The cardiac lipid panel (CLP) is a novel panel of metabolomic biomarkers that has previously shown to improve the diagnostic and prognostic value for CHF patients. Several prognostic scores have been ...developed for cardiovascular disease risk, but their use is limited to specific populations and precision is still inadequate. We compared a risk score using the CLP plus NT-proBNP to four commonly used risk scores: The Seattle Heart Failure Model (SHFM), Framingham risk score (FRS), Barcelona bio-HF (BCN Bio-HF) and Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score. We included 280 elderly CHF patients from the Cardiac Insufficiency Bisoprolol Study in Elderly trial. Cox Regression and hierarchical cluster analysis was performed. Integrated area under the curves (IAUC) was used as criterium for comparison. The mean (SD) follow-up period was 81 (33) months, and 95 (34%) subjects met the primary endpoint. The IAUC for FRS was 0.53, SHFM 0.61, BCN Bio-HF 0.72, MAGGIC 0.68, and CLP 0.78. Subjects were partitioned into three risk clusters: low, moderate, high with the CLP score showing the best ability to group patients into their respective risk cluster. A risk score composed of a novel panel of metabolite biomarkers plus NT-proBNP outperformed other common prognostic scores in predicting 10-year cardiovascular death in elderly ambulatory CHF patients. This approach could improve the clinical risk assessment of CHF patients.
Case reports indicate that magnets in smartphones could be a source of electromagnetic interference (EMI) for active implantable medical devices (AIMD), which could lead to device malfunction, ...compromising patient safety. Recognizing this challenge, we implemented a high-fidelity 3D magnetic field mapping (spatial resolution 1 mm) setup using a three-axis Hall probe and teslameter, controlled by a robot (COSI Measure). With this setup, we examined the stray magnetic field of an iPhone 13 Pro, iPhone 12, and MagSafe charger to identify sources of magnetic fields for the accurate risk assessment of potential interferences with AIMDs. Our measurements revealed that the stray fields of the annular array of magnets, the wide-angle camera, and the speaker of the smartphones exceeded the 1 mT limit defined by ISO 14117:2019. Our data-driven safety recommendation is that an iPhone 13 Pro should be kept at least 25 mm away from an AIMD to protect it from unwanted EMI interactions. Our study addresses safety concerns due to potential device-device interactions between smartphones and AIMDs and will help to define data-driven safety guidelines. We encourage vendors of electronic consumer products (ECP) to provide information on the magnetic fields of their products and advocate for the inclusion of smartphones in the risk assessment of EMI with AIMDs.
Cardiac injury associated with cytokine release frequently occurs in SARS-CoV-2 mediated coronavirus disease (COVID19) and mortality is particularly high in these patients. The mechanistic role of ...the COVID19 associated cytokine-storm for the concomitant cardiac dysfunction and associated arrhythmias is unclear. Moreover, the role of anti-inflammatory therapy to mitigate cardiac dysfunction remains elusive. We investigated the effects of COVID19-associated inflammatory response on cardiac cellular function as well as its cardiac arrhythmogenic potential in rat and induced pluripotent stem cell derived cardiomyocytes (iPS-CM). In addition, we evaluated the therapeutic potential of the IL-1beta antagonist Canakinumab using state of the art in-vitro confocal and ratiometric high-throughput microscopy. Isolated rat ventricular cardiomyocytes were exposed to control or COVID19 serum from intensive care unit (ICU) patients with severe ARDS and impaired cardiac function (LVEF 41±5%; 1/3 of patients on veno-venous extracorporeal membrane oxygenation; CK 154±43 U/l). Rat cardiomyocytes showed an early increase of myofilament sensitivity, a decrease of Ca.sup.2+ transient amplitudes and altered baseline Ca.sup.2+ upon exposure to patient serum. In addition, we used iPS-CM to explore the long-term effect of patient serum on cardiac electrical and mechanical function. In iPS-CM, spontaneous Ca.sup.2+ release events were more likely to occur upon incubation with COVID19 serum and nuclear as well as cytosolic Ca.sup.2+ release were altered. Co-incubation with Canakinumab had no effect on pro-arrhythmogenic Ca.sup.2+ release or Ca.sup.2+ signaling during excitation-contraction coupling, nor significantly influenced cellular automaticity. Serum derived from COVID19 patients exerts acute cardio-depressant and chronic pro-arrhythmogenic effects in rat and iPS-derived cardiomyocytes. Canakinumab had no beneficial effect on cellular Ca.sup.2+ signaling during excitation-contraction coupling. The presented method utilizing iPS-CM and in-vitro Ca.sup.2+ imaging might serve as a novel tool for precision medicine. It allows to investigate cytokine related cardiac dysfunction and pharmacological approaches useful therein.
Introduction
Radiofrequency (RF) ablation is a commonly used tool in the invasive electrophysiology laboratory to treat a variety of rhythm disorders. Reliable creation of transmural ablation lesions ...is crucial for long‐term success. Lesion size index (LSI) is a multiparametric index that incorporates time, power, contact force (CF), and impedance data recorded during RF ablation in a weighted formula and has been shown to predict the extent of myocardial tissue lesions. Whether the force stability of contact influences lesion size in LSI‐guided ablations is unknown.
Objectives
The aim of this study was to analyze the influence of the force stability of contact on lesion size during LSI‐guided ablations in an ex‐vivo model.
Methods and Results
A total of 267 RF lesions (n = 6 hearts) were created on porcine myocardial slabs by using an open‐tip irrigated ablation catheter with the following settings: 35 W with either intermittent (varied between 0 and up to 20 g), variable (10 to 20 g), or constant tissue contact (15 g) in a perpendicular or parallel fashion (applied manually) up to a target LSI of either 5 or 6. Subsequently, lesion width and depth were determined. Lesion width was mainly influenced by catheter tip orientation and LSI, whereas lesion depth was mainly influenced by LSI alone. The force stability of catheter contact had no relevant impact on lesion width or depth.
Conclusion
The force stability of catheter contact has only little effect on lesion depth or width in LSI‐guided catheter ablation while the catheter orientation primarily affects lesion width.
Background
The purpose of this meta‐analysis was to analyze the clinical relevance of left atrial (LA) strain to predict recurrence of atrial fibrillation (AF) after catheter ablation (CA).
Methods ...and Results
We searched in different databases (Medline, EMBASE, and Cochrane) prospective studies that analyzed LA strain before CA. Eight studies (2 with only paroxysmal AF and 6 with mixed population of paroxysmal and persistent AF) were included in the final analysis (total patient number = 686). Patients with recurrence of AF were principally characterized by lower LA strain in comparison with those without AF recurrence (mean 18.4% range 8.8–24.5% versus 25.3% 13.6–32.7%, weighted mean difference −4.89% 95% CI −5.83% to −3.95%, P < 0.001). In addition, receiver operating curves shown that LA strain was strongly associated with recurrence of AF after CA (weighted mean: AUC 0.798 95% CI 0.700–0.943, cutoff 22.8% 18.8–30%, sensitivity 78% 65–86%, and specificity 75% 66–100%). In line, these results were similar using LA strain with QRS‐analysis and P‐analysis as well as using different software package such as Echo‐Pac, QLab, TomTec, and VVI.
Conclusion
In patients with AF candidate for CA, the analysis of the LA using LA strain could be of great usefulness to identify patients with high risk of AF recurrence. Nonetheless, further studies are needed to establish the clinical relevance of LA strain in patients with persistent AF.
There is an association between presence of cardiac implantable electronic devices (CIED) and development of tricuspid regurgitation (TR). Mechanisms proposed to explain CIED-induced TR can be ...classified as implantation-related, lead-related, and pacing-related. Lead-related TR results from the direct interaction of the lead with the tricuspid valve (TV). The localization of the lead at the TV level directly influences the probability of subsequent development of significant TR. A transthoracic subcostal en face view of the TV can be acquired in most patients through a 90° rotation from the subcostal 4-chamber view with clear anatomic delineation of the TV and the commissures including lead position. This case-series presents three examples where the transthoracic en face view could add incremental information on the position of the pacemaker leads and on the mechanism of TR.
Conclusion:
When performing transthoracic echocardiography in patients with trans-tricuspid CIED lead(s), an en face view of the TV with exact reporting of the position of the lead(s) should be included.
Aims
Cardiac resynchronization therapy (CRT) improves functional status, induces reverse left ventricular remodelling, and reduces hospitalization and mortality in patients with symptomatic heart ...failure, left ventricular systolic dysfunction, and QRS prolongation. However, the impact of iron deficiency on CRT response remains largely unclear. The purpose of the study was to assess the effect of functional and absolute iron deficiency on reverse cardiac remodelling, clinical response, and outcome after CRT implantation.
Methods and results
The relation of iron deficiency and cardiac resynchronization therapy response (RIDE‐CRT) study is a prospective observational study. We enrolled 77 consecutive CRT recipients (mean age 71.3 ± 10.2 years) with short‐term follow‐up of 3.3 ± 1.9 months and long‐term follow‐up of 13.0 ± 3.2 months. Primary endpoints were reverse cardiac remodelling on echocardiography and clinical CRT response, assessed by change in New York Heart Association classification. Echocardiographic CRT response was defined as relative improvement of left ventricular ejection fraction ≥ 20% or left ventricular global longitudinal strain ≥ 20%. Secondary endpoints were hospitalization for heart failure and all‐cause mortality (mean follow‐up of 29.0 ± 8.4 months). At multivariate analysis, iron deficiency was identified as independent predictor of echocardiographic (hazard ratio 4.97; 95% confidence interval 1.15–21.51; P = 0.03) and clinical non‐response to CRT (hazard ratio 4.79; 95% confidence interval 1.30–17.72, P = 0.02). We found a significant linear‐by‐linear association between CRT response and type of iron deficiency (P = 0.004 for left ventricular ejection fraction improvement, P = 0.02 for left ventricular global longitudinal strain improvement, and P = 0.003 for New York Heart Association response). Iron deficiency was also significantly associated with an increase in all‐cause mortality (P = 0.045) but not with heart failure hospitalization.
Conclusions
Iron deficiency is a negative predictor of effective CRT therapy as assessed by reverse cardiac remodelling and clinical response. Assessment of iron substitution might be a relevant treatment target to increase CRT response and outcome in chronic heart failure patients.
Aim
Wearable cardioverter defibrillator (WCD, LifeVest, and Zoll) therapy has become a useful tool to bridge a temporarily increased risk for sudden cardiac death. However, despite extensive use, ...there is a lack of evidence whether patients with myocarditis and impaired LVEF may benefit from treatment with a WCD.
Methods and results
We conducted a single‐centre retrospective observational study analysing patients with a WCD prescribed between September 2015 and April 2020 at our institution. In total, 135 patients were provided with a WCD, amongst these 76 patients (mean age 48.9 ± 13.7 years; 84.2% male) for clinically suspected myocarditis. Based on the results of the endomyocardial biopsy and, where available cardiac magnetic resonance imaging, 39 patients (51.3%) were diagnosed with myocarditis and impaired LVEF and 37 patients (48.7%) with dilated cardiomyopathy (DCM) without evidence of cardiac inflammation. The main immunohistopathological myocarditis subtype was lymphocytic myocarditis in 36 (92.3%) patients, and four patients (10.3%) of this group had an acute myocarditis. Three patients had cardiac sarcoidosis (7.7%). Ventricular tachycardia occurred in seven myocarditis (in total 41 VTs; 85.4% non‐sustained) and one DCM patients (in total one non‐sustained ventricular tachycardia). Calculated necessary WCD wearing time until ventricular tachycardia occurrence is 86.41 days in myocarditis compared with 6.46 years in DCM patients.
Conclusions
Our data suggest that myocarditis patients may benefit from WCD therapy. However, as our study is not powered for outcome, further randomized studies powered for the outcome morbidity and mortality are necessary.
Rhythm interpretation of EGMs recorded by implantable loop recorders (ILRs) is facilitated in cases when p-waves are visible. The three most commonly used ILRs (BioMonitor III, Confirm RX and Reveal ...Linq) vary in size, electrode placement and filter algorithms. Therefore, p-wave visibility and amplitude on EGM may vary according to the implanted device.
Consecutive patients were included after ILR implantation. P-wave visibility and amplitude were evaluated in sinus rhythm on 30-s EGMs with standard resolution (25 mm/mV for Biotronik and St. Jude, 30 mm/mV for Medtronic) and after maximum magnification. Additionally, baseline characteristics and p-wave amplitude in lead II on the surface-ECG were documented.
148 patients with either BioMonitor III (n = 48), Confirm Rx (n = 51) or Reveal Linq (n = 49) ILRs were included. With standard resolution, p-waves were visible in 40 patients (83%) implanted with BioMonitor III, 36 patients (71%) with Confirm Rx and in 35 patients (71%) with Reveal Linq ILRs (p = 0.267). After maximum magnification, p-waves could not be identified in 6 patients with Confirm Rx ILR (12%) and 1 patient in both BioMonitor III and Reveal Linq ILR (2%; p = 0.051). The Biomonitor III showed higher p-wave amplitudes compared to the Confirm Rx (0.050 mV (0.040–0.070) vs. 0.030 mV (0.020–0.040); p < 0.001) and the Reveal Linq ILR (0.050 mV (0.040–0.070) vs. 0.030 mV (0.020–0.040); p < 0.001).
P-wave amplitudes were higher in patients with Biomonitor III. This did not lead to higher p-wave visibility compared to the Confirm RX ILR or the Reveal Linq ILR.
•P-wave visibility and amplitude is an important diagnostic tool for ILRs.•The currently used ILRs vary in detection algorithms, size and electrode placement.•The BioMonitor III has higher p-wave amplitudes than Confirm RX and Reveal Linq ILR.
Background and aims
Antiscatter grids improve image contrast by absorbing scattered x‐ray beams, although by removing the antiscatter grid patient dose can be reduced as more x‐ray beams reach the ...image receptor. Additionally, there is a trend toward ultra‐low frame rates for radiation dose reduction during various electrophysiology procedures. As for most cardiac device implantations (CIED) image quality demands are usually modest, the purpose of this study was to assess the safety and efficacy of an ultra‐low frame rate and scatter grid‐less radiation protocol.
Methods/results
A total of 140 patients undergoing CIED implantation between 2014 and 2017 were included in the study. Seventy patients (50%) implanted after implementation of the antiscatter grid‐less and ultra‐low frame rate protocol were matched to controls before the dose‐reduction protocol was established. Forty patients (28.6%) had a one‐chamber pacemaker or one‐chamber implantable cardioverter defibrillator (ICD) implantation/revision, 60 (42.9%) had a two‐chamber pacemaker or two‐chamber ICD implantation/revision, and 40 (28.6%) patients had a cardiac resynchronization therapy device implantation/revision. Removing the antiscatter‐grid and lowering the frame rate led to a 73% reduction of the overall dose area product (1,206 ± 2,015 vs 324 ± 422 μGym, P < 0.001). Procedural duration (95 ± 51 minutes vs 82 ± 44 minutes, P = 0.053) and rate of complications were not significantly different between the two groups.
Conclusion
The use of an ultra‐low frame rate and antiscatter grid‐less radiation protocol significantly reduced radiation dose for implantation of CIED and led to very low average patient doses, while procedural duration and complication rates did not increase.
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