3D echocardiography allows rapid and accurate surgical planning in complex aortic root abscess cases

Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilised in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume-rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3D-TOE under sedation. This led to timely surgery and an excellent outcome for the patient

Use of triple-site ventricular pacing in a patient with severe congestive heart failure and atrial fibrillation.

Cardiac resynchronization therapy (CRT) has become an accepted treatment for selected patients with drug-resistant heart failure. Data for patients in atrial fibrillation (AF) remains limited but suggests benefit in these patients too. We report the case of an 82-year-old patient with heart failure, VVIR permanent pacemaker, and permanent AF who had an upgrade to triple-site CRT implantation with good clinical response. Triple-site ventricular pacing may enhance the chance of response and LV reverse remodeling and should be considered in AF patients undergoing CRT implantation

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Pulmonary Vein Isolation using a High Density Mesh Ablator Catheter: Incorporation of three-Dimensional Navigation and Mappin

Background: We evaluated the use of a novel High Density Mesh Ablator (HDMA) catheter in combination with three-dimensional navigation for the treatment of paroxysmal atrial fibrillation. Methods: The HDMA catheter was used to carry out pulmonary vein isolation in a consecutive series of patients. Three-dimensional geometry of the left atrial-pulmonary vein (LA-PV) junctions were first created with the HDMA catheter. Ostial, proximal and distal sites within the pulmonary veins were tagged with catheter shadows on the created geometry to allow for re-interrogation of these exact sites after ablation. Results: The HDMA catheter was successfully used to create three dimensional geometry of the LA-PV junction in a total of 20 pulmonary veins which involved 5 patients. In all cases, ostial ablation alone was sufficient to achieve electrical isolation. No significant pulmonary vein stenosis was seen acutely after ablation. Conclusion: We describe the successful use of the novel HDMA catheter to create three-dimensional geometry of the LA-PV junction to assist with pulmonary vein isolation

Ganglionic Plexus Ablation During Pulmonary Vein Isolation - Predisposing to Ventricular Arrhythmias?

Catheter ablation is increasingly used to treat patients with atrial fibrillation (AF). Ablation of ganglionic plexi is often performed to reduce vagal innervation and has been shown to confer a better long-term outcome in terms of AF recurrence. We report a case of a patient having AF ablation with a profound vagal response, suggesting ganglionic plexus ablation, who subsequently developed ventricular fibrillation after programmed ventricular stimulation. Reduced vagal modulation is known to predispose to ventricular arrhythmias and vagal denervation following AF ablation may predispose to ventricular arrhythmias and requires further study

Increase in organization index predicts atrial fibrillation termination with flecainide post-ablation: spectral analysis of intracardiac electrograms

Aims: The mechanism of the action of flecainide in the termination of human atrial fibrillation (AF) is not fully understood. We studied the acute effects of flecainide on AF electrograms in the time and frequency domain to identify factors associated with AF termination. Methods and results: Patients who were still in AF at the end of catheter ablation for AF were given intravenous flecainide. Dominant frequency (DF) and organization index (OI) were obtained by fast Fourier transform of electrograms from the coronary sinus catheter over 10 s in AF, before and after flecainide infusion. Mean AF cycle length (CL) was also calculated. Twenty-six patients were studied (16 paroxysmal AF and 10 persistent AF). Seven converted to sinus rhythm (SR) with flecainide. In all patients, mean CL increased from 211 ± 44 to 321 ± 85 ms ( P \u3c 0.001). Mean DF decreased from 5.2 ± 1.03 to 3.6 ± 1.04 Hz ( P \u3c 0.001). Mean OI was 0.33 ± 0.13 before and 0.32 ± 0.11 after flecainide ( P = 0.90). Comparing patients who converted to SR with those who did not, OI post-flecainide was 0.41 ± 0.12 vs. 0.29 ± 0.10 ( P = 0.013), and the relative change in OI was 29 ± 33 vs. −3.9 ± 27% ( P = 0.016), respectively. No significant difference was noted in the change in CL and DF in the two groups. Conclusion: Increase in OI, independent of changes to CL and DF, appears critical to AF termination with flecainide. Increase in OI holds promise as a sensitive predictor of AF termination

Cardiovascular Biomarkers: Lessons of the Past and Prospects for the Future

Cardiovascular diseases (CVDs) are a major healthcare burden on the population worldwide. Early detection of this disease is important in prevention and treatment to minimise morbidity and mortality. Biomarkers are a critical tool to either diagnose, screen, or provide prognostic information for pathological conditions. This review discusses the historical cardiac biomarkers used to detect these conditions, discussing their application and their limitations. Identification of new biomarkers have since replaced these and are now in use in routine clinical practice, but still do not detect all disease. Future cardiac biomarkers are showing promise in early studies, but further studies are required to show their value in improving detection of CVD above the current biomarkers. Additionally, the analytical platforms that would allow them to be adopted in healthcare are yet to be established. There is also the need to identify whether these biomarkers can be used for diagnostic, prognostic, or screening purposes, which will impact their implementation in routine clinical practice

Rationale and study design of the MINERVA study: Multicentre Investigation of Novel Electrocardiogram Risk markers in Ventricular Arrhythmia prediction-UK multicentre collaboration

Introduction The purpose of this study is to assess the ability of two new ECG markers (Regional Repolarisation Instability Index (R2I2) and Peak Electrical Restitution Slope) to predict sudden cardiac death (SCD) or ventricular arrhythmia (VA) events in patients with ischaemic cardiomyopathy undergoing implantation of an implantable cardioverter defibrillator for primary prevention indication. Methods and analysis Multicentre Investigation of Novel Electrocardiogram Risk markers in Ventricular Arrhythmia prediction is a prospective, open label, single blinded, multicentre observational study to establish the efficacy of two ECG biomarkers in predicting VA risk. 440 participants with ischaemic cardiomyopathy undergoing routine first time implantable cardioverter-defibrillator (ICD) implantation for primary prevention indication are currently being recruited. An electrophysiological (EP) study is performed using a non-invasive programmed electrical stimulation protocol via the implanted device. All participants will undergo the EP study hence no randomisation is required. Participants will be followed up over a minimum of 18 months and up to 3 years. The first patient was recruited in August 2016 and the study will be completed at the final participant follow-up visit. The primary endpoint is ventricular fibrillation or sustained ventricular tachycardia >200 beats/min as recorded by the ICD. The secondary endpoint is SCD. Analysis of the ECG data obtained during the EP study will be performed by the core lab where blinding of patient health status and endpoints will be maintained. Ethics and dissemination Ethical approval has been granted by Research Ethics Committees Northern Ireland (reference no. 16/NI/0069). The results will inform the design of a definitive Randomised Controlled Trial (RCT). Dissemination will include peer reviewed journal articles reporting the qualitative and quantitative results, as well as presentations at conferences and lay summaries