Prognostic Importance of Atrial Fibrillation in Implantable Cardioverter-Defibrillator Patients

ObjectivesThis study aimed to assess the prevalence of different types of atrial fibrillation (AF) and their prognostic importance in implantable cardioverter-defibrillator (ICD) patients.BackgroundThe prevalence of AF has taken epidemic proportions in the population with cardiovascular disease. The prognostic importance of different types of AF in ICD patients remains unclear.MethodsData on 913 consecutive patients (79% men, mean age 62 ± 13 years) receiving an ICD at the Leiden University Medical Center were prospectively collected. Among other characteristics, the existence and type of AF (paroxysmal, persistent, or permanent) were assessed at implantation. During follow-up, the occurrence of appropriate or inappropriate device therapy as well as mortality was noted.ResultsAt implantation, 73% of patients had no history of AF, 9% had a history of paroxysmal AF, 7% had a history of persistent AF, and 11% had permanent AF. During 833 ± 394 days of follow-up, 117 (13%) patients died, 228 (25%) patients experienced appropriate device discharge, and 139 (15%) patients received inappropriate shocks. Patients with permanent AF exhibited more than double the risk of mortality, ventricular arrhythmias triggering device discharge, and inappropriate device therapy. Patients with paroxysmal or persistent AF did not show a significant increased risk of mortality or appropriate device therapy but demonstrated almost 3 times the risk of inappropriate device therapy.ConclusionsIn the population currently receiving ICD treatment outside the setting of clinical trials, a large portion has either a history of AF or permanent AF. Both types of AF have prognostic implications for mortality and appropriate as well as inappropriate device discharge

Noninvasive Left Ventricular Myocardial Work in Patients with Chronic Aortic Regurgitation and Preserved Left Ventricular Ejection Fraction

BackgroundLeft ventricular (LV) global longitudinal strain (GLS) has been proposed as a sensitive marker of myocardial damage in patients with chronic severe aortic regurgitation (AR) and preserved LV ejection fraction (LVEF). However, LV GLS does not take into account the afterload. Noninvasive LV myocardial work is a novel parameter of LV myocardial performance, which integrates measurements of myocardial deformation and noninvasive blood pressure (afterload). The aims of this study were (1) to assess noninvasive LV myocardial work in patients with chronic AR and preserved LVEF and its correlation with other echocardiographic parameters, (2) to evaluate changes of LV myocardial work after aortic valve replacement or repair (AVR), and (3) to assess the relationship between LV myocardial work and postoperative LV reverse remodeling.MethodsFifty-seven patients (53 ± 16 years; 67% men) with moderate or severe chronic AR and preserved LVEF treated by AVR were included. Noninvasive LV myocardial work indices were measured at baseline and postoperatively (between 2 and 12 months after surgery) and compared with previously reported normal reference ranges.ResultsBased on normal reference values, patients with chronic AR and preserved LVEF had preserved or increased values of LV global work index (GWI; 82% and 18%, respectively) and LV global constructive work (GCW; 74% and 25%, respectively) and preserved LV global work efficiency (GWE). Left ventricular GWI and GCW showed a positive correlation with markers of AR severity and parameters of LV systolic function. Left ventricular GWI, GCW, and GWE decreased after AVR (P P = .28). The postoperative impairment of LV GWI, observed in 28% of patients, was closely associated with reduced LV reverse remodeling.ConclusionsNoninvasive myocardial work may allow better understanding of myocardial function and energetics than afterload-dependent echocardiographic parameters in chronic AR with preserved LVEF.</p

Corruption in the Middle East and the Limits of Conventional Approaches

Die Unzufriedenheit mit der verbreiteten Korruption war 2011/2012 eine wesentliche Ursache für die arabischen Unruhen und weitere Aufstände weltweit. Der Fall Jordanien zeigt allerdings, dass konventionelle Ansätze zur Bekämpfung von Korruption nicht ausreichen. Eine angemessene Strategie gegen Korruption muss diese als ein Problem der Verteilungsgerechtigkeit und nicht des Strafrechts verstehen. Wie in allen anderen arabischen Staaten ist die Unzufriedenheit in der Bevölkerung über die offensichtliche Korruption auch in Jordanien beträchtlich. Allerdings wird im Allgemeinen nicht über Fälle von Bestechung und Erpressung geklagt, die weniger häufig vorkommen, sondern über lokale Praktiken politischer Patronage und Begünstigung, die unter dem Begriff "Wasta" zusammengefasst werden. "Wasta" wurde bislang als Form der Korruption und strafrechtliches Problem angesehen, weshalb Versuche zur Eindämmung überwiegend ineffizient blieben: "Wasta"-Praktiken werden in der Regel nicht mit Rechtsverstößen verbunden, sondern bewegen sich innerhalb formal legaler Verfahren. Konventionelle Ansätze zur Bekämpfung von Korruption, die sich an rechtsstaatlichen Grundsätzen und Transparenz orientieren, sind deshalb nicht zielführend. Demokratisierung allein ist ebenfalls ungeeignet, das Problem „Wasta” zu lösen. In der parlamentarischen Praxis macht "Wasta" den Großteil der Aktivitäten aller Parlamentsmitglieder aus. Diese werden deshalb als persönliche Dienstleister für ihre Wahlbezirke und nicht als Mitglieder einer gesetzgebenden Körperschaft wahrgenommen. Gleichzeitig hält die Bevölkerung das Parlament für eine zutiefst korrupte Institution. "Wasta" wird problematisch, wenn diese Praxis zu einem ungleichen Zugang der Bürger zu öffentlichen Ressourcen führt. Statt sich nur auf politische und administrative Reformen zu konzentrieren, muss der Fokus der Bekämpfung auf den (Wieder-)Aufbau wohlfahrtsstaatlicher Strukturen gelegt werden, zu denen alle Bürger gleichermaßen Zugang haben

An enhanced DTC component for the EPD-CAR project

This paper describes a module which is a part of the EPD-CAR (Electronic Patient Dossier for Cardiology) project of the Interuniversity Cardiology Institute of the Netherlands. It uses general guidelines to advice on the functional tests that have to be performed depending on the diagnoses. The model differentiates between the diverse conditions under which the patient enters the medical circuit. The model converts the detailed information into a crude code the is becoming the basis of the financial compensation for medical treatment, starting Januari 1st 2003. The system is written in Visual Foxpro 7.0 and is an ActiveX-component

Voltage and activation mapping: how the recording technique affects the outcome of catheter ablation procedures in patients with congenital heart disease

BACKGROUND: Endocardial mapping is mandatory before radiofrequency catheter ablation (RFCA). Mapping can be performed with either unipolar or bipolar recordings. Impact of the recording technique used was studied in patients with and without structural heart disease using the 3D electroanatomic CARTO mapping system. METHODS AND RESULTS: Patients (n=44; 16 males; age 43+/-16 years) referred for RFCA of atrial flutter (AFL, n=18), focal atrial tachycardia (FAT, n=4), AV nodal reentrant tachycardia (AVNRT, n=5), or scar-related atrial reentrant tachycardia (IART, n=17) were studied. Voltage and activation maps were constructed. Unipolar and bipolar voltage distribution in the different groups was studied to establish a cutoff voltage value to facilitate delineation of scar tissue. Electrograms were recorded during tachycardia (FAT: n=246, cycle length [CL]=449+/-35 ms; AVNRT: n=182, CL=359+/-47 ms; AFL: n=1164, CL=255+/-56 ms; IART: n=2431, CL=280+/-74 ms). Unipolar voltages were greater than bipolar voltages (P <0.001). Unipolar voltages <or =1.0 mV were equally distributed in both AFL and IART patients. Bipolar voltages <or =0.1 mV were only found in patients with IART, and subsequently 0.1 mV was used as the cutoff value to delineate scar tissue. No unipolar cutoff value could be established. Timing of unipolar and bipolar local activation was correlated in all patient groups. CONCLUSIONS: The recording technique used has considerable impact on reconstruction of reentrant pathways and on the outcome of RFCA. In general, unipolar and bipolar recordings provide complementary information; however, only bipolar recordings allow voltage-based scar tissue delineation in patients with congenital heart diseas

Adults with congenital heart disease: patients' knowledge and concerns about inheritance

With recent advances in medical and surgical management, most patients with congenital heart disease (CHD) survive to reproductive age. Current guidelines recommend counseling about inheritance and transmission of CHD to offspring. We evaluated whether adult CHD patients recalled having received information about the inheritance of their CHD, patients' knowledge about inheritance and their concerns in this regard. A questionnaire was sent to 486 non-syndromic CHD patients aged 20-45 years. We received 332 useful questionnaires (response rate 68%). One-third (33%) of patients recalled receiving information about inheritance of CHD from their cardiologist, and 13% had consulted a clinical geneticist. Eight percent of patients who were considering having children estimated the recurrence risk for their own offspring to be 1% or lower, whereas one-fourth (25%) estimated it to be higher than 10%. According to our classification, 44% estimated the recurrence risk in a correct range of magnitude. Additional information about inheritance of CHD was desired by 41% of patients. Forty-two percent of patients considering having children reported concerns about transmitting CHD to offspring. We conclude that a substantial proportion of adult CHD patients lacks knowledge and desires more information about inheritance, indicating a need for better patient education. Current guidelines and/or their implementation do not seem to meet the needs of these patients. A dedicated program of counseling for adults with CHD has to be developed to optimize knowledge and satisfaction with information provision and to reduce or manage concerns regarding inheritance of CH