Hand-held echocardiography during complex electrophysiologic procedures

Introduction: Complex electrophysiologic (EP) procedures are time consuming and open to complications. Accurate and rapid recognition of cardiac pathologies is essential before, during, and immediately after such procedures. In this study, we aimed to compare hand-held echocardiography (HHE) with standard echocardiography (SE) to determine whether HHE can be used as a practical and reliable diagnostic tool during such procedures. Methods: One hundred consecutive patients undergoing complex EP procedures and catheter ablation were included in the study. All patients were evaluated with SE or HHE in terms of main cardiac pathologies at the beginning and immediately after the procedure. The diagnostic accuracy and evaluation time of both methods were compared at the beginning and after the procedure. The agreement between both methods was calculated. Results: At the beginning and after the procedure, opening and evaluation times with HHE were significantly shorter than with SE (P<0.001 for all). There was significant agreement between the two methods in the diagnosis of cardiac pathologies (Agreement was 95% for minimal mild aortic regurgitation (AR), 99% for moderate/ severe AR, 93% for minimal/ mild mitral regurgitation (MR), 95% for moderate/ severe MR, 100% for pericardial effusion, and 100% for left ventricular thrombus at the beginning of the procedure). Conclusion: With the use of HHE during complex EP procedures, cardiac pathologies can be diagnosed with similar accuracy as SE. In addition, HHE has a significant advantage over SE in terms of time to diagnosis

Association of ECG characteristics with clinical and echocardiographic outcome to CRT in a non-LBBB patient population

Purpose: Effectiveness of cardiac resynchronization therapy (CRT) in patients without left bundle branch block (non-LBBB) QRS morphology is limited. Additional selection criteria are needed to identify these patients. Methods: Seven hundred ninety consecutive patients with non-LBBB morphology, who received a CRT-device in 3 university centers in the Netherlands, were selected. Pre-implantation 12-lead ECGs were evaluated on morphology, duration, and area of the QRS complex, as well as on PR interval, left ventricular activation time (LVAT), and the presence of fragmented QRS (fQRS). Association of these ECG features with the primary endpoint: a combination of left ventricular assist device (LVAD) implantation, cardiac transplantation and all-cause mortality, and secondary endpoint—echocardiographic reduction of left ventricular end-systolic volume (LVESV)—were evaluated. Results: The primary endpoint occurred more often in non-LBBB patients with with PR interval ≥ 230ms, QRS area < 109μVs, and with fQRS. Multivariable regression analysis showed independent associations of QRS area (HR 2.33 [1.44, 3.77], p = 0.001) and PR interval (HR 2.03 [1.51, 2.74], p < 0.001) only. Mean LVESV reduction was significantly lower in patients with baseline RBBB, QRS duration < 150 ms, PR interval ≥ 230 ms, and in QRS area < 109 μVs. Multivariable regression analyses only showed significant associations between QRS area ≥ 109 μVs (OR 2.00 [1.09, 3.66] p = 0.025) and probability of echocardiographic response to CRT. Conclusions: In the heterogeneous non-LBBB patient population, QRS area and PR prolongation rather than traditional QRS duration and morphology are associated to both clinical and echocardiographic outcomes of CRT

Association of vectorcardiographic T-wave area with clinical and echocardiographic outcomes in cardiac resynchronization therapy

Aims: Data on repolarization parameters in cardiac resynchronization therapy (CRT) are scarce. We investigated the association of baseline T-wave area, with both clinical and echocardiographic outcomes of CRT in a large, multi-centre cohort of CRT recipients. Also, we evaluated the association between the baseline T-wave area and QRS area. Methods and results: In this retrospective study, 1355 consecutive CRT recipients were evaluated. Pre-implantation T-wave and QRS area were calculated from vectorcardiograms. Echocardiographic response was defined as a reduction of ≥15% in left ventricular end-systolic volume between 3 and 12 months after implantation. The clinical outcome was a combination of all-cause mortality, heart transplantation, and left ventricular assist device implantation. Left ventricular end-systolic volume reduction was largest in patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs compared with QRS area ≥ 109 μVs and T-wave area < 66 μVs (P = 0.004), QRS area < 109 μVs and T-wave area ≥ 66 μVs (P < 0.001) and QRS area < 109 μVs and T-wave area < 66 μVs (P < 0.001). Event-free survival rate was higher in the subgroup of patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs (n = 616, P < 0.001) and QRS area ≥ 109 μVs and T-wave area < 66 μVs (n = 100, P < 0.001) than the other subgroups. In the multivariate analysis, T-wave area remained associated with echocardiographic response (P = 0.008), but not with the clinical outcome (P = 0.143), when QRS area was included in the model. Conclusion: Baseline T-wave area has a significant association with both clinical and echocardiographic outcomes after CRT. The association of T-wave area with echocardiographic response is independent from QRS area; the association with clinical outcome, however, is not

Comparison of the relation of the ESC 2021 and ESC 2013 definitions of left bundle branch block with clinical and echocardiographic outcome in cardiac resynchronization therapy

INTRODUCTION: We aimed to investigate the impact of the 2021 European Society of Cardiology (ESC) guideline changes in left bundle branch block (LBBB) definition on cardiac resynchronization therapy (CRT) patient selection and outcomes. METHODS: The MUG (Maastricht, Utrecht, Groningen) registry, consisting of consecutive patients implanted with a CRT device between 2001 and 2015 was studied. For this study, patients with baseline sinus rhythm and QRS duration ≥ 130ms were eligible. Patients were classified according to ESC 2013 and 2021 guideline LBBB definitions and QRS duration. Endpoints were heart transplantation, LVAD implantation or mortality (HTx/LVAD/mortality) and echocardiographic response (LVESV reduction ≥15%). RESULTS: The analyses included 1.202, typical CRT patients. The ESC 2021 definition resulted in considerably less LBBB diagnoses compared to the 2013 definition (31.6% vs. 80.9%, respectively). Applying the 2013 definition resulted in significant separation of the Kaplan-Meier curves of HTx/LVAD/mortality (p < .0001). A significantly higher echocardiographic response rate was found in the LBBB compared to the non-LBBB group using the 2013 definition. These differences in HTx/LVAD/mortality and echocardiographic response were not found when applying the 2021 definition. CONCLUSION: The ESC 2021 LBBB definition leads to a considerably lower percentage of patients with baseline LBBB then the ESC 2013 definition. This does not lead to better differentiation of CRT responders, nor does this lead to a stronger association with clinical outcomes after CRT. In fact, stratification according to the 2021 definition is not associated with a difference in clinical or echocardiographic outcome, implying that the guideline changes may negatively influence CRT implantation practice with a weakened recommendation in patients that will benefit from CRT

Akromegali Hastalarında Aritmik Olayların ve Öngördürücülerinin Belirlenmesi

Cardiovascular complications are the most common causes of morbidity and mortality in acromegaly. Arhythmias and conduction abnormalities are important manifestations of cardiac involvement in patients with acromegaly. However, there is little data regarding cardiac autonomic functions in these patients. In these study, we aimed to investigate several parameters of cardiac autonomic functions and evaluate echocardiographic systolic and diastolic functions in patients with acromegaly compared to healthy subjects. Twenty-one newly diagnosed acromegalic patients (57,1% female, age: 45,76±12,4 years) and 27 age and gender-matched healthy subjects were enrolled in these study. All participants underwent 24h Holter recording and transthorasic echocardiographic (TTE) examination. Heart rate recovery (HRR) indices were calculated by subtracting 1st, 2nd and 3rd minute heart rates from maximal heart rate. All patients underwent heart rate variability (HRV) and QT dynamicity analysis. Baseline characteristics were similar except diabetes mellitus and hypertension among groups. All patients underwent transsphenoidal surgery (TSS), also five (23,8%) patients treated with octreotid and one (4,8%) patient had radiotherapy. Mean HRR1 (27,81±12,4 vs 42,48±6,6, p=0.001), HRR2 (43,43±15,3 vs 61,48±11,5, p=0,001) and HRR3 (47,71±15,4 vs 65,63±10,5, p=0,001) values were significantly higher in control group. HRV parameters as, SDNN (p=0,001), SDANN (p=0,001), RMSSD (p=0,001), PNN50 (p=0,001), variability index (p=0,001) and HF (p=0,001) were significantly decreased in patients with acromegaly; but mean heart rate (p=0,001), LF (p=0,012) and LF/HF (p=0,001) were significantly higher in acromegaly patients. QTec (p=0,005), QTac/RR slope (p=0,001) and QTec/RR slope (p=0,001) were significantly higher in patients with acromegaly.End diastolic diameter (4,9±0,4 vs 4,7±0,3, p=0,019), posterior wall thickness (1,03±0,1 vs 0,93±0,1, p=0,001), septal thickness (1,08±0,1 vs 0,93±0,1, p=0,001), left atrial diameter (3,51±0,3 vs 3,32±0,4, p=0,049), right ventricle diameter (2,76±0,2 vs 2,54±0,1, p=0,001) and septal E/E' ratio (8,25±3,1 vs 6,37±1,7, p=0,01) values were significantly higher in acromegalic patients; but tricuspid annular plane systolic excursion (TAPSE) (22,08±2,9 vs 24,15±1,4, p=0,032), E/A ratio (0,92±0,2'e karşı 1,2±0,3, p=0,002) and septal E' (9,13±2,9'e karşı 12,90±1,7, p=0,001) values were significantly decreased in patients with acromegaly. Additionally, there were significant negative correlation of disease duration with HHR1, HRR2, HRR3, SDNN, E/A ratio and significant positive correlation of disease duration with septal thickness. At a median follow-up time of 10 months; HRR1, HRR2, HRR3, PNN50, RMSSD, E/A ratio, septal E' and TAPSE were significantly increased, LF/HF, mean heart rate, septal thickness, posterior wall thickness, left atrial diameter and IVRT were significantly decreased in patients with acromegaly after the treatment (P<0,05). Our study results suggest that cardiac autonomic functions and left ventricular diastolic functions are impaired in patients with acromaegaly. Also we showed thatthe treatment of acromegaly makes significant improvement in many parameters of cardiac autonomic functions and left ventricular diastolic functions.Akromegalik hastalarda morbidite ve mortalitenin en sık nedenleri kardiyovasküler komplikasyonlardır. Aritmi ve iletim bozuklukları, akromegali hastalarında kardiyak tutulumun önemli klinik bulgularıdır. Ancak bu hastalarda kardiyak otonomik fonksiyonlarla ilgili çok az veri bulunmaktadır. Bu çalışmanın amacı, akromegali hastalarında kardiyak otonomik fonksiyon parametrelerini incelemek, ekokardiyografik sistolik ve diyastolik fonksiyonları değerlendirmek ve bu verileri sağlıklı kontrol grubuyla karşılaştırmaktır. Yirmi bir yeni tanı akromegali hastası (%57,1 kadın, yaş: 45,76±12,4yıl) ve yaşa ve cinsiyete göre eşleştirilmiş 27 sağlıklı birey çalışmaya alındı. Tüm olgulara 24 saatlik Holter monitörizasyonu uygulandı ve transtorasik ekokardiyografi (TTE) yapıldı. Kalp hızı toparlanma indeksi (HRR) verileri, maksimum kalp hızından birinci, ikinci ve üçüncü dakikadaki kalp hızları çıkarılarak hesaplandı. Tüm hastalarda kalp hızı değişkenliği (HRV) ve QT dinamisite analizi yapıldı. Her iki grup arasında diabetes mellitus ve hipertansiyon haricindeki bazal karakteristik özellikler benzerdi. Tüm hastalara transsfenoidal cerrahi (TSC), beş (%23,8) hastaya oktreotid tedavisi ve bir (%4,8) hastaya radyoterapi (RT) uygulandı. Ortalama HRR1 (27,81±12,4'e karşı 42,48±6,6, p=0.001), HRR2 (43,43±15,3'e karşı 61,48±11,5, p=0,001) ve HRR3 (47,71±15,4'e karşı 65,63±10,5, p=0,001) değerleri kontrol grubunda anlamlı olarak daha yüksek bulundu. Akromegali hastalarında SDNN (p=0,001), SDANN (p=0,001), RMSSD (p=0,001), PNN50 (p=0,001), değişkenlik indeksi (p=0,001) ve HF (p=0,001) anlamlı olarak daha düşük; ortalama kalp hızı (p=0,001), LF (p=0,012) ve LF/HF (p=0,001) ise anlamlı olarak daha yüksek bulundu. QTec (p=0,005), QTac/RR eğimi (p=0,001) ve QTec/RR eğimi (p=0,001) değerlerinin akromegali hastalarında anlamlı olarak daha yüksek olduğu görüldü. Diyastol sonu çapı (4,9±0,4'e karşı 4,7±0,3, p=0,019), arka duvar kalınlığı (1,03±0,1'e karşı 0,93±0,1, p=0,001), septum kalınlığı (1,08±0,1'e karşı 0,93±0,1, p=0,001), sol atriyum çapı (3,51±0,3'e karşı 3,32±0,4, p=0,049), sağ ventrikül çapı (2,76±0,2'e karşı 2,54±0,1, p=0,001), septal E/E' oranı (8,25±3,1'e karşı 6,37±1,7, p=0,01) değerleri akromegalik hastalarda anlamlı olarak daha yüksekti; diğer taraftan triküspit anüler düzlem sistolik hareketi (TAPSE) (22,08±2,9'e karşı 24,15±1,4, p=0,032), E/A oranı (0,92±0,2'e karşı 1,2±0,3, p=0,002), septal E' (9,13±2,9'e karşı 12,90±1,7, p=0,001) değerinin ise akromegali hastalarında anlamlı olarak azaldığı görüldü. Ayrıca, hastalık süresi ile HRR1, HRR2, HRR3, SDNN ve E/A oranı arasında anlamlı negatif korelasyon, septum kalınlığı ile anlamlı pozitif korelasyon olduğu tespit edildi. Medyan 10 aylık takip süresi sonunda akromegali hastalarında; HRR1, HRR2, HRR3, PNN50, RMSSD, E/A oranı, septal E' ve TAPSE değerlerinde anlamlı artış olduğu, LF/HF oranı, ortalama kalp hızı, septum kalınlığı, arka duvar kalınlığı, sol atriyum çapında ve IVRT'de ise anlamlı azalma olduğu görüldü (p<0,05). Sonuç olarak çalışmamızda, akromegali hastalarında kardiyak otonomik fonksiyonların ve sol ventriküler diyastolik fonksiyonların bozulduğu tespit edildi. Ayrıca akromegali hastalarında tedavi ile kardiyak otonomik fonksiyonların ve sol ventrikül diyastolik fonksiyonların önemli bir çok parametresinde anlamlı düzelme sağlanabildiği gösterildi

Tips for management of arrhythmias in endocrine disorders from an European Heart Rhythm Association position paper

In endocrine diseases, hormonal changes, electrolyte abnormalities, and the deterioration of heart structure can lead to various arrhythmias. In diabetic patients, hypoglycemia, hyperglycemia, and hypokalemia can trigger arrhythmias, and diabetic cardiomyopathy can also cause electrical and structural remodeling to form substrates for arrhythmias. The risk of atrial fibrillation (AF) increases in hyperthyroidism; however, the prevalence of ventricular arrhythmias in hypothyroidism is higher. Besides AF and ventricular tachycardias, bradycardias and atrioventricular blocks can also be seen in pheochromocytoma due to the desensitization of adrenergic cardiovascular receptors. The correction of metabolic and electrolyte disturbances in patients with adrenal cortex disease should be the main approach in the prevention and treatment of arrhythmias. Early initiation of treatment in patients with acromegaly seems to decrease the development of cardiac remodeling and ventricular arrhythmia. Early and late after depolarizations due to hypercalcemia in hyperparathyroidism can lead to life-threatening ventricular arrhythmias. This elegant position paper provides important recommendations regarding prevention and treatment of arrhythmias for specific endocrine disorders

Cryoballoon ablation of non-PV triggers in persistent atrial fibrillation

Cryoballoon-based catheter ablation has emerged as an efficacious and safe therapeutic intervention for patients with paroxysmal atrial fibrillation (PAF). PAF is primarily associated with the triggers in the pulmonary vein (PV). However, persistent atrial fibrillation (PeAF) is a complex condition that involves changes in the atrial substrate and the presence of non-PV triggers. Therefore, a comprehensive treatment approach is necessary for patients with PeAF. Utilizing a 3D electroanatomical map, the radiofrequency-based ablation technique adeptly identifies and targets the atrial substrate and non-PV triggers. On the other hand, the cryoballoon-based AF ablation was initially designed for PV isolation. However, its single-shot feature makes it a great choice for electrophysiologists looking to address non-PV triggers. It is possible to target the left atrial appendage (LAA), superior vena cava (SVC), left atrial roof, and posterior wall using the apparatus's unique configuration and ablation abilities. This review focuses on the increasing literature regarding cryoballoon-based methods for non-PV trigger ablation. Specifically, it delves into the technical procedures used to isolate the LAA, SVC, and ablate the left atrial roof and posterior wall