The Application of Serial Electrophysiological Testing in the Management of Patients With Ventricular Arrhythmias

The lethal potential of ventricular tachyarrhythmias is well recognised and because of the ineffectiveness of empirically prescribed therapy a directed approach to the treatment of these arrhythmias is mandated. The aim of the studies in this thesis was to further define the applicability of serial electrophysiological testing for the determination of effective antiarrhythmic therapy in patients with these arrhythmias. In Chapter 1, the potential mechanisms for the development of ventricular tachyarrhythmias and their relation to the use of programmed stimulation are discussed. The prognostic impact of ventricular arrhythmias is reviewed. The therapeutic options are described and the classification of antiarrhythmic drugs is explained. The different management strategies for the prescription of antiarrhythmic therapy are discussed. The historical development and rationale for electrophysiological testing is described. The methodology and equipment required for this approach is described in Chapter 2. In particular, the stimulation protocol employed in all studies in this thesis is explained. The induction of ventricular tachyarrhythmia in response to the stimulation protocol is dealt with in Chapter 3. The varying impact of different factors including the type of underlying heart disease in the patient population being studied and the different components of the stimulation protocol are described. The comparability of the results with those reported from other laboratories confirms the utility of the stimulation protocol. The controversial aspect of sensitivity, specificity and reproducibility of programmed stimulation is discussed. In Chapter 4, the techniques for tachycardia termination and the effectiveness of pacing modalities are described. The effect of cycle length and antiarrhythmic therapy on pacing termination are discussed. The concordance between the response to electrophysio-logical testing with both intravenous and oral formulations of procainamide is dealt with in Chapter 5. The advantages of testing intravenous therapy were offset by the observation that non indueibility with intravenous procainamide was not predictive of noninducibility with oral procainamide. The results from this study confirm that retesting on oral therapy is required even if the intravenous agent is shown to be effective. The use of serial electrophysiological drug testing to identify effective therapy in patients with ventricular tachyarrhythmias related to coronary artery disease is described in Chapter 6. Overall drug efficacy, efficacy of individual regimens and the effect of the type of induced arrhythmia on drug response are detailed. The long-term effectiveness of antiarrhythmic regimens identified as successful by electrophysiological testing is confirmed using both the accepted stimulation end-point of noninducibility and the more relaxed end-point of 15 or less repetitive responses. In Chapter 7, similar results confirming the predictive value of serial drug testing were obtained for patients with ventricular tachyarrhythmias related to cardiomyopathy. The effect of the combination of amiodarone plus the Type 1 agent procainamide on arrhythmia inducibility is discussed in Chapter 8. The main benefit of the addition of procainamide was on the haemodynamic impact of the induced arrhythmia which may provide a degree of protection from sudden death. Using multivariate statistical techniques the determinants of the response to serial electrophysiological drug testing were analysed in Chapter 9. Patients with poor left ventricular function were less likely to respond to medical therapy, and suppression of arrhythmia induction was more difficult in patients with induced sustained ventricular tachycardia than in patients with either ventricular fibrillation or nonsustained ventricular tachycardia. During follow up, if recurrence of arrhythmia occurred, it was more likely to be as sudden death if the patients had cardiac failure, and the induced arrhythmia in the discharge drug study was not symptomatically tolerated. The major independent variable which predicted recurrence of arrhythmia during follow-up was failure of serial electrophysiological drug testing to identify a successful therapy. In Chapter 10, the predictive value of the response to procainamide is discussed. Failure of procainamide to suppress arrhythmia inducibility predicts failure of other agents in patients with induced sustained ventricular tachycardia but not in patients with either ventricular fibrillation or nonsustained ventricular tachycardia. The implications of these observations in the evaluation of antiarrhythmic drug efficacy are discussed. In Chapter 11, the use of programmed stimulation to reveal the potential for drug related worsening of arrhythmias is described. The different proarrhythmic responses and their potential clinical value are discussed and the lack of predictability of these responses is investigated. Important unresolved problems in the clinical application of electrophysiological testing for the management of patients with ventricular tachyarrhythmias are discussed in Chapter 12

NH-ME LEND: Advancing Health Equity for Children and Youth with ASD/NDD and their Families through Continuous Quality Improvement

Over the past two decades NH and Maine have experienced rapid growth of racial, ethnic, and linguistic minority populations. New Hampshire’s foreign-born population was 5.7% in 2013, while Maine’s foreign-born population was 3.4% during the same time period (American Immigration Council, 2017). In addition, NH and Maine are designated refugee resettlement areas. NH is now home to refugees from over 40 countries (NH DHHS, 2010) and Maine is home to refugees from over 30 countries (Catholic Charities Refugee and Immigration Services, 2015).https://digitalcommons.library.umaine.edu/ccids_posters/1027/thumbnail.jp

Improving Effective Interdisciplinary Team Work Using Team-Based Learning within the NH-ME LEND Curriculum: Evaluation from Year 2

This poster provided an update on the implementation of Team-Based Learning (TBL) by NH LEND faculty during Academic Year 2015-2016. Improvements to the Readiness Assurance Process included defined learning outcomes, use of reading guides, and improved assessment of trainee knowledge of concepts. Evaluation data from Years 1 and 2 regarding the use of TBL were presented, including positive outcomes and challenges described by faculty and trainees.https://digitalcommons.library.umaine.edu/ccids_posters/1006/thumbnail.jp

Navigating Distance and Technology: Successfully engaging LEND Trainees from New Hampshire and Maine in a Synchronous Online Team-Based Learning Environment

The accomplishments and challenges of distance and technology in an online team-based learning environment.https://digitalcommons.library.umaine.edu/ccids_posters/1018/thumbnail.jp

Design and Testing of Experimental Components Used on Photoelastic Analysis

Exact solutions of the stress distribution in elastic bodies are confined to a selected group of geometric configuration. The nature of irregular-shape problems prohibits a solution by closed formula or even by a general form of solution. All experimental techniques have weaknesses which limit their usage. Strain gauges give a numerical solution but only at a surface. Stress coating are materials which will fail when a prescribed stress value is reached. Such brittle coatings will show the direction, magnitude, and distribution of tensile stresses over an entire surface but they are restricted to some designated level of failure. Two dimensional photo elastic studies require a model of the prototype and a polariscope. Photo elasticity is an experimental technique which will effectively measure the stresses in a cross-sectional areal. Irregularities such as connectors, holes, notches, and other shape complexities cause stress concentrations which are impossible to evaluate. Actual machine parts which have stress-concentrations in three dimensions can be analyzed by three dimensional photo elastic methods. Severe changes in the stress-optic constants and mechanical properties of photoelastic material are observed at the critical temperatures of stress-freezing. This thesis will be concerned with the establishment of a fundamental laboratory procedure and the calibration of the equipment for a complete photoelastic analysis

Improving Effective Interdisciplinary Team Work Using Team-Based Learning within the NH-ME LEND Curriculum: Comparing Years 1 – 3

This poster provided an update on an ongoing effort by faculty in the New Hampshire-Maine Leadership Education in Neurodevelopmental and Related Disabilities (NH-ME LEND) Program to implement Team-Based Learning (TBL). Three years of evaluation data was presented. Changes made to improve the process were identified as well as some of the unique obstacles to implementing TBL in a seminar that was conducted in two classrooms connected through video conferencing and had a high faculty-to-student ratio.https://digitalcommons.library.umaine.edu/ccids_posters/1008/thumbnail.jp

Engaging LEND Trainees in a Leadership and Policy Experience

This poster illustrated how faculty from the New Hampshire-Maine Leadership Education in Neurodevelopmental and Related Disabilities (NH-ME LEND) Program re-envisioned and implemented a comprehensive set of leadership, policy and advocacy experiences to further build upon the leadership potential of 23 LEND trainees by intentionally threading leadership skill development throughout the LEND curriculum.https://digitalcommons.library.umaine.edu/ccids_posters/1010/thumbnail.jp

Coaching LEND Faculty in Implementing Team-Based Learning Across Two States: Lessons Learned over Four Years

This poster describes the implementation of team-based learning (TBL) in the didactic seminar component of the NH-ME LEND program over four years. TBL has been found to be an effective instructional method, fostering communication, collaboration, and conflict negotiation among interdisciplinary teams. The process of coaching a large faculty across two states to implement TBL, faculty perceptions with TBL, lessons learned, and quality improvement strategies is described.https://digitalcommons.library.umaine.edu/ccids_posters/1028/thumbnail.jp

Assessing Trainee Understanding of Health Equity & Diversity

The NH-ME LEND Program engages in quality improvement efforts aimed at increasing trainee’s understanding of health equity and cultural competence. This poster 1) provided an overview of the curricular components related to health equity and diversity, 2) reported on six cohorts of trainees’ self-assessments in these areas, and 3) shared trainees’ personal reflections on their growth. Finally, ongoing program improvements efforts in these areas were discussed.https://digitalcommons.library.umaine.edu/ccids_posters/1011/thumbnail.jp

Aspects of glaciation in Orkney

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