Twitter for professional use in electrophysiology: practical guide for #EPeeps.

Abstract Social media (SoMe) becomes more and more popular in the cardiological community. Among them, Twitter is an emerging and dynamic medium to connect, communicate and educate academic and clinical cardiologists. However, in contrast to traditional scientific communications, the content provided through SoMe is not peer-reviewed and may not necessarily always represent scientific evidence or may even be used to unjustifiably promote therapies for commercial purposes. For the unintended, this means of communication might be appear difficult to handle. This article aims to provide a practical guide on how to use Twitter efficiently for professional use to keep yourself up-to-date about new techniques, the latest study results and news presented at national or international conferences. Additionally, important limitations will be discussed

Novel approaches using electrocardiographic imaging for early detection of ARVC in patients and relatives and symptoms preceding sudden death

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is an inherited disease of the myocardium, predominantly affecting the right ventricle (RV). Arrhythmias are common among patients with the disease and Sudden Cardiac Death (SCD) can occur even in early stages.  The overall purpose of this thesis was to investigate the effectiveness of new diagnostic methods in detecting early abnormalities in genetically predisposed individuals and to emphasize the importance of early diagnosis.  The analysis of body surface mapping (BSM) signals recorded using a 252-lead vest revealed abnormal repolarisation patterns in all ARVC patients, but also in 25% of family members who were carriers of the family pathogenic variant (M-carriers). The abnormal repolarization patterns preceded repolarization abnormalities on 12-leads electrocardiogram (ECG). Depolarization abnormalities were also detected by the analysis of body surface signals. The QRS dispersion calculated by the body surface signals was significantly higher among ARVC patients compared with controls. 20% of M-carriers presented also with a slightly elevated QRS dispersion. ECG based QRS dispersion could not adequately differentiate ARVC patients from controls. Thus, the higher resolution of the BSM system permitted the detection of repolarization and depolarization abnormalities even in early stages of the disease. The analysis of reconstructed epicardial signals using Electrocardiographic Imaging (ECGI) revealed terminal ventricular epicardial activation (the last 20msecs) located only in parts of RV, as opposed to controls, where the right ventricular outflow tract (RVOT) and cardiac base (both right and left ventricle) were activated last. The total ventricular activation time and the RV activation time were both longer in ARVC patients, whereas the area activated during the last 20 msecs was smaller. Similar pattern with delayed conduction in limited areas of the RV were also observed in 50% of the M-carriers. This subgroup presented also smaller area of terminal ventricular activation and longer RV activation time, but the total ventricular activation was normal.  Through nationwide registries, the first SCD cohort due to ARVC in Sweden was described. Cardiac related symptoms were common (68%) prior to death and 36% of cases had sought medical care the last six months prior to death. A family history of SCD was present in 45% of the cases.  The careful clinical evaluation of young individuals seeking with cardiac related symptoms and the evaluation of both medical and family history is crucial. In conclusion, new technologies, using multiple electrodes for the recording of body surface signals and the reconstruction of the epicardial signals have shown promising results in detecting early repolarization and depolarization abnormalities and could facilitate the early diagnosis in M-carriers

Novel approaches using electrocardiographic imaging for early detection of ARVC in patients and relatives and symptoms preceding sudden death

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is an inherited disease of the myocardium, predominantly affecting the right ventricle (RV). Arrhythmias are common among patients with the disease and Sudden Cardiac Death (SCD) can occur even in early stages.  The overall purpose of this thesis was to investigate the effectiveness of new diagnostic methods in detecting early abnormalities in genetically predisposed individuals and to emphasize the importance of early diagnosis.  The analysis of body surface mapping (BSM) signals recorded using a 252-lead vest revealed abnormal repolarisation patterns in all ARVC patients, but also in 25% of family members who were carriers of the family pathogenic variant (M-carriers). The abnormal repolarization patterns preceded repolarization abnormalities on 12-leads electrocardiogram (ECG). Depolarization abnormalities were also detected by the analysis of body surface signals. The QRS dispersion calculated by the body surface signals was significantly higher among ARVC patients compared with controls. 20% of M-carriers presented also with a slightly elevated QRS dispersion. ECG based QRS dispersion could not adequately differentiate ARVC patients from controls. Thus, the higher resolution of the BSM system permitted the detection of repolarization and depolarization abnormalities even in early stages of the disease. The analysis of reconstructed epicardial signals using Electrocardiographic Imaging (ECGI) revealed terminal ventricular epicardial activation (the last 20msecs) located only in parts of RV, as opposed to controls, where the right ventricular outflow tract (RVOT) and cardiac base (both right and left ventricle) were activated last. The total ventricular activation time and the RV activation time were both longer in ARVC patients, whereas the area activated during the last 20 msecs was smaller. Similar pattern with delayed conduction in limited areas of the RV were also observed in 50% of the M-carriers. This subgroup presented also smaller area of terminal ventricular activation and longer RV activation time, but the total ventricular activation was normal.  Through nationwide registries, the first SCD cohort due to ARVC in Sweden was described. Cardiac related symptoms were common (68%) prior to death and 36% of cases had sought medical care the last six months prior to death. A family history of SCD was present in 45% of the cases.  The careful clinical evaluation of young individuals seeking with cardiac related symptoms and the evaluation of both medical and family history is crucial. In conclusion, new technologies, using multiple electrodes for the recording of body surface signals and the reconstruction of the epicardial signals have shown promising results in detecting early repolarization and depolarization abnormalities and could facilitate the early diagnosis in M-carriers

Epicardial conduction abnormalities in patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) and mutation positive healthy family members – a study using electrocardiographic imaging

Background: The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) in early stages is challenging. The aim was therefore to study whether electrocardiographic imaging (ECGI) can detect epicardial depolarization changes in ARVC patients and healthy mutation-carriers (M-carriers). Method: Twelve ARVC patients, 20 M-carriers and 8 controls underwent 12-lead ECG, signal-averaged ECG, 2-dimensional echocardiography, 24-hours Holter monitoring and ECGI (body surface mapping and computer tomography with offline analysis of reconstructed epicardial signals). Total and Right Ventricular Activation Time (tVAT and RVAT respectively), area of Ventricular Activation during the terminal 20 milliseconds (aVAte20) and the activation patterns were compared between groups. Results: In ARVC patients the locations of aVAte20 were scattered or limited to smaller RV parts versus in controls, in whom aVAte20 was confined to RVOT and LV base (+/- RV base). ARVC patients had smaller aVAte20 (35cm2 vs 87cm2, p<0.05), longer tVAT (99msec vs 58msec, p<0.05) and longer RVAT (66msec vs 43msec, p<0.05) versus controls. In 50% of M-carriers, the locations of aVAte20 were also eccentric. This sub-group presented smaller aVAte20 (53cm2 vs 87cm2, p= 0.009), longer RVAT (55msec vs 48msec, p=0.043), but similar tVAT (65msec vs 60msec, p=0.529) compared with the M-carriers with normal activation pattern. Conclusions: The observation of localized delayed epicardial conduction in the RV in M-carriers suggests an early stage of ARVC and may be a useful diagnostic marker enhancing an early detection of the disease

Repolarisation abnormalities unmasked with a 252-lead BSM system in patients with ARVC and healthy Gene Carriers

BACKGROUND: Diagnosing Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) at an early stage can be challenging even after ECG recording and a combination of several imaging techniques. The purpose of this study was to explore if a Body Surface Mapping (BSM) system with 252-leads could identify repolarization abnormalities and thereby diagnose early stages of ARVC. METHODS: ARVC patients, gene carriers without signs of ARVC and controls underwent a 12 lead resting ECG, signal-averaged ECG, echocardiography, 24-hours Holter monitoring and BSM with electrocardiographic imaging (ECGI). All 252-leads, divided into four quadrants of the vest, were analyzed regarding concordances between T wave polarity and QRS main vector. RESULTS: Of 40 patients included there were 12 ARVC patients, 20 gene carriers and 8 controls. The ARVC patients had two different repolarization patterns, one with more pronounced negative T waves at the lower left panel and another with mixed changes that clearly differed from the controls, all of whom had a normal 12 lead ECGs and consistent repolarization patterns on their BSM recordings. The patterns observed in ARVC patients were also present in 5/20 (25%) gene carriers, three of whom had normal resting ECG. A novel repolarization index successfully detected all ARVC patients and 88% of gene carriers with pathologic repolarization pattern. CONCLUSIONS: The finding that abnormal repolarization patterns could be unmasked by BSM in 25% of healthy gene carriers, suggests that it may potentially be a useful tool for identifying early manifestations of ARVC. Further and larger studies are warranted to assess its diagnostic accuracy

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QRS dispersion detected in ARVC patients and healthy gene carriers using 252-leads body surface mapping : an explorative study of a potential diagnostic tool for arrhythmogenic right ventricular cardiomyopathy

BACKGROUND: The diagnosis of ARVC remains complex requiring both imaging and electrocardiographic (ECG) techniques. The purpose was therefore to investigate whether QRS dispersion assessed by body surface mapping (BSM) could be used to detect early signs of ARVC, particularly in gene carriers. METHODS: ARVC patients, gene carriers without a history of arrhythmias or structural cardiac changes and healthy controls underwent 12-lead resting ECG, signal-averaged ECG, echocardiographic examination, 24-hours Holter monitoring, and BSM with electrocardiographic imaging. All 252-leads BSM recordings and 12-leads ECG recordings were manually analyzed for QRS durations and QRS dispersion. RESULTS: Eight controls, 12 ARVC patients with definite ARVC and 20 healthy gene carriers were included. The ECG-QRS dispersion was significantly greater in ARVC patients (42 vs. 25 ms, p < .05), but failed to fully differentiate them from controls. The BSM-derived QRS dispersion was also significantly greater in ARVC patients versus controls (65 vs. 29 ms, p < .05) and distinguished 11/12 cases from controls using the cut-off 40msec. The BSM derived QRS dispersion was abnormal (> 40 ms) in 4/20 healthy gene carriers without signs of ARVC, which may indicate early depolarization changes. CONCLUSIONS: QRS dispersion, when assessed by BSM versus 12-lead ECG, seem to better distinguish ARVC patients from controls, and could potentially be used to detect early ARVC in gene carriers. Further studies are required to confirm the value of BSM-QRS dispersion in this respect

Family History and Warning Symptoms Precede Sudden Cardiac Death in Arrhythmogenic Right Ventricular Cardiomyopathy (from a Nationwide Study in Sweden)

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiac disease explaining about 4% of sudden cardiac death (SCD) cases in the young in Sweden. This study aimed to describe the circumstances preceding SCD in all victims <35 years of age who received an autopsy-confirmed diagnosis of ARVC from January 1, 2000, to December 31, 2010, in Sweden (n = 22). Data on demographics, medical and family history, circumstances of death, and anatomopathological findings were collected from several compulsory national health registries, clinical records, family interviews, and autopsy reports. Registry-based data were compared with age-matched, gender-matched, and geographically-matched population controls. During the 6 months preceding SCD, 15 cases (68%) had experienced symptoms of cardiac origin, mainly syncope or presyncope (54%) and chest discomfort (27%). A total of 8 cases (36%) had sought medical care because of cardiac symptoms. The occurrence of hospital visits was significantly increased in cases compared with controls (odds ratio 4.62 [1.35 to 15.8]). A total of 10 cases (45%) had a family history of SCD. The most common activity at the time of death was exercise (41%). A complete cardiac investigation was seldom performed; only 1 case was diagnosed with ARVC before death. In conclusion, in this nationwide study, we observed a high prevalence of symptoms of cardiac origin, healthcare use, and family history of SCD preceding SCD in the young caused by ARVC. Increased awareness of these warning signals in younger patients is critical to improving risk stratification and early disease detection

The ‘myrhythmdevice.org’ educational website for patients with implanted cardiac devices from the European Heart Rhythm Association

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The use of social media for professional purposes by healthcare professionals:the #intEHRAct survey

Social media (SoMe) represents a medium of communication in everyday life and has gained importance for professional use among clinicians. In the #intEHRAct survey, we aimed to describe the use of SoMe by the healthcare community in a professional setting. The EHRA e-Communication Committee and the Scientific Initiatives Committee prepared a questionnaire and distributed it via newsletters, Twitter, LinkedIn, and Facebook. The survey consisted of 19 questions made on an individual basis and collected anonymously. Two hundred and eighty-five responders from 35 countries (72.3% male, age 49 ± 11 years old) completed the survey. Most respondents (42.7%) declared to use SoMe as passive users while 38.3% and 19.0% declared to share content on a non-daily and daily basis, respectively. The respondents estimated they spent a median of 5 (Q1-Q3: 2-10) h per week on SoMe. The most widely used SoMe was LinkedIn (60.8%), but the use of each platform was heterogeneous between countries. Among the advantages of SoMe, respondents indicated the chance of being updated on recent publications (66.0%), networking (48.5%), and the availability of rare or interesting cases (47.9%) as the most useful. Regarding the disadvantages of SoMe, the respondents underlined the loss of personal contact (40.7%), the inability to get 'hands-on' training (38.7%), and the lack of control regarding quality of scientific evidence (37.1%). Social media is increasingly used for professional purposes for scientific updating, networking, and case-based learning. The results of this survey encourage scientific societies, journals, and authors to enhance the quality, reach and impact of scientific content provided through SoMe