Serum lactate in refractory out-of-hospital cardiac arrest:Post-hoc analysis of the Prague OHCA study

Background: The severity of tissue hypoxia is routinely assessed by serum lactate. We aimed to determine whether early lactate levels predict outcomes in refractory out-of-hospital cardiac arrest (OHCA) treated by conventional and extracorporeal cardiopulmonary resuscitation (ECPR). Methods: This study is a post-hoc analysis of a randomized Prague OHCA study (NCT01511666) assessing serum lactate levels in refractory OHCA treated by ECPR (the ECPR group) or conventional resuscitation with prehospital achieved return of spontaneous circulation (the ROSC group). Lactate concentrations measured on admission and every 4 hours (h) during the first 24 h were used to determine their relationship with the neurological outcome (the best Cerebral Performance Category score within 180 days post-cardiac arrest). Results:In the ECPR group (92 patients, median age 58.5 years, 83% male) 26% attained a favorable neurological outcome. In the ROSC group (82 patients, median age 55 years, 83% male) 59% achieved a favorable neurological outcome. In ECPR patients lactate concentrations could discriminate favorable outcome patients, but not consistently in the ROSC group. On admission, serum lactate &gt;14.0 mmol/L for ECPR (specificity 87.5%, sensitivity 54.4%) and &gt;10.8 mmol/L for the ROSC group (specificity 83%, sensitivity 41.2%) predicted an unfavorable outcome. Conclusion: In refractory OHCA serum lactate concentrations measured anytime during the first 24 h after admission to the hospital were found to correlate with the outcome in patients treated by ECPR but not in patients with prehospital ROSC. A single lactate measurement is not enough for a reliable outcome prediction and cannot be used alone to guide treatment.</p

Electrocardiographic findings in patients with arrhythmogenic cardiomyopathy and right bundle branch block ventricular tachycardia

AIMS: Little is known about patients with right bundle branch block (RBBB)-ventricular tachycardia (VT) and arrhythmogenic cardiomyopathy (ACM). Our aims were: (i) to describe electrocardiogram (ECG) characteristics of sinus rhythm (SR) and VT; (ii) to correlate SR with RBBB-VT ECGs; and (iii) to compare VT ECGs with electro-anatomic mapping (EAM) data. METHODS AND RESULTS: From the European Survey on ACM, 70 patients with spontaneous RBBB-VT were included. Putative left ventricular (LV) sites of origin (SOOs) were estimated with a VT-axis-derived methodology and confirmed by EAM data when available.  Overall, 49 (70%) patients met definite Task Force Criteria. Low QRS voltage predominated in lateral leads (n = 37, 55%), but QRS fragmentation was more frequent in inferior leads (n = 15, 23%). T-wave inversion (TWI) was equally frequent in inferior (n = 28, 42%) and lateral (n = 27, 40%) leads. TWI in inferior leads was associated with reduced LV ejection fraction (LVEF; 46 ± 10 vs. 53 ± 8, P = 0.02). Regarding SOOs, the inferior wall harboured 31 (46%) SOOs, followed by the lateral wall (n = 17, 25%), the anterior wall (n = 15, 22%), and the septum (n = 4, 6%). EAM data were available for 16 patients and showed good concordance with the putative SOOs. In all patients with superior-axis RBBB-VT who underwent endo-epicardial VT activation mapping, VT originated from the LV. CONCLUSIONS: In patients with ACM and RBBB-VT, RBBB-VTs originated mainly from the inferior and lateral LV walls. SR depolarization and repolarization abnormalities were frequent and associated with underlying variants

3D electroanatomical mapping is less sensitive to atrial remodeling in estimation of true left atrial volume than echocardiography

Abstract Background Left atrial (LA) enlargement has been identified as a predictor of worse clinical outcome after catheter ablation for atrial fibrillation (AF). We investigated the correspondence of LA size parameters assessed by echocardiography, CT and 3D electroanatomical mapping in patients with AF treated by catheter ablation. Methods We analyzed echocardiographic LA volume measurements by disc summation method (LAVDISC), computed tomography (LAVCT) and 3D electroanatomical mapping (LAVCARTO) in 100 pts. (71% males; aged 63 ± 8 years; paroxysmal AF in 55% of patients). Results Mean LAVDISC was 83 ± 25 ml (median: 115; IQR: 98–140 ml), mean LAVCT was 120 ± 34 ml (median: 115; IQR: 98–140 ml) and mean LAVCARTO was 123 ± 36 ml (median: 118; IQR: 99–132 ml). Pearson’s correlation coefficient between LAVDISC a LAVCT was 0.6 (p < 0.0001) and between LAVCARTO and LAVCT was 0.79 (p < 0.0001). There was a significant difference between the two correlation coefficients (p < 0.004). The absolute difference between LAVCARTO and LAVCT (3.5 (95% CI -42 – 43) ml) was significantly lower (p < 0.0001) as compared to LAVDISC and LAVCT (− 39 (95% CI -102 – 24) ml). In opposite to LAVDISC, the bias between LAV obtained by CT and CARTO did not differentiate according to presence of spherical remodeling (1.7 ± 28 vs. vs. 5.1 ± 31 ml). Only presence of sinus rhythm was significant and independent covariate of the difference between CARTO and CT-derived LAVs by multivariate regression analysis. Conclusions Even though LA volumes evaluated by 3D-electroanatomical mapping have quite good accuracy, the precision is low. For volumes estimated by echocardiography, both precision and accuracy are low

Role of magnetic resonance in the detection of cardiac involvement in patients with newly diagnosed extracardiac sarcoidosis: Single center experience

BACKGROUND: Sarcoidosis is a systemic inflammatory disease of unknown etiology, which can affect almost any organ. Cardiac involvement determines the prognosis of the affected individuals. Its prevalence in patients with extracardiac sarcoidosis with the absence of cardiac symptoms remains unclear. Cardiac magnetic resonance (CMR) provides an excellent diagnostic accuracy in the detection of the heart involvement by sarcoidosis. AIM: We sought to determine the prevalence of cardiac sarcoidosis in asymptomatic individuals with newly diagnoses extracardiac sarcoidosis using CMR. METHODS: We prospectively evaluated 55 consecutive patients mean (SD) aged 43 (11) years, including 23 women with newly diagnosed extracardiac sarcoidosis who underwent contrast-enhanced CMR and had no symptoms of heart disease. The presence of myocardial late gadolinium enhancement (LGE) of non-ischemic etiology on CMR examination was considered diagnostic for the presence of cardiac sarcoidosis. RESULTS: In 3 (6%) patients LGE pattern consistent with cardiac sarcoidosis was detected. In all these patients, preserved left ventricular systolic regional a well as global function was present and in none of them the elevation of blood biomarkers of myocardial injury or overload was found. CONCLUSIONS: Our study suggests that the prevalence of cardiac involvement in patients with newly diagnosed extracardiac sarcoidosis and no symptoms of heart disease is very low as assesed by CMR.  However, CMR may be considered as a part of routine evaluation of patients with extracardiac sarcoidosis due its higher diagnostic yield in comparison with echocardiography and ECG, respectively

Multivariate Analysis of Correspondence between Left Atrial Volumes Assessed by Echocardiography and 3-Dimensional Electroanatomic Mapping in Patients with Atrial Fibrillation.

BACKGROUND:Left atrial (LA) enlargement is a predictor of worse outcome after catheter ablation for atrial fibrillation (AF). Widely used two-dimensional (2D)-echocardiography is inaccurate and underestimates real LA volume (LAV). We hypothesized that baseline clinical characteristics of patients can be used to adjust 2D-ECHO indices of LAV in order to minimize this disagreement. METHODS:The study enrolled 535 patients (59 ± 9 years; 67% males; 43% paroxysmal AF) who underwent catheter ablation for AF in three specialized centers. We investigated multivariately the relationship between 2D-echocardiographic indices of LA size, specifically LA diameter in M-mode in the parasternal long-axis view (LAD), LAV assessed by the prolate-ellipsoid method (LAVEllipsoid), LAV by the planimetric method (LAVPlanimetry), and LAV derived from 3D-electroanatomic mapping (LAVCARTO). RESULTS:Cubed LAD of 106 ± 45 ml, LAVEllipsoid of 72 ± 24 ml and LAVPlanimetry of 88 ± 30 ml correlated only modestly (r = 0.60, 0.69, and 0.53, respectively) with LAVCARTO of 137 ± 46 ml, which was significantly underestimated with a bias (±1.96 standard deviation) of -31 (-111; +49) ml, -64 (-132; +2) ml, and -49 (-125; +27) ml, respectively; p < 0.0001 for their mutual difference. LA enlargement itself, age, gender, type of AF, and the presence of structural heart disease were independent confounders of measurement error of 2D-echocardiographic LAV. CONCLUSION:Accuracy and precision of all 2D-echocardiographic LAV indices are poor. Their agreement with true LAV can be significantly improved by multivariate adjustment to clinical characteristics of patients

Correlation of raw and adjusted 2D-ECHO-based LAV with CARTO-derived LAV.

<p>Upper row: raw values. Middle row: simple linear adjustment. Lower row: multivariate adjustment for clinical covariates. Regression coefficients from Tables <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0152553#pone.0152553.t002" target="_blank">2</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0152553#pone.0152553.t003" target="_blank">3</a> were used for the simple and multivariate adjustment, respectively. Specifically, adjusted LAV was calculated as:</p> <p>68 + 0.62 LAD³;</p> <p>42 + 1.32 LAV_Ellipsoid;</p> <p>66 + 0.81 LAV_Planimetry;</p> <p>67 + 0.42 LAD³ + 15 (if male) + 0.44 Age + 34 (if persistent AF) + 14 (if SHD);</p> <p>49 + 0.98 LAV_Ellipsoid + 12 (if male) + 0.34 Age + 32 (if persistent AF) + 10 (if SHD);</p> <p>64 + 0.60 LAV_Planimetry + 18 (if male) + 0.38 Age + 40 (if persistent AF) + 14 (if SHD).</p> <p>Red line–identity line; black line–regression line. Adj = adjusted. Other abbreviations as in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0152553#pone.0152553.g001" target="_blank">Fig 1</a>.</p

Stepwise forward multivariate regression analysis of determinants of LAV_CARTO.

<p>Stepwise forward multivariate regression analysis of determinants of LAV_CARTO.</p

Baseline characteristics.

<p>Baseline characteristics.</p