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Background: Previous studies described a higher prevalence of cardiovascular comorbidities during the winter season. Data regarding seasonal association of atrioventricular (AV) block are scarce. Methods: A retrospective cohort analysis of all patients admitted to a tertiary medical center with AV block requiring a permanent pacemaker (PPM) implantation between 2006-2017 was performed. In a time-series analysis, the seasonal incidence of PPM implementations due to AV block was assessed and adjusted for meteorological factors. The association between the weekly incidence of PPM implantations and the weekly rates of influenza as reported by the Israel Center of Disease Control (ICDC) were also assessed. Result: The study population included 759 patients. Mean age was 76.1 years and 55% were males. Most of the patients (34.1%) were admitted in the winter season. In multivariate analysis, there was a significantly higher incidence of PPM implantations among men during the winter season as compared to the fall season (Adjusted IRR [Incidence Rate-Ratio] 1.40, 95% CI 1.05;1.88; pConclusion: In the present analysis the incidence of PPM implantations due to AV block was higher among men during the winter season and correlated with high influenza illness rates. Further prospective and larger studies are required to assess these findings.

A 13-year-old boy was hospitalized after a syncopal episode that occurred during exercise. He suddenly felt chest tightness, sweating and palpitations, followed by a transient loss of conciseness. Upon emergency medical team arrival, he was awake and oriented. Baseline ECG showed sinus rhythm at a rate of 98 bpm, with narrow QRS, and no signs of long QT, Brugada, or pre-excitation. Physical examination, blood tests, 24 hours Holter monitoring, transthoracic echocardiography and stress test were all within normal limits. Eight days later he experienced a second episode of palpitations while walking to school. ECG revealed regular wide complex tachycardia (WCT) at a rate of 200 bpm, with LBBB morphology that terminated with Adenosine (Figure 1). The clinical tachycardia was easily induced by programmed electrical stimulation (Figure 2A). Diagnostic electrophysiological maneuver (Figure 2B) was followed by successful ablation, during which a unique phenomenon was noted (Figure 3). What is the diagnosis of the tachycardia and what are the unique findings noted during and after ablation?

Background A high percentage of SARS-CoV-2 patients suffer from comorbidities and there is increasing evidence that previous cardiac disease contributes to poor outcome in these patients (1,2). There is a paucity of information regarding the implications of the disease in patients with cardiac implantable electronic devices (CIEDs). Due to the increasing use of CIEDs in the management of arrhythmias and heart failure, determining the association between CIEDs and the severity of this disease is essential. Aim To obtain an adequate understanding regarding the association between cardiac devices and severity of COVID-19 infection in order to achieve optimum management of these patients. Methods All clinical and demographic parameters were collected retrospectively from a cohort of patients who underwent implantation of CIED in our Medical Center, Israel. We included 42 patients who tested positive for SARS-CoV-2, between January and December of 2020. Propensity score matching based on age and gender and adjusted Kaplan Meier curve of mortality were performed in order to evaluate the clinical outcome of patients with CIEDs and SARS- CoV-2 infection in comparison to the control group. Results The mean age of patients was 72.9 years, compose of 50% male and 50% female in both groups. In the group of patients with CIEDs, 11 (26.1%) patients had implantable defibrillator, and 31 (73.8%) had pacemaker. Univariate analysis revealed that patients with CIEDs suffered more from heart failure, coronary artery disease and atrial fibrillation, as well as hypertension, diabetes, and chronic kidney disease. Four patients (9.5%) with cardiac devices were hospitalized in the ICU due to critical illness, as compared to 1 (0.6%) patient in the control group (p=0.005). Moreover, 10 patients in the cardiac devices group (23.8%) died of SARS-CoV-2 infection, versus 25 (14.9%) in the control group. Conclusions CIEDs are a marker of poor outcome in patients with SARS-CoV-2 infection. Patients with CIEDs suffer from increased comorbidities in comparison with age and gender matched population and therefore should be managed with the utmost caution. Funding Acknowledgement Type of funding sources: None. KM curve of all-cause mortality

Background Herpes simplex virus (HSV) encephalitis is a known cause of cognitive deterioration, neurological disturbances, and seizures though are rarely associated with sinus node dysfunction. Case summary We present a 54-year-old man admitted to the hospital with a 10-day history of fever, confusion, and fatigue, 1 week following a transient loss of consciousness. An initial workup suggested HSV encephalitis and the patient was started on intravenous Acyclovir. Due to his episode of syncope, a 24 h Holter electrocardiogram monitoring was performed. The Holter documented multiple episodes of sinus arrest, with a second episode of syncope noticed by the hospital staff concurrent with the last documented sinus arrest. Following antiviral treatment and resolution of the encephalitis we noticed complete resolution of sinus node dysfunction. We subsequently avoided permanent pacemaker implantation. Discussion Our case of proven HSV encephalitis complicated by sinus node arrest and syncope with complete resolution following antiviral treatment suggests no indication for permanent pacemaker implantation. This approach is consistent with data from previously reported cases.

We discuss an unusual case of a patient who initially presented with apparent commotio cordis but returned several months later with spontaneous wide complex tachycardia. This case highlights the importance of investigation of survivors of commotio cordis, especially if atypical, to determine if there is underlying cardiac disease. (Level of Difficulty: Beginner.), Graphical abstract, We discuss an unusual case of a patient who initially presented with apparent commotio cordis but returned several months later with recurrent wide…

Background Brugada syndrome (BrS) is an inherited disorder associated with increased risk of ventricular arrhythmias and sudden cardiac death. The most common genetic alteration is a loss of function mutation of SCN5A gene. Several mutations in SCN5A gene were found to be associated with an overlap phenotype of both BrS and long QT3 (LQT3) syndrome. Case summary We report of a 29-year-old man with familial LQT3 syndrome that was diagnosed at age 6 during evaluation of syncope. He has been treated for several years with Flecainide. Now presented with recurrent episodes of syncope. Electrocardiogram (ECG) upon admission was notable for Brugada type 1 pattern that was attenuated after Flecainide was discontinued. Genetic analysis revealed SCN5A 1790D>G mutation that is associated with overlap of LQT3 and BrS. Due to recurrent syncope and difficult management of both LQT3 and BrS, an implantable cardioverter-defibrillator was implanted together with beta-blockers treatment. The patient was discharged home with no evidence of Brugada type 1 pattern on his ECG. He had no further syncope or arrhythmias during 6 months of follow-up. Discussion There are few reports describing the phenotypic overlap between LQT3 and BrS. Despite the confirmed genetic link between both syndromes, their management strategy is controversial. In particularly, the treatment with sodium channel blockers for LQT3 syndrome may increase the risk for arrhythmias in patients with coexisting BrS. The present case demonstrates the link between LQT3 and BrS and the difficult dilemma in the management of these patients.

Funding Acknowledgements None Background Patients with preserved LVEF and atrioventricular block (AVB) who are anticipated for high-burden of right ventricular (RV) pacing possess a risk to develop pacing induced cardiomyopathy (PICM). Aims To evaluate the incidence and outcomes of RV-PICM in this patient"s population. Methods 1013 patients with AVB underwent first time pacemaker (PM) implantation between 2002 and 2016. A total of 203 patients with normal LVEF were included. Follow-up echocardiography was examined for a decrease in LVEF > 10%. Alternative causes for cardiomyopathy were excluded. Patient"s characteristics, mortality and hospitalizations for heart failure (HF) were compared between the PICM and non-PICM groups. Results 51 patients (25%) developed PICM, with 22 patients (11%) showing LVEF Conclusions The incidence of PICM in patients with normal LVEF and AVB is alarmingly high. PICM in patients with a previously normal LVEF is associated with unfavorable outcomes. Table 1 Characteristics Cohort without PICM (152) n (%) Cohort with PICM (51) n(%) p Age mean ± SD 74.6 ± 10.5 71 ± 13 0.04 Gender (male) 80 (52.6) 29 (56.9) 0.6 Pacing modeDDDVDDVVI 108 (71.1) 38 (25) 6 (3.9) 34 (66.7) 15 (29.4) 2(3.9) 0.83 Hypertension 112 (73.7) 36 (70.6) 0.67 PVD 16 (10.5) 5 (8.9) 0.88 CAD 36 (23.7) 19 (37.3) 0.01 CVA / TIA 17 (11.2) 7 (13.7) 0.63 Atrial fibrillation / flutter 18 (11.8) 9 (17.6) 0.29 COPD 15 (9.9) 2 (3.9) 0.25 Diabetes Mellitus 56 (36.8) 27 (52.9) 0.04 Chronic Kidney Disease 27 (17.9) 14 (27.5) 0.14 Statins 65 (43) 30(60) 0.04 ACE inhibitors / ARBs 52 (34.4) 18 (36) 0.84 Beta Blockers 42 (28) 10 (20) 0.26 LVEDD mm 45.13 ± 5.53 48.46 ± 5.97 Abstract Figure. HF and Mortality outcomes

Patients with preserved left ventricular (LV) ejection function (EF) and atrioventricular block (AVB) who are anticipated for high-burden of right ventricular (RV) pacing possess a risk to develop pacing-induced cardiomyopathy (PIC) and adverse clinical outcomes. Hence, the aim of the study is to evaluate the incidence, predictors, and clinical outcomes of RV PIC in patients with preserved LVEF, AVB, and high-burden of RV pacing. One thousand and thirteen patients with second or third-degree AVB underwent first time pacemaker implantation between January 2002 and August 2016. A total of 203 patients with a newly implanted pacemaker, normal baseline LVEF, and high burden of RV pacing were included in the present study. Follow-up echocardiography was examined for a new decrease in LVEF of 10% or higher. Alternative causes for cardiomyopathy were ruled out. Patient characteristics, echocardiographic measurements, device clinic data, mortality, and hospitalizations for heart failure were collected and compared between the PIC and the non-PIC groups. Fifty-one patients (25%) developed LV dysfunction with 22 patients (11%), showing LVEF40%. During a mean follow-up of 49.2 months, the risk of heart failure hospitalization or all-cause mortality was significantly higher in the PIC group versus non-PIC group (35.3% vs 19.1%, p = 0.009). In conclusion the incidence of PIC in patients with normal LVEF and AVB, who are anticipated for high-burden of RV pacing is high. PIC in patients with a previously normal LV function is associated with unfavorable long-term clinical outcomes, including higher rates of heart failure hospitalizations and all-cause mortality.

Aims Dual-coil leads were traditionally considered standard of care due to lower defibrillation thresholds (DFT). Higher complication rates during extraction with parallel progression in implantable cardioverter defibrillator (ICD) technology raised questions on dual coil necessity. Prior substudies found no significant outcome difference between dual and single coils, although using higher rates of DFT testing then currently practiced. We evaluated the temporal trends in implantation rates of single- vs. dual-coil leads and determined the associated adverse clinical outcomes, using a contemporary nation-wide ICD registry. Methods and results Between July 2010 and March 2015, 6343 consecutive ICD ( n = 3998) or CRT-D ( n = 2345) implantation patients were prospectively enrolled in the Israeli ICD Registry. A follow-up of at least 1 year of 2285 patients was available for outcome analysis. The primary endpoint was all-cause mortality. Single-coil leads were implanted in 32% of our cohort, 36% among ICD recipients, and 26% among CRT-D recipients. Secondary prevention indication was associated with an increased rate of dual-coil implantation. A significant decline in dual-coil leads with reciprocal incline of single coils was observed, despite low rates of DFT testing (11.6%) during implantation, which also declined from 31 to 2%. In the multivariate Cox model analysis, dual- vs. single-coil lead implantation was not associated with an increased risk of mortality [hazard ratio (HR) = 1.23; P = 0.33], heart failure hospitalization (HR = 1.34; P =0.13), appropriate (HR = 1.25; P = 0.33), or inappropriate ICD therapy (HR = 2.07; P = 0.12). Conclusion Real-life rates of single-coil lead implantation are rising while adding no additional risk. These results of single-coil safety are reassuring and obtained, despite low and contemporary rates of DFT testing.

INTRODUCTION: We aim to compare the acute and long-term success of defibrillation between non-apical and apical ICD lead position. METHODS AND RESULTS: The position of the ventricular lead was recorded by the implanting physician for 2475 of 2500 subjects in the Shockless IMPLant Evaluation (SIMPLE) trial, and subjects were grouped accordingly as non-apical or apical. The success of intra-operative defibrillation testing and of subsequent clinical shocks were compared. Propensity scoring was used to adjust for the impact of differences in baseline variables between these groups. There were 541 leads that were implanted at a non-apical position (21.9%). Patients implanted with a non-apical lead had a higher rate of secondary prevention indication. Non-apical location resulted in lower mean R-wave amplitude (14.0 vs. 15.2, p\textless 0.001), lower mean pacing impedance (662 Ohms vs. 728 Ohms, p\textless 0.001), and higher mean pacing threshold (0.70V vs. 0.66V, p = 0.01). Single-coil leads, and cardiac resynchronization devices were used more often in non-apical implants. The success of intra-operative defibrillation was similar between propensity score matched groups (89%). Over a mean follow-up of 3 years, there were no significant differences in the yearly rates of appropriate shock (5.5% vs. 5.4%, p = 0.98), failed appropriate first shock (0.9% vs. 1.0%, p = 0.66) or the composite of failed shock or arrhythmic death (2.8% vs. 2.3% p = 0.35) according to lead location. CONCLUSION: We did not detect any reduction in the ICD efficacy at the time of implant or during follow-up in patients receiving a non-apical RV lead. This article is protected by copyright. All rights reserved

Objective To compare the clinical outcomes of a single- versus dual-chamber ICD for primary prevention of sudden cardiac death in a large, national ICD registry. Methods Data were collected from the prospective Israeli ICD Registry. Baseline characteristics and clinical outcomes including mortality, admissions for heart failure (HF), and ICD therapy were compared between the two groups. Results A total of 1,125 subjects, 37% with a single-chamber and 63% with a dual-chamber ICD, constructed the baseline cohort. Approximately 80% had ischemic heart disease (IHD). Mean follow-up was 22 months, mean ejection fraction was 30%, and mean QRS width was 103 milliseconds in both groups. During follow-up, there were no significant differences in the rate of mortality, admissions for HF, appropriate or inappropriate therapy, or in time to any of the clinical outcomes. Using multivariate analysis, single-chamber ICD was not associated with increased risk of death or admission for HF. In a subgroup of patients with IHD, single-chamber ICD was associated with a higher rate of inappropriate therapy. Conclusions In this large retrospective population-based cohort, dual-chamber ICD showed no benefit in reducing the incidence of death or HF admissions, whereas in a subgroup of patients with IHD, single-chamber ICD was associated with increased inappropriate therapy. Further prospective studies are necessary to assess the benefit of dual-chamber ICD in reducing the rate of inappropriate therapy.

Sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is caused by ventricular tachyarrhythmia that can be effectively treated by implantable cardioverter defibrillator (ICD) therapy. We report of a 28-year-old man with HCM and a dual chamber ICD, originally implanted for primary prevention of SCD, (programmed to AAI(R)-DDD(R); managed ventricular pacing (MVP) mode, Medtronic Inc. St Paul, MN USA). He presented with recurrent ICD shocks due to ventricular fibrillation (VF) despite antiarrhythmic therapy. Careful assessment of the stored electrograms demonstrated a repetitive pattern of VF initiation following short-long-short sequences. Initially, activation of ventricular rate stabilization (VRS) algorithm failed to prevent recurrent VF. Ultimately, deactivation of MVP and reprogramming the device to DDD mode with VRS on, resulted in arrhythmia suppression and avoidance of ICD shocks. Physicians should be aware that although VRS function is available in MVP mode, it does not function in the AAI mode during MVP; in order to effectively treat short-long-short sequence induced ventricular arrhythmia by device programming.

Swallow induced syncope is a rare clinical condition which is thought to result from an abnormal vagal reflex leading to bradycardia and cerebral hypoperfusion. It mostly occurs in patients with organic or functional disorders of the esophagus, and often requires permanent pacemaker implantation, along with treatment of the underlying esophageal pathology. In the following case, we report of a 71-year-old male with achalasia post per oral endoscopic myectomy, who presented with syncope and documented AV-block while eating solid food. In addition, long sinus pauses were noted during carotid sinus massage, suggesting that the two distinct entities may be associated, and further supporting the mechanism of neurally mediated syncope in the pathophysiology of swallow-induced syncope.

Limited information exists about detailed clinical characteristics and management of the small subset of Brugada syndrome (BrS) patients who had an arrhythmic event (AE).To conduct the first nationwide survey focused on BrS patients with documented AE.Israeli electrophysiology units participated if they had treated BrS patients who had cardiac arrest (CA) (lethal/aborted; group 1) or experienced appropriate therapy for tachyarrhythmias after prophylactic implantable cardioverter defibrillator (ICD) implantation (group 2).The cohort comprised 31 patients: 25 in group 1, 6 in group 2. Group 1: 96% male, mean CA age 38 years (range 13-84). Nine patients (36%) presented with arrhythmic storm and three had a lethal outcome; 17 (68%) had spontaneous type 1 Brugada electrocardiography (ECG). An electrophysiology study (EPS) was performed on 11 patients with inducible ventricular fibrillation (VF) in 10, which was prevented by quinidine in 9/10 patients. During follow-up (143 ± 119 months) eight patients experienced appropriate shocks, none while on quinidine. Group 2: all male, age 30-53 years; 4/6 patients had familial history of sudden death age50 years. Five patients had spontaneous type 1 Brugada ECG and four were asymptomatic at ICD implantation. EPS was performed in four patients with inducible VF in three. During long-term follow-up, five patients received ≥ 1 appropriate shocks, one had ATP for sustained VT (none taking quinidine). No AE recurred in patients subsequently treated with quinidine.CA from BrS is apparently a rare occurrence on a national scale and no AE occurred in any patient treated with quinidine.

Introduction Life expectancy of less than 1 year is usually a contraindication for implantable cardioverter defibrillator (ICD) implantation. The aim was to identify patients at risk of death during the first year after implantation. Methods and results Data were derived from a prospective Israeli ICD Registry. Two groups of patients were compared, those who died and those who were alive 1 year after ICD implantation. Factors associated with 1-year mortality were identified on a derivation cohort. A risk score was established and validated. A total of 2617 patients have completed 1 year of follow-up after ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Age greater than 75 years (hazard ratio [HR], 2.7; 95% confidence interval [95% CI], 1.6 to 4.4), atrial fibrillation (AF; HR, 1.9; 95% CI, 1.12 to 3.17), chronic lung disease (HR, 2.0; 95% CI, 1.1 to 3.76), anemia (HR, 2.3; 95% CI, 1.3 to 3.93) and chronic renal failure (CRF; HR, 3.4; 95% CI, 1.74 to 6.6) were independent risk factors for 1-year mortality. We propose a simple AAACC ("triple A double C") score for prediction of 1-year mortality after ICD implantation: Age greater than 75 years (3 points(pts)), anemia (2 pts), AF (1 pt), CRF (3 pts) and chronic lung disease (1 pt). Mortality risk increased with rising number of points (from 1% with 0 pts to 12.5% with >4 pts). The risk score was evaluated with receiver operating characteristic curve and the area under the curve of the validation curve is 0.71 (95% CI, 0.66 to 0.76). Conclusions Age greater than 75, AF, chronic lung disease, anemia, and CRF were independent risk factors for 1-year mortality. AAACC risk score identifies patients at high risk of death during 1 year after ICD implantation.

Biventricular pacing is an important modality to improve left ventricular (LV) synchronization and long-term function. However, the biological effects of this treatment are far from being elucidated and existing animal models are limited and demanding. Recently, we introduced an implanted device for double-site epicardial pacing in rats and echocardiographically demonstrated favorable effects of LV and biventricular (LV-based) pacing modes typically observed in humans. Here, this new animal model was further characterized. Electrodes were implanted either on the right atria (RA) and right ventricle (RV) or on the RV and LV. Following recovery, rats were either used for invasive hemodynamic measurements (pressure-volume analysis) or exposed to sustained RV vs. biventricular tachypacing for 3 days. RV pacing compromised, while LV-based pacing modes markedly enhanced cardiac performance. Changes in LV performance were associated with prominent compensatory changes in arterial resistance. Sustained RV tachypacing increased the electrocardiogram QTc interval by 7.9 ± 3.1 ms (n = 6, p

Atrial fibrillation (AF) is a common complication of coronary artery bypass graft (CABG) surgery, occurring in 20%-40% of patients, mostly during the first week after surgery. It is associated with increased morbidity and mortality, but data are limited.To assess the correlation between new-onset in-hospital AF following CABG and long-term AF, cerebrovascular accident (CVA), or death.We conducted an analysis of 161 consecutive patients who underwent isolated CABG surgery in a tertiary center during the period 2002-2003.Patients' mean age was 72 years, and the majority were males (77%). Approximately half of the patients experienced prior myocardial infarction, and 14% had left ventricular ejection fraction40%. Postoperative AF (POAF) occurred in 27% of the patients. Patients were older and had larger left atrium diameter. POAF was strongly correlated with late AF (OR 4.34, 95%CI 1.44-13.1, P = 0.01) during a mean follow-up of 8.5 years. It was also correlated with long-term stroke but was not associated with long-term mortality.POAF is a common complication of CABG surgery, which is correlated with late AF and stroke. Patients with POAF should be closely monitored to facilitate early administration of anticoagulant therapy in a high risk population upon recurrence of AF.

We presented a unique phenomenon of 2:1 cardiac resynchronization therapy pacing due to T wave oversensing. Ultimately, by utilizing a unique feature of integrated bipolar sensing, we succeeded to eliminate the T wave oversensing signals, and restore 1:1 CRTD pacing. Importantly, this feature enabled us to overcome the T wave oversensing issue, without the need to decrease the ventricular sensitivity, which could potentially interfere with ventricular arrhythmia detection and appropriate shock delivery when required.

Complementing the physical examination with a point-of-care ultrasound study (POCUS) can improve patient triage. We aimed to study the impact of POCUS on the diagnosis and management of outpatients and hospitalized patients with suspected cardiac disease. In this multicenter study, a pocket-sized device was used to perform POCUS when the diagnosis or patient management was unclear based on anamnesis, physical examination, and basic diagnostic testing. Eighteen physicians (cardiac fellows 49%, cardiologists 30%, and echocardiographers 21%) performed physical examinations extended by POCUS on 207 patients (inpatients 83% and outpatients 17%). POCUS findings resulted in a change in the primary diagnosis in 14% of patients. In patients whose diagnosis remained unchanged, POCUS results reinforced the initial diagnosis in 48% of the cases. In 39% of the patients, the diagnostic plan was altered, including referral (16%) or deferral (23%) to other diagnostic techniques. Alteration in medical treatment (drug discontinuation or initiation) occurred in 11% of the patients, and in 7% POCUS results influenced the decision whether to perform a therapeutic procedure. Hospitalization or discharge was determined after POCUS in 11% of the patients. In conclusion, during patient triage, extension of the physical examination by POCUS can cause physicians to alter their initial diagnosis, resulting in an immediate change of diagnostic and therapeutic procedures. Based on POCUS results, physicians altered the diagnostic plan either by avoiding or referring patients to other diagnostic procedures in almost half of the studied population.

Implantable cardioverter defibrillators (ICDs) reduce mortality in patients implanted for primary and secondary prevention of sudden cardiac death. Data on the incidence of appropriate ICD therapies in primary vs. secondary prevention are limited.To compare ICD therapies and mortality in primary vs. secondary prevention of sudden cardiac death.We conducted a retrospective analysis of 581 consecutive patients receiving an ICD for primary (66%) or secondary (34%) prevention indications.During long-term follow-up, 29% of patients implanted for secondary prevention received appropriate ICD therapy vs. 18% implanted for primary prevention. However, the overall 7 year mortality rate was not significantly different between the two groups (26.9%, P = 0.292). Multivariate analysis showed that patients implanted for primary prevention had a significantly lower risk of appropriate ICD therapy even after adjustment for age, left ventricular ejection fraction0.35 and chronic renal failure (HR 1.63, 95% CI 1.10-2.41, P = 0.015).Patients implanted for secondary prevention were more likely to receive appropriate ICD therapy, with a significantly shorter time period from ICD implant to the first therapy. However, all-cause mortality was comparable between primary and secondary prevention groups.

Heart failure (HF) is associated with poor outcome after acute myocardial infarction (AMI). Women have higher mortality rate than men after AMI, however, it is unknown whether women with HF after AMI have different prognosis than men.To compare the prognosis of men and women with AMI and mild-moderate HF.We analyzed data of 3456 consecutive patients with AMI hospitalized in all cardiac care units in Israel during two nationwide surveys.Among patients with AMI and HF on admission: women were older, had more risk factors, and were less likely to undergo percutaneous coronary angiography/intervention. Women with HF had higher (7-days, 30-days, and 1-year) crude mortality rates than men. However, adjusted mortality rates were not significantly different between genders.Women with AMI complicated by HF had higher crude mortality rate than men that was eliminated after multivariate analysis, suggesting that the higher mortality rate may be attributed to increased prevalence of risk factors and lower rate of revascularization and medical therapies among women. Women with AMI and HF should be considered as a high-risk subgroup with adverse outcome. It remains to be determined whether more intensive management will improve their prognosis.

To compare the clinical outcomes of a single- versus dual-chamber ICD for primary prevention of sudden cardiac death in a large, national ICD registry.Data were collected from the prospective Israeli ICD Registry. Baseline characteristics and clinical outcomes including mortality, admissions for heart failure (HF), and ICD therapy were compared between the two groups.A total of 1,125 subjects, 37% with a single-chamber and 63% with a dual-chamber ICD, constructed the baseline cohort. Approximately 80% had ischemic heart disease (IHD). Mean follow-up was 22 months, mean ejection fraction was 30%, and mean QRS width was 103 milliseconds in both groups. During follow-up, there were no significant differences in the rate of mortality, admissions for HF, appropriate or inappropriate therapy, or in time to any of the clinical outcomes. Using multivariate analysis, single-chamber ICD was not associated with increased risk of death or admission for HF. In a subgroup of patients with IHD, single-chamber ICD was associated with a higher rate of inappropriate therapy.In this large retrospective population-based cohort, dual-chamber ICD showed no benefit in reducing the incidence of death or HF admissions, whereas in a subgroup of patients with IHD, single-chamber ICD was associated with increased inappropriate therapy. Further prospective studies are necessary to assess the benefit of dual-chamber ICD in reducing the rate of inappropriate therapy.

Dilated cardiomyopathy (DCM) and malignant ventricular arrhythmias are important causes of congestive heart failure, heart transplantation, and sudden cardiac death in young patients. Cypher/ZASP is a cytoskeletal protein localized in the sarcomeric Z-line that has a pivotal role in maintaining adult cardiac structure and function. The putative mutation p.(D117N) in Cypher/ZASP has been suggested to cause systolic dysfunction, dilated left ventricle with hypertrabeculated myocardium, and intraventricular conduction disturbance, based on two reported sporadic cases. In two unrelated Bedouin families, one with pediatric DCM and the other with DCM and ventricular arrhythmias at young adulthood searching for the causative mutation by exome sequencing we identified the p.(D117N) variant in Cypher/ZASP. However, p.(D117N) did not segregate as the causative mutation in these families, i.e. it was not present in some patients and was found in several individuals who had no clinical manifestations. Furthermore, the carrier frequency in the Bedouin population of origin is estimated to be 5.2%, which is much higher than the incidence of idiopathic DCM in this population. Thus, our data support the notion that the p.(D117N) variant in Cypher/ZASP is not a causative mutation in the families tested by us. The results also indicates that at least in some cases, the p.(D117N) in Cypher/ZASP is not a causative mutation and the role of D117N in Cypher/ZASP in cardiac pathologies should be further clarified and re-evaluated.

Background: Although clopidogrel and aspirin (dual therapy, DT) are used for acute coronary syndrome (ACS), sometimes treatment with warfarin (triple therapy, TT) is required. Aim: To determine the incidence, complications, and outcomes of TT. Methods: We analyzed Israeli surveys of ACS from 2000 to 2004. Results: In these surveys, 5,706 (96%) were discharged alive from hospital. Post-ACS TT and DT were 76 patients (1.3%) and 2,661 patients (46.7%), respectively. The TT group was older with more prior cardiac disease. During hospitalization, the TT patients received more intravenous anticoagulant and antithrombotic agents, and had more heart failure, arrhythmias, ischemia, and major bleeding (2.6 vs. 0.6%, p = 0.03). There were no differences in adjusted 30-day and 6-month mortality between the 2 groups. Conclusion: TT is feasible among ACS patients who require concomitant warfarin treatment.

Background: It remains unknown whether patients with severe decompensated class IV heart failure (HF) receiving intravenous inotropic treatment benefit from cardiac resynchronization therapy (CRT). Methods: We identified patients who underwent urgent CRT implantation due to decompensated class IV HF necessitating intravenous inotropic therapy. Results: Of 10 patients with chronic ischemic cardiomyopathy (median QRS duration of 170 ms), CRT implantation was associated with symptomatic improvement in 8 patients. The mortality rate was 50% during a median follow-up of 9.5 months, with a median CRT-to-death duration of 6 months. Conclusions: CRT was feasible among class IV patients receiving inotropic treatment and was associated with clinical improvement.

Objectives: To assess bleeding complications among patients undergoing percutaneous coronary intervention (PCI) and receiving triple therapy of warfarin, aspirin, and a thienopyridine. Background: Triple therapy of warfarin, aspirin, and a thienopyridine is strongly discouraged, given the potential risk of bleeding complications. Methods and Results: Post-PCI patients receiving triple therapy thereafter underwent assessment for bleeding complications. Continuous variables are presented as median (25th–75th percentiles). The study group included 180 patients (80% males; age 65 (52, 75.5)). PCI was on an urgent/emergent basis in 86.6%. The main indications for warfarin use were left ventricular mural thrombus and atrial fibrillation (46.9 and 36.9% respectively). Glycoprotein IIb/IIIa receptor antagonists were used in 47.7%. Post-PCI triple therapy duration was 30 days (30, 30). During the post-triple therapy, 104 patients (57.8%) continued treatment with warfarin and aspirin for 376 days (150, 775). During the triple therapy period, 20 patients developed bleeding complications, (mean INR 2.1 ± 0.7 at 7 (6, 8.5) days post-PCI): 2 major groin hematoma (initial phase of warfarin treatment during overlap with heparin) and 18 minor. During post-triple therapy, primarily under warfarin and aspirin, 19 patients developed bleeding complications: 1 major and 18 minor. Conclusion: Short-term triple therapy after PCI was not associated with prohibitively high bleeding complication rates, and thus should be favorably considered in patients with a clear indication for warfarin use. © 2006 Wiley-Liss, Inc.

A 56-year-old man underwent a single lead Lumax 640 DX implantable cardioverter defibrillator implantation for primary prevention of sudden cardiac death. A DX system consists of a single lead, which provides atrial as well as ventricular electrograms, and enhances atrial arrhythmia detection. Three months after the implantation, high-frequency episodes were detected on the far field and the atrial channels, but not on the bipolar right ventricular channel; these were classified as atrial tachycardia. In the present report, we discussed the unusual pattern of the artifacts that was related to an electromagnetic interference detected by the novel DX system.

The aim of this study was to analyze surface expression of neutrophil adhesion molecules in Yemenite Jews as compared to other ethnic populations in Israel. The constitutive neutrophil expression of CD11b and L-selectin (LS), as well as their expression in response to an in vitro chemoattractant and growth factor stimulation were studied by flow cytometry. Mean surface expression of CD11b molecule was statistically significantly increased among the Yemenite Jews tested compared to the non-Yemenite Jews (327.1 +/- 129.2 vs. 237.0 +/- 133.1; p = 0.002), with no significant correlation to their absolute neutrophil count. LS expression was similar in the two study groups. In vitro analysis of CD11b and LS expression induced by chemoattractant and G-CSF showed no difference between neutrophils of Yemenite versus non-Yemenite Jews. The study results suggest that in Yemenite Jews, circulating neutrophils display significantly increased expression of beta2-integrin molecules on their surface compared to non-Yemenite Jews.

Aims Implantable cardioverter-defibrillators (ICDs) improve survival in certain high arrhythmic risk populations. However, there are sex differences regarding both the utilization and the benefit of these devices. Using a prospective national ICD registry, we aim to compare the indications for ICD implantation as well as outcomes in implanted women vs. men. Methods and results All subjects implanted with an ICD or cardiac resynchronization therapy with a defibrillator (CRTD) in Israel between July 2010 and February 2013 were included. A total of 3544 subjects constructed the baseline cohort, of whom 615 (17%) were women. Women had the same age (64 years) and rate of secondary prevention indication (26%) as men. However, women were more likely than men to have significant heart failure symptoms (52 vs. 45%), QRS > 120 ms (41 vs. 36%), and a higher rate of non-ischaemic cardiomyopathy (54 vs. 21%, all P values

Implantable cardioverter defibrillator (ICD) is a life-saving therapy for patients at risk of ventricular arrhythmias. Due to its high cost, its cost-effectiveness is highly dependent on its longevity, which is currently only based upon the manufacturer’s predicted device life span. We sought to assess the ICDs’ longevity and the factors influencing it, and to compare the observed (real life) to the expected (manufacturer’s prediction) life span at a device level. We retrospectively identified all patients who underwent an ICD implantation in a tertiary care medical center. For each device, an expected longevity was assigned based on the manufacturer/model, pacing percentage, and number of shocks per year. We defined device failure if the observed survival was shorter than 80 % of the expected. Only devices with follow-up time that exceeded the expected longevity were included. Of the 275 devices in the cohort, 79 (29 %) failed. Median device longevity was 5 years and varied markedly between manufacturers (4.3, 4.8, 5.1, and 6.3 years for Biotronik, St. Jude Medical, Boston Scientific, and Medtronic, respectively). There were significant differences among the manufacturers in device failure rates: 48, 17, 22, and 14 % for Biotronik, St. Jude Medical, Boston Scientific, and Medtronic, respectively). In multivariate analysis, manufacturer, earlier year of implantation, congestive heart failure and chronic renal failure significantly predicted device failure. In conclusion, there is a significant device failure rate among ICDs, with variability among manufacturers, impacting both patients and the medical economic systems.

Ventricular fibrillation (VF) is a lethal arrhythmia that requires immediate cardioversion and is rarely self-terminating. Spontaneous termination is typically associated with more organized activation than sustained VF terminated by shock, but the precise mechanism is unclear. In the present case, we describe a patient with recurrent syncope and documented self-terminating VF, who ultimately underwent implantable cardioverter defibrillator insertion. Assessment of the rhythm strip revealed organization of a chaotic rhythm into monomorphic ventricular tachycardia before termination, in supportive of previous reports. In conclusion, self-terminating VF is a very rare condition that can cause syncope.

Low-flow, low-gradient aortic stenosis is a heterogeneous entity that encompasses truly severe aortic stenosis as well as mild-to-moderate aortic stenosis in which aortic valve orifice area is severely reduced primarily due to left ventricular (LV) contractile dysfunction. Under such circumstances the capacity of the LV to generate stroke-work is severely compromised. In this case report, we describe a patient with severe LV dysfunction and ventricular dyssynchrony due to right ventricular pacing who presented with decompensated heart failure in the setting of low-flow, low-gradient aortic stenosis. We discuss the management of this high-operative-risk patient, who ultimately underwent upgrading of his dual chamber pacemaker to a biventricular pacemaker with significant echocardiographic, haemodynamic, and clinical improvement.

Background: Matrix metalloproteinase (MMP)-9, a member of the MMP superfamily is consistently implicated in the pathophysiology of atherosclerosis and plaque rupture, the most common mechanism responsible for acute coronary syndrome (ACS). Aim: To summarize the role of MMP-9 in atherosclerosis and its potential implications in assessment and treatment of coronary artery disease (CAD). Methods: We reviewed the PubMed database for relevant data regarding the role of MMP-9 in the pathophysiology of atherosclerosis. In the light of these data, we postulate potential implications of MMP-9 in the management and treatment of CAD. Results and conclusions: Existing data strongly support the role of MMP-9 in plaque destabilization and rupture. Based on the current knowledge, MMP-9 can potentially serve as a diagnostic biomarker in ACS and a prognostic biomarker in ACS and chronic CAD patients. MMP-9 is reduced by therapies that are associated with favourable outcome in atherosclerosis and thus may serve as a surrogate biomarker of treatment efficacy. However, large morbidity and mortality trials are still required to confirm that MMP-9 reduction is associated with improved outcome independent of the traditional risk factors (i.e. low-density lipoprotein cholesterol). Given its role in plaque rupture, inhibition of MMP-9 may promote plaque stabilization and consequently reduce cardiovascular events. Yet, the efficacy and safety of MMPs inhibitors should be first studied in preclinical models of atherosclerosis.

Persistent left superior vena cava (PLSVC) is a benign vascular anomaly that complicates pacemaker or implantable cardioverter defibrillator (ICD) lead implantation. Thus far, right ventricular lead implantation via PLSVC has been mostly accomplished by forming a U-shaped stylet, necessitating considerable manoeuvring depending on the heart size and geometry. In this article we report a technique of ICD lead implantation via PLSVC, using a coronary sinus delivery system as used today in cardiac resynchronization therapy.

Background: Elevated levels of inflammatory biomarkers and brain natriuretic peptide (BNP) are associated with increased mortality in patients with heart failure (HF). Hypothesis: The aim of the current study was to assess the correlation between circulating biomarkers and ventricular tachyarrhythmias among patients with HF. Methods: Blood samples from 50 stable ambulatory HF patients with moderate to severe systolic left ventricular (LV) dysfunction and an implantable cardioverter defibrillator (ICD) were analyzed for interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), high-sensitivity C-reactive protein (hsCRP) and BNP. Thereafter, the patients were followed for a mean period of 152 ± 44 days, during which ventricular tachyarrhythmias were recorded by the ICDs. Results: Follow-up data were obtained from 47 patients. Of them, 45 (96%) had ischemic cardiomyopathy, 38 (81%) had New York Heart Association class I–II, 43 (91%) were males, and the mean age was 68.6 ± 11.1 years. During follow-up, 5 patients (11%) had nonsustained ventricular tachycardia (NSVT), 6 patients (13%) had sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) and 36 patients (76%) had no events. The circulating biomarkers' levels upon enrollment were not significantly different between patients who subsequently had NSVT or VT/VF and patients who were free of events. Conclusions: No correlation was found between plasma levels of IL-6, TNF-α, hsCRP and BNP and ventricular arrhythmic events among stable HF patients during an intermediate term follow-up of 5.1 months. Further studies are still required to assess the association between these biomarkers and long-term risk of ventricular tachyarrhythmia. Copyright © 2007 Wiley Periodicals, Inc.

It remains unknown whether patients with severe decompensated class IV heart failure (HF) receiving intravenous inotropic treatment benefit from cardiac resynchronization therapy (CRT).We identified patients who underwent urgent CRT implantation due to decompensated class IV HF necessitating intravenous inotropic therapy.Of 10 patients with chronic ischemic cardiomyopathy (median QRS duration of 170 ms), CRT implantation was associated with symptomatic improvement in 8 patients. The mortality rate was 50% during a median follow-up of 9.5 months, with a median CRT-to-death duration of 6 months.CRT was feasible among class IV patients receiving inotropic treatment and was associated with clinical improvement.

The aim of this study was to analyze surface expression of neutrophil adhesion molecules in Yemenite Jews as compared to other ethnic populations in Israel. The constitutive neutrophil expression of CD11b and L-selectin (LS), as well as their expression in response to an in vitro chemoattractant and growth factor stimulation were studied by flow cytometry. Mean surface expression of CD11b molecule was statistically significantly increased among the Yemenite Jews tested compared to the non-Yemenite Jews (327.1 +/- 129.2 vs. 237.0 +/- 133.1; p = 0.002), with no significant correlation to their absolute neutrophil count. LS expression was similar in the two study groups. In vitro analysis of CD11b and LS expression induced by chemoattractant and G-CSF showed no difference between neutrophils of Yemenite versus non-Yemenite Jews. The study results suggest that in Yemenite Jews, circulating neutrophils display significantly increased expression of beta2-integrin molecules on their surface compared to non-Yemenite Jews.