Electrocardiographic (ECG) criteria for determining left ventricular mass in young healthy men; data from the LARGE Heart study

Background: Doubts remain over the use of the ECG in identifying those with increased left ventricular (LV) mass. This is especially so in young individuals, despite their high prevalence of ECG criteria for LV hypertrophy. We performed a study using cardiovascular magnetic resonance (CMR), which provides an in vivo non-invasive gold standard method of measuring LV mass, allowing accurate assessment of electrocardiography as a tool for defining LV hypertrophy in the young.Methods and results: Standard 12-lead ECGs were obtained from 101 Caucasian male army recruits aged (mean +/- SEM) 19.7 +/- 0.2 years. LV mass was measured using CMR. LV mass indexed to body surface area demonstrated no significant correlation with the Cornell Amplitude criteria or Cornell Product for LV hypertrophy. Moderate correlations were seen with the Sokolow-Lyon Amplitude (0.28) and Sokolow-Lyon Product (0.284). Defining LV hypertrophy as a body surface area indexed left ventricular mass of 93 g/m(2), calculated sensitivities [and specificities] were as follows; 38.7% [74.3%] for the Sokolow-Lyon criteria, 43.4% [61.4%] for the Sokolow-Lyon Product, 19.4% [91.4%] for Cornell Amplitude, and 22.6% [85.7%] for Cornell Product. These values are substantially less than those reported for older age groups.Conclusion: ECG criteria for LV hypertrophy may have little value in determining LV mass or the presence of LV hypertrophy in young fit males

British randomised controlled trial of AV and VV optimization ("BRAVO") study:rationale, design, and endpoints

Background Echocardiographic optimization of pacemaker settings is the current standard of care for patients treated with cardiac resynchronization therapy. However, the process requires considerable time of expert staff. The BRAVO study is a non-inferiority trial comparing echocardiographic optimization of atrioventricular (AV) and interventricular (VV) delay with an alternative method using non-invasive blood pressure monitoring that can be automated to consume less staff resources. Methods/Design BRAVO is a multi-centre, randomized, cross-over, non-inferiority trial of 400 patients with a previously implanted cardiac resynchronization device. Patients are randomly allocated to six months in each arm. In the echocardiographic arm, AV delay is optimized using the iterative method and VV delay by maximizing LVOT VTI. In the haemodynamic arm AV and VV delay are optimized using non-invasive blood pressure measured using finger photoplethysmography. At the end of each six month arm, patients undergo the primary outcome measure of objective exercise capacity, quantified as peak oxygen uptake (VO2) on a cardiopulmonary exercise test. Secondary outcome measures are echocardiographic measurement of left ventricular remodelling, quality of life score and N-terminal pro B-type Natriuretic Peptide (NT-pro BNP). The study is scheduled to complete recruitment in December 2013 and to complete follow up in December 2014. Discussion If exercise capacity is non-inferior with haemodynamic optimization compared with echocardiographic optimization, it would be proof of concept that haemodynamic optimization is an acceptable alternative which has the potential to be more easily implemented

Efficacy of pulmonary vein isolation in preventing atrial fibrillation: meta-analysis of randomized controlled trials with an invasive control procedure

Introduction Pulmonary vein isolation (PVI) is a commonly used element in treatment of atrial fibrillation (AF) but has never been tested in an intentionally placebo (sham) controlled trial. Nevertheless there have been several randomized controlled trials (RCTs) in which both arms receive an ablation procedure but the only difference between treatment arms is inclusion or omission of PVI. As long as both doctor and patient have reason to believe that the procedures in both arms are effective, such RCTs could be an effective proxy for placebo controlled trials. Methods Medline and Cochrane databases were searched for RCTs comparing catheter ablation including PVI with left atrial ablation excluding PVI. The primary efficacy endpoint was freedom from AF/atrial tachycardia at 6 months. A random-effects meta-analysis was performed using the restricted maximum likelihood (REML) estimator. Results Overall, seven studies (909 patients) met inclusion criteria. Across the 7 trials, mean age was 57.3, 70.2% of participants were male. In four trials (352 patients) the non-PVI ablation procedure was performed in both arms, while PVI was performed in only one arm. The non-PVI ablation procedures were complex fractionated atrial electrogram ablation (2 studies), ganglionated plexi ablation (1 study) and focal impulse and rotor modulation (1 study). In these, AF recurrence was significantly lower when PVI was included (RR 0.48, 95% CI 0.26-0.90, I2 64.4%)In an analysis of all 7 studies, AF recurrence was significantly lower in ablation with an ablation strategy including PVI compared to one without PVI (Figure 1, RR 0.67, 95% CI 0.53-0.85, p = 0.001, I2 0%). Neither type of AF (persistent vs. paroxysmal, p=0.43) nor type of non-PVI ablation (p=0.35) were significant moderators of the effect size. A sensitivity analysis omitting each study in turn showed similar results to the primary analysis. In particular exclusion of the retracted OASIS trial showed results similar to the primary analysis. Conclusion PVI significantly reduces AF recurrence against a procedural control. A true placebo controlled trial of PVI versus placebo PVI (and no other procedure) might show an even larger efficacy because there would be no background efficacy in the control arm. It remains unknown how these convincing reductions in electrically documented AF would relate to symptom regression, since the correspondence between arrhythmia and symptoms is imperfect. A placebo (sham) controlled RCT would be the ideal method of testing this

Meta-analysis of randomized controlled trials of atrial fibrillation ablation with pulmonary vein isolation versus without

Objectives This meta-analysis examined the ability of pulmonary vein isolation (PVI) to prevent atrial fibrillation in randomized controlled trials (RCTs) in which the patients not receiving PVI nevertheless underwent a procedure. Background PVI is a commonly used procedure for the treatment of atrial fibrillation (AF), and its efficacy has usually been judged against therapy with anti-arrhythmic drugs in open-label trials. There have been several RCTs of AF ablation in which both arms received an ablation, but the difference between the treatment arms was inclusion or omission of PVI. These trials of an ablation strategy with PVI versus an ablation strategy without PVI may provide a more rigorous method for evaluating the efficacy of PVI. Methods Medline and Cochrane databases were searched for RCTs comparing ablation including PVI with ablation excluding PVI. The primary efficacy endpoint was freedom from atrial fibrillation (AF) and atrial tachycardia at 12 months. A random-effects meta-analysis was performed using the restricted maximum likelihood estimator. Results Overall, 6 studies (610 patients) met inclusion criteria. AF recurrence was significantly lower with an ablation including PVI than an ablation without PVI (RR: 0.54; 95% confidence interval [CI]: 0.33 to 0.89; p 1⁄4 0.0147; I2 1⁄4 79.7%). Neither the type of AF (p 1⁄4 0.48) nor the type of non-PVI ablation (p 1⁄4 0.21) was a significant moderator of the effect size. In 3 trials the non-PVI ablation procedure was performed in both arms, whereas PVI was performed in only 1 arm. In these studies, AF recurrence was significantly lower when PVI was included (RR: 0.32; 95% CI: 0.14 to 0.73; p 1⁄4 0.007, I2 78% Conclusion In RCTs where both arms received an ablation, and therefore an expectation amongst patients and doctors of benefit, being randomized to PVI had a striking effect, reducing AF recurrence by a half

Young@Heart: empowering the next generation of cardiovascular researchers

In recognition of the increasing health burden of cardiovascular disease, the Dutch CardioVascular Alliance (DCVA) was founded with the ambition to lower the cardiovascular disease burden by 25% in 2030. To achieve this, the DCVA is a platform for all stakeholders in the cardiovascular field to align policies, agendas and research. An important goal of the DCVA is to guide and encourage young researchers at an early stage of their careers in order to help them overcome challenges and reach their full potential. Young@Heart is part of the DCVA that supports the young cardiovascular research community. This article illustrates the challenges and opportunities encountered by young cardiovascular researchers in the Netherlands and highlights Young@Heart’s vision to benefit from these opportunities and optimise collaborations to contribute to lowering the cardiovascular disease burden together as soon as possible. Dutch contribution to the field Dutch cardiovascular alliance (DCVA) is a platform that combines stakeholders in the cardiovascular field with the goal to lower cardiovascular disease burden by 25% in 2030. Young@Heart is part of the talent pillar of DCVA and represents young researchers in the Netherlands. Young@Heart aims to provide career perspectives in academic, corporate and non-governmental settings for talented basic and clinical scientists. By providing workshops, national and international networking and funding opportunities, Young@Heart hopes to ensure a bright future for cardiovascular research in the Netherlands

Visualizing Localized Reentry With Ultra-High Density Mapping in Iatrogenic Atrial Tachycardia Beware Pseudo-Reentry

Background—The activation pattern of localized reentry (LR) in atrial tachycardia remains incompletely understood. We used the ultra–high density Rhythmia mapping system to study activation patterns in LR. Methods and Results—LR was suggested by small rotatory activations (carousels) containing the full spectrum of the color-coded map. Twenty-three left-sided atrial tachycardias were mapped in 15 patients (age: 64±11 years). 16 253±9192 points were displayed per map, collected over 26±14 minutes. A total of 50 carousels were identified (median 2; quartiles 1–3 per map), although this represented LR in only n=7 out of 50 (14%): here, rotation occurred around a small area of scar (<0.03 mV; 12±6 mm diameter). In LR, electrograms along the carousel encompassed the full tachycardia cycle length, and surrounding activation moved away from the carousel in all directions. Ablating fractionated electrograms (117±18 ms; 44±13% of tachycardia cycle length) within the carousel interrupted the tachycardia in every LR case. All remaining carousels were pseudo-reentrant (n=43/50 [86%]) occurring in areas of wavefront collision (n=21; median 0.5; quartiles 0–2 per map) or as artifact because of annotation of noise or interpolation in areas of incomplete mapping (n=22; median 1, quartiles 0–2 per map). Pseudo-reentrant carousels were incorrectly ablated in 5 cases having been misinterpreted as LR. Conclusions—The activation pattern of LR is of small stable rotational activations (carousels), and this drove 30% (7/23) of our postablation atrial tachycardias. However, this appearance is most often pseudo-reentrant and must be differentiated by interpretation of electrograms in the candidate circuit and activation in the wider surrounding region