atrial fibrillation (AF) ablation that can deliver energy precisely with a lower risk of damage to the surrounding organs. Persistent left superior vena cava (PLSVC) is a congenital variant that can act as a driver of AF, and its isolation may be required in recurrent persistent AF. We describe a case where PFA was used for isolation of the right superior vena cava, PLSVC, and posterior wall of the left atrium., Competing Interests: The authors report no conflicts of interest for the published content. No funding information was provided., (Copyright: © 2024 Innovations in Cardiac Rhythm Management.)

Introduction: Catheter ablation (CA) can interfere with cardiac implantable electronic device (CIED) function. The safety of CA in the 1st year after CIED implantation/lead revision is uncertain., Methods: This single center, retrospective cohort included patients who underwent CA between 2012 and 2017 and had a CIED implant/lead revision within the preceding year. We assessed the frequency of device/lead malfunctions in this population., Results: We identified 1810 CAs in patients between 2012 and 2017, with 170 CAs in 163 patients within a year of a CIED implant/lead revision. Mean age 68 ± 12 years (68% men). Time between the CIED procedure and CA was 158 ± 99 days. The CA procedures included AF ablation (n = 57, 34%), AV node ablation (n = 40, 24%), SVT ablation (n = 37, 22%), and PVC/VT ablations (n = 36, 21%). The cumulative frequency of lead dislodgement, significant CIED dysfunction, and/or CIED-related infection following CA was (n = 1/170, 0.6%). There was a single atrial lead dislodgement (0.6%). There were no instances of power-on-reset or CIED-related infection. Following CA, there was no significant difference in RA or RV lead sensing (p = 0.52 and 0.84 respectively) or thresholds (p = 0.94 and 0.17 respectively). The RA impedance slightly decreased post-CA from 474 ± 80 Ohms to 460 ± 73 Ohms (p = 0.002), as did the RV impedance (from 515 ± 111 Ohms to 497 ± 98 Ohms, p < 0.0001)., Conclusions: CA can be performed within 1 year following CIED implantation/lead revision with a low risk of CIED/lead malfunction or lead dislodgement. The ideal time to perform CA after a CIED remains uncertain., (© 2024 Wiley Periodicals LLC.)

Background: Left atrial appendage (LAA) occlusion (LAAO) is performed to prevent LAA thrombus in patients with atrial fibrillation (AF). The risk of device-related thrombus (DRT) on the atrial side of the LAAO device is approximately 4%. Identifying patients at high risk of DRT would enable closer surveillance and more-aggressive anticoagulation to prevent post-LAAO DRT-related stroke., Methods: From the LAAO registry at The University of Kansas Medical Center, we identified patients who developed DRT. We chose 3 unmatched controls per DRT case from LAAO recipients without DRT. Predictor variables were obtained from transesophageal echocardiogram reports and/or images, transthoracic echocardiogram reports, and chart review. Implant depth was measured from the limbus of the left atrial ridge to the centre of the atrial aspect of the LAAO device, on a 45° transesophageal echocardiogram view., Results: We identified 26 patients with DRT (aged 77.7 ± 9.7 years; 34.6% female) and selected 78 unmatched controls without DRT. Univariate predictors of DRT, comprising a novel TED-F 2 score, included history of venous T hromboembolism (23.1% vs 5.1%, P  = 0.01), an LAA E mptying velocity ≤ 20 cm/s (45.8% vs 18.9%, P  = 0.01), an implant D epth > 2 cm (34.6% vs 12.8%, P  = 0.02), and presence of A F rhythm at time of device implantation (50.0 % vs 11.5%, P  = 0.0001). A TED-F 2 score of ≥ 3 was very strongly associated with DRT-odds ratio 12.5 (95% confidence interval, 3.8-41.1, P < 0.0001)., Conclusions: We propose a novel risk score to predict development of DRT after LAAO, comprising history of venous T hromboembolism, LAA E mptying velocity ≤ 20 cm/s, implant D epth > 2 cm (1 point each), and an A F rhythm at implantation (2 points). A TED-F 2 risk score of ≥ 3 identified patients who are at greatly elevated risk of developing DRT., (© 2024 The Authors.)

Background: Cardiac resynchronization therapy (CRT) is indicated for patients with heart failure with reduced left ventricular ejection fraction (LVEF) and chronic right ventricular (RV) pacing burden ≥40% (pacing-induced cardiomyopathy, PICM). It is uncertain whether baseline RV pacing burden impacts response to CRT., Methods: We conducted a retrospective study of all CRT upgrades for PICM at our hospital from January 2017 to December 2018. Univariate and multivariable-adjusted changes in LVEF, and echocardiographic response (≥10% improvement in LVEF) at 3-12 months post-CRT upgrade were compared in those with RV pacing burden ≥90% versus <90%., Results: We included 75 patients (age 74 ± 11 years, 71% male) who underwent CRT upgrade for PICM. The baseline RV pacing burden was ≥90% in 56 patients (median 99% [IQR 98%-99%]), and <90% in 19 patients (median 79% [IQR 73%-87%]). Improvement in LVEF was greater in those with baseline RV pacing burden ≥90% versus <90% (15.7 ± 9.3% vs. 7.5 ± 9.6%, p = .003). Baseline RV pacing burden ≥90% was a strong predictor of an improvement in LVEF ≥10% after CRT upgrade both in univariate and multivariate-adjusted models (p = .005 and .02, respectively)., Conclusion: A higher baseline RV pacing burden predicts a greater improvement in LVEF after CRT upgrade for PICM., (© 2024 Wiley Periodicals LLC.)

Atopic dermatitis (AD) is a chronic burdensome inflammatory skin disease with well-established cutaneous and systemic comorbidities and disease burden. AD particularly has profound impacts on sleep in individuals of all ages. Sleep disturbances (SDs) affect 6.2% of school-age children and 33-87.1% of adults with AD. This narrative review addresses the burden of SD in AD patients, as well as biological mechanisms of SD in AD, including biological clocks influencing sleep, inflammation, and behavior. Approaches for early detection, diagnosis, objective quantification, patient education, and management are reviewed. It is imperative to break the itch-scratch cycle to reduce SDs and improve quality of life in individuals with AD.

Background: Right bundle branch block (RBBB) can be benign or associated with right ventricular (RV) functional and structural abnormalities. Our aim was to evaluate QRS-T voltage-time-integral (VTI) compared to QRS duration and lead V1 R' as markers for RV abnormalities., Methods: We included adults with an ECG demonstrating RBBB and echocardiogram obtained within 3 months of each other, between 2010 and 2020. VTI QRS and VTI QRST were obtained for 12 standard ECG leads, reconstructed vectorcardiographic X, Y, Z leads and root-mean-squared (3D) ECG. Age, sex and BSA-adjusted linear regressions were used to assess associations of QRS duration, amplitudes, VTIs and lead V1 R' duration/VTI with echocardiographic tricuspid annular plane systolic excursion (TAPSE), RV tissue Doppler imaging S', basal and mid diameter, and systolic pressure (RVSP)., Results: Among 782 patients (33% women, age 71 ± 14 years) with RBBB, R' duration in lead V1 was modestly associated with RV S', RV diameters and RVSP (all p ≤ 0.03). QRS duration was more strongly associated with RV diameters (both p < 0.0001). Amplitude QRS-Z was modestly correlated with all 5 RV echocardiographic variables (all p ≤ 0.02). VTI R'-V1 was more strongly associated with TAPSE, RV S' and RVSP (all p ≤ 0.0003). VTI QRS-Z and VTI QRST-Z were among the strongest correlates of the 5 RV variables (all p < 0.0001). VTI QRST-Z .√BSA cutoff of ≥62 μVsm had sensitivity 62.7% and specificity 65.7% for predicting ≥3 of 5 abnormal RV variables (AUC 0.66; men 0.71, women 0.60)., Conclusion: In patients with RBBB, VTI QRST-Z is a stronger predictor of RV dysfunction and adverse remodeling than QRS duration and lead V1 R'., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Standard ECG criteria for left ventricular (LV) hypertrophy rely on QRS amplitudes. However, in the setting of left bundle branch block (LBBB), ECG correlates of LV hypertrophy are not well established. We sought to evaluate quantitative ECG predictors of LV hypertrophy in the presence of LBBB., Methods: We included adult patients with typical LBBB having ECG and transthoracic echocardiogram performed within 3 months of each other in 2010-2020. Orthogonal X, Y, Z leads were reconstructed from digital 12‑lead ECGs using Kors's matrix. In addition to QRS duration, we evaluated QRS amplitudes and voltage-time-integrals (VTIs) from all 12 leads, X, Y, Z leads and 3D (root-mean-squared) ECG. We used age, sex and BSA-adjusted linear regressions to predict echocardiographic LV calculations (mass, end-diastolic and end-systolic volumes, ejection fraction) from ECG, and separately generated ROC curves for predicting echocardiographic abnormalities., Results: We included 413 patients (53% women, age 73 ± 12 years). All 4 echocardiographic LV calculations were most strongly correlated with QRS duration (all p < 0.00001). In women, QRS duration ≥ 150 ms had sensitivity/specificity 56.3%/64.4% for increased LV mass and 62.7%/67.8% for increased LV end-diastolic volume. In men, QRS duration ≥ 160 ms had a sensitivity/specificity 63.1%/72.1% for increased LV mass and 58.3%/74.5% for increased LV end-diastolic volume. QRS duration was best able to discriminate eccentric hypertrophy (area under ROC curve 0.701) and increased LV end-diastolic volume (0.681)., Conclusions: In patients with LBBB, QRS duration (≥ 150 in women and ≥ 160 in men) is a superior predictor of LV remodeling esp. eccentric hypertrophy and dilation., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The subcutaneous ICD (S-ICD) is a viable alternative to transvenous ICD and avoids intravascular complications in patients without a pacing indication. The outcomes of S-ICD implantation are uncertain in patients with prior sternotomy., Objective: We aim to compare the implant techniques and outcomes with S-ICD implantation in patients with and without prior sternotomy., Methods: Multicenter retrospective cohort study including adult patients with an S-ICD implanted between January 2014 and June 2020. Outcomes were compared between patients with and without prior sternotomy., Results: Among the 212 patients (49 ± 15 years old, 43% women, BMI 30 ± 8 kg/m 2 , 68% primary prevention, 30% ischemic cardiomyopathy, LVEF median 30% IQR 25%-45%) who underwent S-ICD implantation, 47 (22%) had a prior sternotomy. There was no difference in the sensing vector (57% vs. 53% primary, p = 0.55), laterality of the S-ICD lead to the sternum (94% vs. 96% leftward, p = 0.54), or the defibrillation threshold (65 ± 1.4 J vs. 65 ± 0.8 J, p = 0.76) with versus without prior sternotomy. The frequency of 30-day complications was similar with and without prior sternotomy (n = 3/47 vs. n = 15/165, 6% vs. 9%, p = 0.56). Over a median follow-up of 28 months (IQR 10-49 months), the frequency of inappropriate shocks was similar between those with and without prior sternotomy (n = 3/47 and n = 16/165, 6% vs. 10%, p = 0.58)., Conclusion: Implantation of an S-ICD in patients with prior sternotomy is safe with a similar risk of 30-day complications and inappropriate ICD shocks as patients without prior sternotomy., (© 2022 Wiley Periodicals LLC.)

Background: Many techniques exist for venous access (VA) during cardiac implantable electronic device (CIED) implantation., Objective: We sought to evaluate the learning curve with ultrasound (US) guided axillary vein access (USAA)., Methods: Single-center prospective randomized controlled trial of patients undergoing CIED implantation. Patients were randomized in a 2:1 fashion to USAA versus conventional VA techniques. The primary outcomes were the success rates, VA times and 30-day complication rates., Results: The study included 100 patients (age 68 ± 14 years, BMI 27 ± 4 kg/m 2 ). USAA was successful in 66/70 implants (94%). Initial attempts at conventional VA included 47% axillary (n = 14), 30% (n = 9) cephalic, and 23% (n = 7) subclavian. The median access time was longer for USAA than conventional access (8.3 IQR 4.2-15.3 min vs. 5.2 IQR 3.4-8.6 min, p = .009). Among the five inexperienced USAA implanters, there was a significant improvement in median access time from first to last tertile of USAA implants (17.0 IQR 7.0-21.0 min to 8.6 IQR 4.5-10.8 min, p = .038). The experienced USAA implanter had similar access times with USAA compared with conventional access (4.0 IQR 3.3-4.7 min vs. 5.2 IQR 3.4-8.6 min, p = .15). Venograms were less common with USAA than conventional access (2% vs. 33%, p < .0001). The 30-day complication rate was similar with USAA (n = 4/70, 6%) versus conventional (n = 3/30, 10%, p = .44)., Conclusion: Although the success rate with USAA was high, there was a significant learning curve. Once experienced with the USAA technique, there is the potential for reduced complications without adding to the procedure duration., (© 2022 Wiley Periodicals LLC.)

Cardiac implantable electronic devices, including implantable cardioverter-defibrillators and therapy, are part of guideline-indicated treatment for a subset of patients with heart failure with reduced ejection fraction. Current technological advancements in cardiac implantable electronic devices have allowed the detection of specific physiological parameters that are used to forecast clinical decompensation through algorithmic, multiparameter remote monitoring. Other recent emerging technologies, including cardiac contractility modulation and baroreflex activation therapy, may provide symptomatic or physiological benefits in patients without indications for cardiac resynchronization. Our goal in this state-of-the-art review is to describe the new commercially available technologies, their purported mechanisms of action, and the evidence surrounding their clinical roles, limitations and future directions. Finally, we underline the need for standardized workflow and close interdisciplinary management of this population to ensure the delivery of high-quality care., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Study Objectives: Obstructive sleep apnea (OSA) negatively impacts health-related quality of life (HR-QoL) in adults, but few pediatric studies have explored this relationship or the relationships between HR-QoL domains., Methods: Patients aged 8-17 years visiting the sleep laboratory from July 2019 to January 2020 for overnight polysomnography participated in the study. Controls seen for problems other than sleep disturbance were recruited from Department of Pediatrics outpatient clinics. HR-QoL was assessed by Patient-Reported Outcome Measure Information System (PROMIS) profile questionnaires, version 2.0. Statistical analysis was conducted using R 3.6.0 (R Foundation for Statistical Computing, Vienna, Austria)., Results: One hundred twenty-two patients were included in the final analysis. Sixty-four patients were males (52.4%). Twenty-nine (23.8%) had mild OSA, 8 (6.6%) had moderate OSA, 17 (13.9%) had severe OSA, 46 (37.7%) were without OSA, and 22 (18.0%) were controls. Patients referred for polysomnography had lower physical function mobility compared with controls ( P = .03). Increased OSA severity was linearly associated with a decrease in physical function mobility ( P = .008). Correlation analysis revealed that physical function mobility was positively associated with total sleep time ( P = .02) and negatively associated with apnea-hypopnea index ( P = .01). Age was positively associated with fatigue ( P = .02) and negatively associated with deep sleep ( P < .001). Regression analysis revealed that physical function mobility was positively associated with total sleep time ( P = .02) and negatively associated with apnea-hypopnea index ( P = .04) after controlling for age, sex, and number of arousals., Conclusions: OSA and total sleep time were associated with problems with physical function mobility after adjusting for age, sex, and number of arousals., Citation: Xu S, Turakhia S, Miller M, et al. Association of obstructive sleep apnea and total sleep time with health-related quality of life in children undergoing a routine polysomnography: a PROMIS approach. J Clin Sleep Med . 2022;18(3):801-808., (© 2022 American Academy of Sleep Medicine.)

Background: Patients with left ventricular assist devices (LVAD) often tolerate ventricular arrhythmias (VA). We aim to assess the frequency and outcomes of ICD therapies averted by ultraconservative ICD programming (UCP) in LVAD patients., Methods: This single center, retrospective cohort study included patients with LVADs and ICDs implanted from 2015 to 2019 that had UCP. The aim for UCP was to maximally delay VA treatments and maximize anti-tachycardia pacing (ATP) prior to ICD shocks. VA events were reviewed after UCP and evaluated under prior conservative programming to assess for potentially averted events (that would have resulted in either ATP or defibrillation with prior programming)., Results: Fifty patients were included in the study with follow-up of median 16 ± 10.2 months after UCP. The median time from LVAD implantation to reprogramming was 7 days (IQR 5-9 days). Fourteen patients (28%) had potentially averted VA events that would have been treated with their prior ICD programming (82 total events, median two events per patient, IQR 1-10 events). Treated VA events occurred in 15 patients (30%). Eleven of the 14 patients with potentially averted VAs had treated events as well. Only one patient reported definitive symptoms of self-limited "dizziness" during a potentially averted event that did not result in hospitalization. No patients died of complications from or needed emergent care/hospitalization due a potentially averted VA., Conclusions: UCP in LVAD patients likely prevented unnecessary VA treatments in many patients with minimal reported symptoms during these potentially averted events. Prospective studies are necessary to confirm these findings., (© 2022 Wiley Periodicals LLC.)

Introduction: Electromagnetic interference (EMI) from left ventricular assist devices (LVADs) can cause implantable cardioverter-defibrillator (ICD) oversensing. We sought to assess the frequency of inappropriate shocks/oversensing due to LVAD-related EMI and prospectively compare integrated (IB) versus dedicated bipolar (DB) sensing in patients with LVADs., Methods: Single-center study in LVAD patients with Medtronic or Abbott ICDs between September 2017 and March 2020. We excluded patients that were pacemaker dependent. Measurements were obtained of IB and DB sensing and noise to calculate a signal-to-noise ratio (SNR). Device checks were reviewed to assess appropriate and inappropriate sensing events., Results: Forty patients (age 52 ± 14 years, 75% men, 38% ischemic cardiomyopathy) were included with the median time between LVAD implantation and enrollment of 6.7 months (2.3, 11.4 months). LVAD subtypes included: HeartWare (n = 22, 55%), Heartmate II (n = 10, 25%), and Heartmate III (n = 8, 20%). Over a follow-up duration of 21.6 ± 12.9 months after LVAD implantation, 5% of patients (n = 2) had oversensing of EMI from the LVAD (both with HeartWare LVADs and Abbott ICDs) at 4 days and 10.8 months after LVAD implantation. Both patients underwent adjustment of ventricular sensing with resolution of oversensing and no further events over 5 and 15 months of further follow-up. The SNR was similar between IB and DB sensing (50 [29-67] and 57 [41-69], p = 0.89)., Conclusion: ICD oversensing of EMI from LVADs is infrequent and can be managed with reprogramming the sensitivity. There was no significant difference in the R-wave SNR with IB versus DB ICD leads., (© 2021 Wiley Periodicals LLC.)

Introduction: Left atrial appendage occlusion (LAAO) is recommended in patients with non-valvular atrial fibrillation (AF) who have contraindications to or are intolerant of long-term oral anticoagulants (OAC), but its impact on hospitalization rates has not been well described. The objective of our study is to describe the incidence of all-cause, bleeding-related, and thrombosis-related hospitalizations before and after LAAO., Material and Methods: We used the Nationwide Readmission Database to include patients aged ≥ 18 years with a diagnosis of AF who underwent transcatheter LAAO during the months of February-November in each year between 2016 and 2018. Patients who died during the index procedure or had missing length of hospital stay or mortality information were excluded., Results: A total of 27,633 patients were included (median age: 77 years, 41% female) with an average pre- and post-LAAO monitoring period of 6.5 and 5.5 months respectively. Of these, 10,808 (39.1%) patients had one or more admissions prior to the procedure compared to 7,196 (26.0%) after the procedure. There was a 26% reduction in incidence of all-cause admissions (rate ratio (RR) = 0.74, 95% confidence interval (CI): 0.71-0.76; p < 0.001), 49% reduction in bleeding-related admissions (RR = 0.51, 95% CI: 0.48-0.55; p < 0.001), and 71% reduction in thrombosis-related readmissions (RR = 0.29, 95% CI: 0.26-0.33; p < 0.001) after LAAO., Conclusions: In a contemporary, nationally representative dataset, we found that LAAO is associated with a significant decrease in all-cause, bleeding-related, and thrombosis-related admissions. These findings lend support to the current use of transcatheter LAAO in clinical practice for patients with contraindications to OAC and/or at high risk of bleeding., Competing Interests: The authors declare no conflict of interest., (Copyright: © 2021 Termedia & Banach.)

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Introduction: Ultrasound guided axillary vein access (UGAVA) is an emerging approach for cardiac implantable electronic device (CIED) implantation not widely utilized., Methods and Results: This is a retrospective, age and sex-matched cohort study of CIED implantation from January 2017 to July 2019 comparing UGAVA before incision to venous access obtained after incision without ultrasound (conventional). The study population included 561 patients (187 with attempted UGAVA, 68 ± 13 years old, 43% women, body mass index (BMI) 30 ± 8 kg/m 2 , 15% right-sided, 43% implantable cardioverter-defibrillator, 15% upgrades). UGAVA was successful in 178/187 patients (95%). In nine patients where UGAVA was abandoned, the vein was too deep for access before incision. BMI was higher in abandoned patients than successful UGAVA (38 ± 6 vs. 28 ± 6 kg/m 2 , p < .0001). Median time from local anesthetic to completion of UGAVA was 7 min (interquartile range [IQR]: 4-10) and median procedure time 61 min (IQR: 50-92). UGAVA changed implant laterality in two patients (avoiding an extra incision in both) and could have prevented unnecessary incision in four conventional patients. Excluding device upgrades, there was reduced fluoroscopy time in UGAVA versus conventional (4 vs. 6 min; IQR: 2-5 vs. 4-9; p < .001). Thirty-day complications were similar in UGAVA versus conventional (n = 7 vs. 26, 4 vs. 7%; p = .13, p = .41 adjusting for upgrades), partly driven by a trend towards reduced pneumothorax (n = 0 vs. 3, 0 vs. 1%; p = .22)., Conclusions: UGAVA is a safe approach for CIED implantation and helps prevent an extra incision if a barrier is identified changing laterality preincision., (© 2020 Wiley Periodicals LLC.)

Background: Voltage mapping is critical to define substrate during ablation. In ventricular tachycardia, abnormal potentials may be targets. However, wavefront of activation could impact local signal characteristics. This may be particularly true when comparing sinus rhythm versus paced rhythms. We sought to determine how activation wavefront impacts electrogram characteristics., Methods: Patients with ischemic cardiomyopathy, ventricular tachycardia, and without fascicular or bundle branch block were included. Point by point mapping was done and at each point, one was obtained during an atrial paced rhythm and one during a right ventricular paced rhythm. Signals were adjudicated after ablation to define late potentials, fractionated potentials, and quantify local voltage. Areas of abnormal voltage (defined as <1.5 mV) were also determined., Results: 9 patients were included (age 61.3 ± 9.2 years, 56% male, mean LVEF 34.9 ± 8.6%). LV endocardium was mapped with an average 375 ± 53 points/rhythm. Late potentials were more frequent during right ventricular pacing (51 ± 21 versus 32 ± 15, p < 0.01) while overall scar area was higher during atrial pacing (22 ± 11% vs 13 ± 7%, p < 0.05). In 1/9 patients, abnormal potentials were seen during a right ventricular paced rhythm that were not apparent in an atrial paced rhythm, ablation of which resulted in non-inducibility., Conclusion: Rhythm in which mapping is performed has an impact on electrogram characteristics. Whether one rhythm is preferable to map in remains to be determined. However, it is possible defining local signals during normal conduction as well as variable paced rhythms may impart a greater likelihood of elucidating arrhythmogenic substrate., Competing Interests: Declaration of competing interest None of the authors have any conflicts of interest to disclose., (Copyright © 2020 Indian Heart Rhythm Society. Production and hosting by Elsevier B.V. All rights reserved.)

Purpose: To examine results of magnetic resonance imaging (MRI), polysomnograms (PSG), and patient outcomes in patients with achondroplasia in light of recent screening recommendations for infants with achondroplasia., Methods: We reviewed medical records of 49 patients with achondroplasia followed at our institution between September 1997 and January 2017, including physical exams, MRIs, PSGs (when available), and surgical histories. Appropriate PSG data were available for 39 of these patients., Results: Twenty-seven of 49 patients had cervical cord compression on MRI, and 20 of those patients required surgery. Central apnea was detected in 2/23 patients with cervical cord compression in whom PSG data was available. Physical exam revealed depressed deep-tendon reflexes in two patients with cord compression and one patient without cord compression. Besides hypotonia in some, the neurological exams of these patients were unremarkable., Conclusions: Cervical cord compression is a common occurrence in infants with achondroplasia and necessitates surgical intervention in some patients. Physical exam and PSG are poor predictors of the presence of cord compression or the need for surgery. All infants with achondroplasia should have MRIs of the craniocervical junction in the first 6 months of life.

Background: The safety of perioperative anticoagulation (AC) and antiplatelet (AP) therapy with subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is unknown. The purpose of this study was to identify the risk factors associated with hematoma complicating S-ICD implantation., Methods: Records were retrospectively reviewed from 200 consecutive patients undergoing S-ICD implantation at two academic medical centers. A hematoma was defined as a device site blood accumulation requiring surgical evacuation, extended hospital stay, or transfusion., Results: Among 200 patients undergoing S-ICD implantation (age 49 ± 17 years, 67% men), 10 patients (5%) had a hematoma, which required evacuation in six patients (3%). Warfarin was bridged or uninterrupted in 12 and 13 patients, respectively (6% and 6.5%). Four of 12 patients with warfarin and bridging AC (33%) and two of 13 patients with uninterrupted warfarin (15%) developed a hematoma. Neither of the two patients with uninterrupted DOAC had a hematoma. No patients on interrupted AC without bridging (n = 26, 13 with warfarin, 13 with DOAC) developed a hematoma. A hematoma was also more likely with the use of clopidogrel (n = 4/10 vs 10/190, 40% vs 5.3%, P < 0.0001) in combination with aspirin in 12/14 patients. Any bridging AC (odds ratio [OR] 10.3, 1.8-60.8, P = 0.01), clopidogrel (OR 10.0, 1.7-57.7, P = 0.01), and uninterrupted warfarin without bridging (OR 11.1, 1.7-74.3, P = 0.013) were independently associated with hematoma formation., Conclusion: AC and/or AP therapy with clopidogrel appears to increase the risk for hematoma following S-ICD implantation. Interruption of AC without bridging should be considered when it is an acceptable risk to hold AC., (© 2018 Wiley Periodicals, Inc.)

Left ventricular assist devices (LVAD) are increasingly used in the management of patients with advanced heart failure. Many of these patients have or will be considered for a cardiac implantable electronic device (CIED) such as an implantable cardioverter-defibrillator or a cardiac resynchronization therapy device. Frequent interplay is often encountered due to the complexity of these devices and the underlying disease states. Proactive management strategies and an awareness of interactions may help reduce adverse events. Here we review the current literature, present management recommendations, and discuss potential future investigations for CIEDs in patients with LVADs., (Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Left atrial appendage closure (LAAC) has emerged as a viable option for stroke prevention, especially in those intolerant of or not suitable for long-term oral anticoagulation therapy. This article describes the clinical characteristics, indications, and a proposed referral system for potential LAAC patients. Patient selection remains a challenge because of the paradox between the available randomized data on this intervention and the actual patient population who may gain maximum benefit. Further investigations comparing different LAAC devices with each other and with novel oral anticoagulants are needed. Also, the optimal antithrombotic regimen post-procedure has yet to be determined., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Premature ventricular complexes (PVCs) often originate from multiple locations., Objective: The goals of this study were to assess characteristics of patients with pleomorphic, idiopathic PVCs and to determine the impact of pleomorphic PVCs on outcomes., Methods: Records were collected from 153 consecutive patients referred for ablation of PVCs. Patients with structural heart disease (n = 34) or inadequate ambulatory electrocardiographic data (n = 19) were excluded., Results: Among 100 consecutive patients (age 52 ± 15 years, 53% men, 31% pleomorphic vs 69% monomorphic) referred for ablation of idiopathic PVCs, the success rate was lower in patients with pleomorphic PVCs than in those with monomorphic PVCs (71% vs 90%, P = .017, overall 84%). The presence of pleomorphic PVCs was independently associated with unsuccessful ablation. A cutoff of ≥156 nonpredominant PVCs over 24 hours best differentiated successful from unsuccessful ablation procedures (area under the curve 0.64, sensitivity 56%, specificity 74%). Pleomorphic PVCs more often had an epicardial origin than did monomorphic PVCs (29% vs 9%, P = .008). Repeat ablation procedures were required in 20 patients (20%; 6 had pleomorphic PVCs). Of these 20 patients, 16 (80%) had recurrence of the former predominant PVC, 3 patients (15%) had an increase of a nonpredominant PVC, and 1 patient (5%) had a newly emerging PVC focus., Conclusion: The presence of pleomorphic PVCs affects ablation outcomes. Successful elimination of the predominant PVC often results in successful ablation, even if not all PVCs are targeted. Although pleomorphic PVCs infrequently require repeat ablation procedures, most recurrences are due to reemergence of the originally targeted predominant PVC morphology., (Copyright © 2017 Heart Rhythm Society. All rights reserved.)

Study Objectives: Polysomnography is the gold standard for diagnosis and characterization of severity of sleep-disordered breathing. Accuracy and reliability of the technology used are critical to the integrity of the study's interpretation. Strict criteria for obstructive sleep apnea in children are lacking and diagnosis often requires consideration of frequency of respiratory events in addition to other measures. Current American Academy of Sleep Medicine recommendations for pediatric patients includes use of respiratory inductance plethysmography (RIP) belts, whereas polyvinylidene fluoride (PVDF) belts are currently only acceptable for use in adults. We hypothesized that PVDF belts would be equally effective as RIP belts for detection of respiratory effort and events in children., Methods: Children ages 2-17 y were recruited from a large pediatric tertiary referral center after obtaining consent for participation. Fifty subjects were recruited (average age, 7.8 y). Clinically relevant limits of agreement were predetermined to be a difference in total count of obstructive or central apneas or hypopneas of ± 5 events., Results: Scoring of respiratory events was not significantly different by belt type based on Bland-Altman plots of total apnea-hypopnea index and obstructive apneas. Obstructive hypopneas scoring ranged beyond our clinical limit of agreement. Findings in obese subjects were consistent with the larger sample with the exception of an increase in outliers. Artifact amount was comparable (RIP 10.9% ± 22.5% and PVDF 10.5% ± 19.5%)., Conclusions: Based on these findings, PVDF belts appear to be as effective as RIP belts in detection of respiratory effort and events in children., Commentary: A commentary on this article appears in this issue on page 159., (© 2017 American Academy of Sleep Medicine)

Background: Detection of atrial fibrillation after ischemic stroke is challenging due to its paroxysmal nature. We aimed to assess predictors of paroxysmal atrial fibrillation using non-invasive surface ECG and transthoracic echocardiography to select candidates for atrial fibrillation screening., Methods: Ischemic stroke patients without documented atrial fibrillation (n = 110, 67 ± 10 years, 40 female) and a control group of age- and gender-matched patients with history of paroxysmal atrial fibrillation prior to stroke (n = 55, 67 ± 10 years, 19 female) comprised the study sample. Using non-invasive ECG monitoring for three weeks, short episodes of paroxysmal atrial fibrillation were detected in 24 of 110 patients (22 %). The standard 12-lead ECG with sinus rhythm at stroke onset was digitally processed and analyzed. Transthoracic echocardiography data were reviewed for these patients., Results: Atrial fibrillation history was independently associated with P terminal force in lead V 1 > 40 mm*ms (OR 4.04 95 % CI 1.34-12.14, p = 0.013) and left atrial volume index (OR 1.08 95 % CI 1.03-1.13, p = 0.002; for LAVI > 40 mL/m 2 OR 6.40 95 % CL 1.47-27.91, p = 0.013). Among patients without atrial fibrillation history, no ECG characteristics were predictive of atrial fibrillation detected after stroke. Left atrial volume index remained an independent predictor of atrial fibrillation detected after stroke (OR 1.09 95 % CI 1.02-1.16, p = 0.017). A cutoff of <40 mL/m 2 had an 84 % negative predictive value for ruling out atrial fibrillation on ambulatory monitoring with a sensitivity of 50 % and a specificity of 86 %., Conclusion: In a post hoc analysis, left atrial dilatation assessed by left atrial volume index independently predicted atrial fibrillation after stroke in patients without prior atrial fibrillation history, while the other clinical or ECG markers were not predictive of atrial fibrillation detected early after ischemic stroke., Trial Registration: This study is a post hoc analysis from the prospective case-control study registered in December 2011, ClinicalTrials.gov ID: NCT01325545 .

Felid herpesvirus 1 (FHV-1) mutants were constructed using two-step Red-mediated recombination techniques based on a virulent full-length FHV-1 BAC clone. The individual mutant viruses generated were deficient in glycoprotein C (gC), glycoprotein E (gE), US3 serine/threonine protein kinase (PK), or both gE and thymidine kinase (TK). The gC- mutant virus produced plaques that were similar in size to those resulting from infection with the C-27 parent strain. In contrast, the gE(-), PK(-), and gE(-)PK(-) deletion mutants produced plaques that were significantly smaller. Multistep in vitro growth kinetics of the gE(-), PK(-), and gE(-)PK(-) viruses were slightly delayed compared to those of the C-27 parent strain. Peak progeny titers of these three mutants were approximately 10-fold lower than those generated with the C-27 strain. There was no delay in the growth kinetics of the gC- mutant, but the progeny virus titer obtained with this mutant was at least 3 logs lower compared to the parental strain titer. Based upon their in vitro characteristics, these mutants will be useful for the development of novel immunization strategies against this important feline pathogen., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Neuraminidase inhibitors (NAIs), including the most frequently prescribed oral therapeutic oseltamivir, play a critical role in the control of severe influenza virus (IFV) infections. However, recent reports of spread of an oseltamivir-resistant H1N1 pandemic strain in individuals who have never been exposed to oseltamivir highlight an urgent need for new antivirals against NAI-resistant IFVs. Difluorosialic acids (DFSAs) are a novel class of anti-IFV NAIs designed based on the mechanism of action of IFV NA, and distinguished by their covalent inhibition mode and their high structural similarity to the natural substrate, sialic acid. These characteristics should render the development of resistance a less rapid process. In this report, we evaluated the relative propensity of influenza A virus (IFV-A) NA to develop resistance against the DFSA class of inhibitor by passaging IFV-A strains in vitro in the presence of either oseltamivir or a representative DFSA (FeqGuDFSA). All the passage-selected lines gained mutations in hemagglutinin. Among the 12 oseltamivir-resistant passaged lines, five gained NA mutations and four of these were the well-defined H275Y mutation that causes oseltamivir resistance. In contrast, out of 15 DFSA-passaged lines, only 2 lines gained NA mutations. Further, NA inhibition assays indicated that these mutations did not change the sensitivity of NA to DFSA and thus the resistance to DFSA was not conferred by these NA mutations. These results strongly suggest that, compared to oseltamivir, IFV is less prone to development of resistance against DFSAs through NA mutations., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Children with atopic dermatitis (AD) experience significant sleep disruption, and clinically, the disease is noted to worsen in a circadian manner at night. Epidemiologic findings highlight many negative consequences of AD, such as impaired linear growth, which is uniquely related to disturbed sleep. Clinical guidelines currently recommend assessing sleep in patients with AD as a crucial parameter of disease control with appropriate treatment. In this review we describe our current understanding of the roles of sleep cycles and circadian rhythms in the nighttime exacerbation of AD (nocturnal eczema). We present a schematic to explain the mechanism of nocturnal eczema. Treatment options for sleep disturbance and future directions for research are discussed in the context of AD., (Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: There is evidence that atypical fast-slow and typical atrioventricular nodal re-entrant tachycardia (AVNRT) do not use the same limb for fast conduction, but no data exist on patients who have presented with both typical and atypical forms of this tachycardia. We compared conduction intervals during typical and atypical AVNRT that occurred in the same patient., Methods and Results: In 20 of 1299 patients with AVNRT, both typical and atypical AVNRT were induced at electrophysiology study by pacing maneuvers and autonomic stimulation or occurred spontaneously. The mean age of the patients was 47.6±10.9 years (range, 32-75 years), and 11 patients (55%) were women. Tachycardia cycle lengths were 368.0±43.1 and 365.8±41.1 ms, and earliest retrograde activation was recorded at the coronary sinus ostium in 60% and 65% of patients with typical and atypical AVNRT, respectively. Thirteen patients (65%) displayed atypical AVNRT with fast-slow characteristics. By comparing conduction intervals during slow-fast and fast-slow AVNRT in the same patient, fast pathway conduction times during the 2 types of AVNRT were calculated. The mean difference between retrograde fast pathway conduction during slow-fast AVNRT and anterograde fast pathway conduction during fast-slow AVNRT was 41.8±39.7 ms and was significantly different when compared with the estimated between-measurement error (P=0.0055)., Conclusions: Our data provide further evidence that typical slow-fast and atypical fast-slow AVNRT use different anatomic pathways for fast conduction., (© 2015 The Authors.)

Background: Magnetic resonance imaging (MRI) has been safely performed in some patients with cardiac implantable electronic devices (CIEDs) under careful monitoring and prespecified conditions. Pacemaker-dependent patients are often excluded, partly because of the potential for "power-on reset" (PoR), which can lead to a change from asynchronous to inhibited pacing with consequent inhibition of pacing due to electromagnetic interference during MRI., Objective: The purpose of this study was to review risk factors for PoR during MRI., Methods: A prospective study was performed between January 2008 and May 2013 in patients with CIEDs undergoing clinically indicated MRI. Eligible patients were not pacemaker dependent. Devices were interrogated before and after MRI, programmed to an asynchronous mode or an inhibition mode with tachyarrhythmia therapies turned off, and reprogrammed to their original settings after MRI., Results: MRI scans (n = 256) were performed in 198 patients with non-MRI-conditional CIEDs between 2008 and 2013 (median age 66 years; interquartile range 57-77 years; 59% men). PoR occurred during 9 MRI scans (3.5%) in 8 patients. PoR was more frequent with Medtronic devices than with other generator brands (n = 9/139 vs 0/117 [6% vs 0%]; P = .005). Devices with PoR were all released before 2002 and were implanted from 1999 to 2004. Effects of PoR included a decrease in heart rate during MRI (n = 4) and transient anomalous battery life indication (n = 1). All devices functioned normally after MRI., Conclusion: PoR occurs infrequently but can cause deleterious changes in pacing mode and heart rate. MRI should not be performed in pacemaker-dependent patients with older at-risk generators. Continuous monitoring during MRI is essential because unrecognized PoR may inhibit pacing or accelerate battery depletion due to high pacing output., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Magnetic resonance imaging (MRI) in patients with left ventricular (LV) leads may cause tissue or lead heating, dislodgment, venous damage, or lead dysfunction., Objective: The purpose of this study was to determine the safety of MRI in patients with LV pacing leads., Methods: Prospective data on patients with coronary sinus LV leads undergoing clinically indicated MRI at 3 institutions were collected. Patients were not pacemaker-dependent. Scans were performed under pacing nurse, technician, radiologist, and physicist supervision using continuous vital sign, pulse oximetry, and ECG monitoring and a 1.5-T scanner with specific absorption rate <1.5 W/kg. Devices were interrogated pre- and post-MRI, programmed to asynchronous or inhibition mode with tachyarrhythmia therapies off (if present), and reprogrammed to their original settings post-MRI., Results: MRI scans (n = 42) were performed in 40 patients with non-MRI conditional LV leads between 2005 and 2013 (mean age 67 ± 9 years, n = 16 [40%] women, median lead implant duration 740 days with interquartile range 125-1173 days). MRIs were performed on the head/neck/spine (n = 35 [83%]), lower extremities (n = 4 [10%]), chest (n = 2 [5%]), and abdomen (n = 1 [2%]). There were no overall differences in pre- and post-MRI interrogation LV lead sensing (12.4 ± 6.2 mV vs 12.9 ± 6.7 mV, P = .38), impedance (724 ± 294 Ω vs 718 ± 312 Ω, P = .67), or threshold (1.4 ± 1.1 V vs 1.4 ± 1.0 V, P = .91). No individual LV lead changes required intervention., Conclusion: MRI scanning was performed safely in non-pacemaker-dependent patients with coronary sinus LV leads who were carefully monitored during imaging without clinically significant adverse effect on LV lead function., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Initiation of class III anti-arrhythmic medications requires telemetric monitoring for ventricular arrhythmias and QT prolongation to reduce the risk of torsades de pointes (TdP). Heart rate-corrected QT interval (QTc) is an indicator of risk, however it is imperfect, and subtle abnormalities of repolarization have been linked with arrhythmogenesis., Purpose: Identification of electrocardiographic predictors of torsadogenic risk through the application of a novel T wave analysis tool., Methods: Among all patients admitted to Mayo Clinic for initiation of dofetilide or sotalol, we identified 13 cases who developed drug-induced TdP and 26 age and sex matched controls that did not develop TdP. The immediate pre-TdP ECG of those with TdP was compared to the last ECG performed prior to hospital discharge in controls using a novel T wave program that quantified subtle changes in T wave morphology., Results: The QTc and 12 T wave parameters successfully distinguished TdP cases from controls. The top performing parameters were the QTc in lead V3 (mean case vs control 480 vs 420 msec, p < 0.001, r = 0.72) and T wave right slope in lead I (mean case vs control -840.29 vs -1668.71 mV/s, p = 0.002, r = 0.45). The addition of T wave right slope to QTc improved prediction accuracy from 79 to 88 %., Conclusion: Our data demonstrate that, in addition to QTc, the T wave right slope is correlated strongly with TdP risk. This suggests that a computer-based repolarization measurement tool that integrates additional data beyond the QTc may identify patients with the greatest torsadogenic potential.

Introduction: Abandoned cardiovascular implantable electronic device (CIED) leads remain a contraindication to magnetic resonance imaging (MRI) studies, largely due to in vitro data showing endocardial heating secondary to the radiofrequency field. We tested the hypothesis that abandoned CIED leads do not pose an increased risk of clinical harm for patients undergoing MRI., Methods: This single-center retrospective study examined the outcomes of patients who had device generators removed before MRI, rendering the device leads abandoned. Information was gathered through chart review. Data collected included lead model, pacing threshold before MRI, anatomic region examined, threshold data after generator reimplantation, and clinical patient outcome., Results: Patients (n = 19, 11 men and eight women) ranged in age from 19 to 85 at the time of MRI. There was a mean of 1.63 abandoned leads at the time of imaging; none of the leads were MRI conditional. Of the three implantable cardioverter defibrillator (ICD) leads, two of three were dual coil. Most (31/35) of the scans performed were of the central nervous system, including head and spinal imaging. There were no adverse events associated with MRI in any of these patients with abandoned leads within 7 days of the scan. No lead malfunctions or clinically significant change in pacing thresholds were noted with generator reimplantation., Conclusion: The use of MRI in patients with abandoned cardiac device leads appears feasible when performed under careful monitoring, with no adverse events, although the experience is small. MRI did not affect the function of leads that were subsequently reconnected to a cardiac device., (©2014 Wiley Periodicals, Inc.)

Rationale: Pediatric obstructive sleep apnea (OSA) is common, and a delay in diagnosis can lead to significant morbidity. Polysomnography (PSG) is the gold standard for the diagnosis of OSA. However, difficulty accessing PSG due to the relative shortage of sleep centers with pediatric expertise can lead to a delay in the diagnosis and management of OSA., Objectives: To assess the utility of Mallampati score (sitting and supine) in predicting the presence and severity of OSA in children., Methods: A retrospective study of 158 children from a single pediatric sleep center. All patients had a PSG and a physical examination documenting Mallampati score. The Mallampati score, tonsillar size, age, sex, and apnea hypopnea index (AHI) were analyzed. Odds ratio of having pediatric OSA (AHI > 1) with increase in Mallampati score and tonsillar size were calculated., Measurements and Main Results: A significant correlation was found between Mallampati score, tonsillar size, and AHI. For every point increase in the Mallampati score, the odds ratio of having OSA increased by more than 6-fold. For every point increase in tonsillar size, the odds ratio of having OSA increased by more than 2-fold., Conclusions: Mallampati score and tonsillar size are independent predictors of OSA. Oral examination including Mallampati score and tonsillar size should be considered when evaluating a patient for OSA. They can be used to prioritize children who may need PSG., (© 2014 American Academy of Sleep Medicine.)