Noninvasive electrocardiographic imaging of dynamic atrioventricular delay programming in a patient with left bundle branch block

Introduction The response to cardiac resynchronization therapy (CRT) is determined by various factors, including left ventricular (LV) lead location, atrioventricular (AV) delay, and inter-/intraventricular delays. Advances in quadripolar lead technology and device algorithms have improved patient response, yet selection of optimal settings remains challenging. Studies have shown acute improvement in electrical synchrony with manual AV optimization by fusion optimized intervals1,2; automated device algorithms, for example AdaptivCRT (Medtronic, Minneapolis, MN),3 SmartDelay (Boston Scientific, Marlborough, MA),4 and SyncAVTM (Abbott, Sylmar, CA)5; and pacing from multiple LV lead electrodes with MultiPoint Pacing (MPP).6,7 The aim of this clinical case report was to evaluate the acute benefits of SyncAV Plus in the new-generation, Bluetooth-enabled GallantTM CRT device (Abbott, Sylmar, CA). SyncAV Plus continually programs the paced AV delay shorter than the intrinsic PR interval by a programmable offset (% of PR duration) to synchronize intrinsic and ventricular paced activation wavefronts. Twelve-lead electrocardiogram (ECG) and noninvasive electrocardiographic imaging (ECGi) epicardial mapping analyses were performed to characterize the impact of SyncAV Plus on electrical synchrony during a range of CRT programming strategies, including biventricular (BiV) pacing, MPP, LV-only pacing, and LV-only pacing with MPP

Impact of pacing configuration and right ventricular lead location on dynamic atrioventricular delay optimization

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abbott Introduction Automatic adjustment of atrioventricular delay (AVD) with SyncAV has been shown to improve electrical synchronization. However, the effect of pacing configuration and right ventricular (RV) lead location on SyncAV programming is unknown. Purpose Evaluate the effect of pacing configuration and lead location on SyncAV optimization during biventricular (BiV) and LV-only pacing, with and without MultiPoint Pacing (MPP). Methods Patients with LBBB and QRS duration (QRSd) ≥ 150 ms scheduled for CRT-P/D device implantation with quadripolar LV lead were enrolled in this prospective study. RV lead location was classified at implant by the operator via fluoroscopy. QRSd was measured post-implant from 12-lead surface ECG by blinded experts during the following pacing modes: intrinsic conduction, BiV (BiV = RV + LV1), MPP (MPP = RV + LV1 + LV2), LV-only single-site (LVSS = LV1 only), and LV-only MPP (LVMPP = LV1 + LV2). For each mode, SyncAV was enabled (e.g. BiV + SyncAV) with the patient-tailored SyncAV offset that minimized QRSd. For BiV and LVSS, LV1 was the latest activating LV cathode; for MPP and LVMPP, LV1 + LV2 were the two LV cathodes with the widest possible separation (≥30mm). All modes used minimal RV-LV and LV1-LV2 delays. Results Fifty-three patients (68% male, 36% ischemic, 26% ejection fraction, 169 ms intrinsic QRSd) completed device implant and QRSd assessment. RV leads were implanted in either the septum (48%) or apex (52%), according to implanting physician preference. Relative to intrinsic conduction, BiV + SyncAV and MPP + SyncAV reduced QRSd by 23% and 27%, respectively (p < 0.01). LVSS + SyncAV reduced QRSd by 22% (p < 0.01 vs BiV + SyncAV), and LVMPP + SyncAV reduced QRSd by 25% (p < 0.05 vs MPP + SyncAV). RV apex or septum lead location did not have a significant impact on QRS reduction for each pacing configuration. As a percent of PR interval, optimal SyncAV offsets were similar for BiV + SyncAV and MPP + SyncAV (16% vs 13%, p = 0.05), and for LVSS + SyncAV and LVMPP + SyncAV (18% vs 21%, p = 0.46), but were significantly higher for LV-only settings vs. corresponding BiV/MPP settings (p < 0.05 for both pairs). For BiV + SyncAV, apical vs septal RV leads required greater SyncAV offsets (22% vs 11%, p < 0.05). SyncAV offsets also tended to be higher in apical vs septal RV leads for MPP (21% vs 11%), LVSS (20% vs 15%), and LVMPP (25% vs 16%), but without statistical significance. Conclusion SyncAV improves acute electrical synchronization in CRT patients with LBBB, particularly with patient-specific SyncAV programming. Pacing configuration (RV + LV or LV only, with or without MPP) and RV lead location (apex or septum) could potentially influence optimal SyncAV programming. Abstract Figure

Implementing civic engagement within mental health services in South East Asia: a systematic review and realist synthesis of current evidence

Introduction: Civic engagement (CE) has the potential to transform mental health services and could be particularly important for low and middle-income countries (LMICs), which are rapidly developing to respond to the burden of poor mental health. Research from high income countries has found many challenges associated with the meaningful implementation of CE in practice, but this has been underexplored in LIMCS and in South East Asia (SEA) in particular. Methods: We completed a realist synthesis and systematic review of peer reviewed publications and grey literature to identify the context and actions which promote successful implementation of CE approaches in SEA. We used a theory-driven approach—realist synthesis—to analyse data and develop context-mechanism-outcome configurations that can be used to explain how civic engagement approaches operate in South East Asian contexts. We worked closely with patient and public representatives to guide the review from the outset. Results: Fifty-seven published and unpublished articles were included, 24 were evaluations of CE, including two Randomized Controlled Trials. The majority of CE interventions featured uptake or adaptation of Western models of care. We identified important cultural differences in the enactment of civic engagement in SEA contexts and four mechanisms which, alongside their contextual barriers and facilitators, can be used to explain how civic engagement produces a range of outcomes for people experiencing mental health problems, their families and communities. Our review illustrates how CE interventions can be successfully implemented in SEA, however Western models should be adapted to fit with local cultures and values to promote successful implementation. Barriers to implementation included distrust of services/outside agencies, stigma, paternalistic cultures, limited resource and infrastructure. Conclusion: Our findings provide guidance for the implementation of CE approaches within SEA contexts and identify areas for further research. Due to the collectivist nature of many SEA cultures, and the impact of shared traumas on community mental health, CE might best be implemented at community level, with a focus on relational decision making. Registration This review is registered on PROSPERO: CRD42018087841

Mechanical properties of amorphous indium-gallium-zinc oxide thin films on compliant substrates for flexible optoelectronic devices

Amorphous indium–gallium–zinc-oxide (a-IGZO) thin films were deposited using RF magnetron sputtering on polyethylene naphthalate (PEN) and polyethylene terephthalate (PET) flexible substrates and their mechanical flexibility investigated using uniaxial tensile and buckling tests coupled with in situ optical microscopy. The uniaxial fragmentation test demonstrated that the crack onset strain of the IGZO/PEN was ~ 2.9%, which is slightly higher than that of IGZO/PET. Also, uniaxial tensile crack density analysis suggests that the saturated crack spacing of the film is strongly dependent on the mechanical properties of the underlying polymer substrate. Buckling test results suggest that the crack onset strain (equal to ~ 1.2%, of the IGZO/polymer samples flexed in compression to ~ 5.7 mm concave radius of curvature) is higher than that of the samples flexed with the film being in tension (convex bending) regardless whether the substrate is PEN or PET. The saturated crack density of a-IGZO film under the compression buckling mode is smaller than that of the film under the tensile buckling mode. This could be attributed to the fact that the tensile stress encouraged this crack formation originating from surface defects in the coating. It could also be due to the buckling delamination of the thin coating from the substrate at a lower strain than that at which a crack initiates during flexing in compression. These results provide useful information on the mechanical reliability of a-IGZO films for the development of flexible electronics.The authors would like to thank DuPont-Teijin for donating polymer samples. We would also like to thank Mr. Frank Biddlestone for his technical support and Mr. Warren Hay for his help in the workshop. Financial support from the Kurdistan Regional Government HCDP programme is gratefully acknowledged. The atomic force microscope used in this research was obtained, through Birmingham Science City: Innovative Uses for Advanced Materials in the Modern World (West Midlands Centre for Advanced Materials Project 2), with support from Advantage West Midlands (AWM) (DD-07) and partly funded by the European Regional Development Fund (ERDF) (SY/SP80). R.W. gratefully acknowledges funding from the EPSRC Centre for Doctoral Training in Photonic Systems Development.This is the author accepted manuscript. The final version is available from Elsevier via http://dx.doi.org/10.1016/j.tsf.2015.09.05

A proposal for using benefit-risk methods to improve the prominence of adverse event results when reporting trials

Adverse events suffer from poor reporting within randomised controlled trials, despite them being crucial to the evaluation of a treatment. A recent update to the CONSORT harms checklist aims to improve reporting by providing structure and consistency to the information presented. We propose an extension wherein harms would be reported in conjunction with effectiveness outcome(s) rather than in silo to provide a more complete picture of the evidence acquired within a trial. Benefit-risk methods are designed to simultaneously consider both benefits and risks, and therefore, we believe these methods could be implemented to improve the prominence of adverse events when reporting trials. The aim of this article is to use case studies to demonstrate the practical utility of benefit-risk methods to present adverse events results alongside effectiveness results. Two randomised controlled trials have been selected as case studies, the Option-DM trial and the SANAD II trial. Using a previous review, a shortlist of 17 benefit-risk methods which could potentially be used for reporting RCTs was created. From this shortlist, three benefit-risk methods are applied across the two case studies. We selected these methods for their usefulness to achieve the aim of this paper and which are commonly used in the literature. The methods selected were the Benefit-Risk Action Team (BRAT) Framework, net clinical benefit (NCB), and the Outcome Measures in Rheumatology (OMERACT) 3 × 3 table. Results using the benefit-risk method added further context and detail to the clinical summaries made from the trials. In the case of the SANAD II trial, the clinicians concluded that despite the primary outcome being improved by the treatment, the increase in adverse events negated the improvement and the treatment was therefore not recommended. The benefit-risk methods applied to this case study outlined the data that this decision was based on in a clear and transparent way. Using benefit-risk methods to report the results of trials can increase the prominence of adverse event results by presenting them alongside the primary efficacy/effectiveness outcomes. This ensures that all the factors which would be used to determine whether a treatment would be recommended are transparent to the reader

Iatrogenic cardiac perforation due to pacemaker and defibrillator leads: a contemporary multicentre experience

AIMS: To determine the incidence, clinical features, management, and outcomes of pacemaker (PM) and implantable cardioverter-defibrillator (ICD) lead cardiac perforation. Cardiac perforations due to PM and ICD leads are rare but serious complications. Clinical features vary widely and may cause diagnostic delay. Management strategies are non-guideline based due to paucity of data. METHODS AND RESULTS: A multicentre retrospective series including 3 UK cardiac tertiary centres from 2016 to 2020. Patient, device, and lead characteristics were obtained including 6-month outcomes. Seventy cases of perforation were identified from 10 631 procedures; perforation rate was 0.50% for local implants. Thirty-nine (56%) patients were female, mean ( ± standard deviation) age 74 ( ± 13.8) years. Left ventricular ejection fraction 51 ( ± 13.2) %. Median time to diagnosis was 9 (range: 0-989) days. Computed tomography (CT) diagnosed perforation with 97% sensitivity. Lead parameter abnormalities were present in 86% (whole cohort) and 98.6% for perforations diagnosed >24 h. Chest pain was the commonest symptom, present in 46%. The management strategy was percutaneous in 98.6% with complete procedural success in 98.6%. Pericardial effusion with tamponade was present in 17% and was associated with significantly increased mortality and major complications. Anticoagulation status was associated with tamponade by multivariate analysis (odds ratio 21.7, 95% confidence interval: 1.7-275.5, P = 0.018). CONCLUSIONS: Perforation was rare (0.50%) and managed successfully by a percutaneous strategy with good outcomes. Tamponade was associated with increased mortality and major complications. Anticoagulation status was an independent predictor of tamponade. Case complexity is highly variable and requires skilled operators with a multi-disciplinary approach to achieve good outcomes

Персональные данные в автоматизированных системах финансовых организаций

Previous studies have shown that patients with Takotsubo syndrome (TS) have supranormal nitric oxide signaling, and post-mortem studies of TS heart samples revealed nitrosative stress. Therefore, we first showed in a female rat model that isoproterenol induces TS-like echocardiographic changes, evidence of nitrosative stress, and consequent activation of the energy-depleting enzyme poly(ADP-ribose) polymerase-1. We subsequently showed that pre-treatment with an inhibitor of poly(ADP-ribose) polymerase-1 ameliorated contractile abnormalities. These findings thus add to previous reports of aberrant β-adrenoceptor signaling (coupled with nitric oxide synthase activation) to elucidate mechanisms of impaired cardiac function in TS and point to potential methods of treatment.Sven Y. Surikow, Thanh H. Nguyen, Irene Stafford, Matthew Chapman, Sujith Chacko, Kuljit Singh, Giovanni Licari, Betty Raman, Darren J. Kelly, Yuan Zhang, Mark T. Waddingham, Doan T. Ngo, Alexander P. Bate, Su Jen Chua, Michael P. Frenneaux, John D. Horowit

Assessing the Effect of Twisting and Twisting Fatigue on ZnO:Al Thin Film Performance on PEN and PET Substrates

This study examines the electromechanical characteristics of aluminium-doped zinc oxide (AZO) films. The films were produced using the RF magnetron sputtering process with a consistent thickness of 150 nm on various polymer substrates. The study focuses on assessing the electro-mechanical failure processes of coated segments using flexible substrates, namely polyethylene naphthalate (PEN) and polyethylene terephthalate (PET), with a specific emphasis on typical cracking and delamination occurrences. This examination involves conducting twisting deformation together with using standardised electrical resistance measurements and optical microscope monitoring instruments. It was found that the crack initiation angle is mostly dependent on the mechanical mismatch between the coating and substrate. Higher critical twisting angle values are observed for the AZO/PEN film during twisting testing. Relative to the perpendicular plane of the untwisted sample, it was found that cracks initiated at a twist angle equal to 42° ± 2.1° and 38° ± 1.7° for AZO/PEN and AZO/PET, respectively, and propagated along the sample length. SEM images indicate that the twisting motion results in deformation in the thin film material, leading to the presence of both types of stress in the film structure. These discoveries emphasise the significance of studying the mechanical properties of thin films under different stress conditions, as it can impact their performance and reliability in real-world applications. The electromechanical stability of AZO was found to be similar on both substrates during fatigue testing. Studying the electromechanical properties of various material combinations is important for selecting polymer substrates and predicting the durability of flexible electronic devices made from polyester