"We are not a typical family anymore": Exploring the experiences and support needs of fathers of children with Fragile X syndrome in Australia

A diagnosis of the X-linked condition Fragile X syndrome (FXS) in a child commonly reveals the mother's carrier status. Previous research focused on the genetic counseling process for the child and maternal family, despite calls for more research on the support needs of fathers. This study explored experiences and support needs of fathers at least 1 year after their child's FXS diagnosis to understand barriers and enablers and optimize health outcomes for the family. In-depth interviews were conducted with 11 fathers recruited through the Australian Genetics of Learning Disability Service and the Fragile X Association. Deidentified transcripts were analyzed using thematic analysis guided by an inductive approach. Four themes emerged: (1) making life easier through understanding-yesterday and today, (2) the path to a new normal-today and tomorrow, (3) seeking information and support, and (4) what men want. Fathers reported diagnostic odysseys, postdiagnostic grief, and challenges adjusting. They highlighted difficulties in understanding their child's unique behaviors and needs, responding to their partner's psychological support needs, planning for their child's future, and navigating complex health and disability systems. Participants suggested health professionals facilitate father-to-father support and psychological counseling. These findings highlight the unmet needs of fathers and suggest that a strengths-based approach is critically important given the recognized mental health impact.

High-rate atrial pacing to reduce left-sided filling pressures: a combined computational and clinical pilot study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): This work was supported by the Netherlands Organisation for Scientific Research (NWO- ZonMw, VIDI grant 016.176.340 to J.L.) and the Dutch Heart Foundation (ERA-CVD JTC2018 grant 2018T094; Dr. Dekker Program grant 2015T082 to J.L.)

Background

In heart failure patients, interventions to reduce elevated left ventricular (LV) filling pressure improve symptoms and reduce the risk of hospitalization. In this combined computational-clinical study, we explore high-rate atrial pacing as an alternative intervention to reduce LV filling pressure.

Methods

First, the theoretical basis was explored in a computational model of reduced LV compliance and various fixed atrioventricular delays. Second, an explorative clinical study was conducted in 19 paroxysmal atrial fibrillation (AF) patients undergoing pulmonary vein isolation (PVI) with sinus rhythm at the beginning of the procedure. Prior to the PVI, atrial pacing rate was gradually increased from resting heart rate to Wenckebach point with 10bpm increments. LA pressure was continuously monitored with a fluid-filled transseptal catheter.

Results

Computational modelling demonstrated a parabolic relationship between atrial pacing rate and LA pressure depending on atrioventricular delay (Figure A). In patients (Figure B), intermediately increased rates (60bpm[60-70], median[IQR], to 90bpm[73-100], respectively) reduced LA pressure from 16.0mmHg[14.0-20.5] to 14.0mmHg[10.8-16.8]. Highly increased rates (130bpm[120-140]) significantly increased LA pressure to 26.0mmHg[21.5-27.8].

Conclusions

Both the model simulations and the subsequent clinical pilot study support the hypothesis that high-rate atrial pacing can reduce left-sided filling pressure. However, inter-patient variability of response to high-rate pacing was observed, to which simulations identified atrioventricular conduction to be a potential source.

Impact of the ESC 2021 guidelines on cardiac pacing and cardiac resynchronization therapy left bundle branch block definition on CRT patient selection and survival

Funding Acknowledgements

Type of funding sources: None.

Background

The recently published ESC 2021 guidelines on cardiac pacing and cardiac resynchronization therapy (CRT) underwent significant changes compared to the ESC 2013 guidelines regarding the definition of left bundle branch block (LBBB) by adding notching or slurring in 2 adjacent leads as a prerequisite. The level of recommendation for CRT depends on diagnosing LBBB or non-LBBB. These changes may have a significant impact on patient selection for CRT, as fewer patients may be diagnosed with LBBB and may therefore get a lower level of recommendation for CRT.

Purpose

In this study we investigated the impact of these changes in LBBB definition on patient selection and heart transplantation/left ventricular assist device (LVAD) free survival.

Methods

A large multicenter CRT database, consisting of consecutive patients implanted with a CRT device between 2001 and 2015 in 3 university hospitals in the Netherlands, was used for this study. Patient selection, device implantation, lead positioning and follow-up were according to then prevailing guidelines and local protocols. For this study, patients were selected with baseline sinus rhythm, QRS duration >130ms, and without right ventricular pacing. Patients were stratified according to ESC 2013 and ESC 2021 guideline definitions on LBBB.

Results

The current analyses included 1.202 CRT patients. 66% of patients were male with an age of 66±11 years. Heart failure etiology was ischemic in 49% of patients with baseline left ventricular ejection fraction of 25% and baseline NYHA class II-III in 93% of patients. There is a considerable difference in LBBB diagnoses when stratifying patients according to ESC 2013 and ESC 2021 guideline definitions as especially the number of LBBB patients is reduced from 80.9% to 31.6% (Figure 1). Heart transplantation/LVAD free survival analyses when stratifying according to ESC 2013 LBBB definition showed significant separation of the curves (p<0.0001) (Figure 2). Furthermore, there was a significant difference between the wide (QRS>150ms) LBBB and wide non-LBBB subgroup concerning heart transplantation/LVAD free survival (p<0.0001). In contrast, there was no significant separation of the curves when stratifying according to ESC 2021 LBBB definition (Figure 2).

Conclusion

The changes made in LBBB definition in the ESC 2021 CRT guidelines lead to a difference in stratification of LBBB and non-LBBB. The ESC 2013 LBBB definition, however, seems to be better in predicting heart transplantation/LVAD free survival after CRT.

Electrical characteristics of deep septal vs. left bundle branch (area) pacing

Background/Introduction

Recent studies have described transvenous left bundle branch (LBB) pacing as a new conduction system pacing strategy. However, information on effect of pacing depth within the septum and the additional effect of LBB capture is unknown.

Purpose

To investigate the relation of electrocardographic characteristics with transseptal LV lead implantation depth and LBB capture.

Methods

20 consecutive patients referred for pacemaker implantation were enrolled. The right atrial (RA) lead was positioned according to routine practice. The LV septal pacing lead (Medtronic 3830) was transvenously positioned against the right side of the interventricular septum and advanced in small steps of 1–2mm towards the left side of the septum. At each depth in the septum 12-lead ECG's were recorded during pacing, from which vectorcardiograms (VCG) were calculated. QRS duration and QRS area were measured, the latter being the integral of the QRSarea in X, Y and Z directions. Successful LBB capture was defined as paced right bundle branch block (RBBB) morphology, stable and short stimulus to LV activation time (LVAT; R in V5) and recorded LBB potential.

Differences were compared among pacing conditions using repeated measures ANOVA with Bonferroni multiple comparisons procedure applied to pairwise comparisons. Statistical significance was assumed at p<0.05.

Results

LV septal lead implantation was successful in all patients. Left bundle branch capture was achieved in 10/20 patients (50%). Post-procedural LV pacing threshold, impedance and sensing was 0.7±0.1 V at 0.5 ms pulse width, 658±5 Ω and 13±10 mV, respectively. Compared to intrinsic rhythm, QRS duration was significantly increased by both RV septum (RVS; 124±5 vs. 161±3 ms) and LV septum pacing (LVS; 142±3 ms).

QRS area increased significantly during RVS pacing as compared to intrinsic rhythm but decreased when moving from RVS to LVS to values close to intrinsic rhythm (panel A & B). LVS-pacing derived QRS area was significantly lower in patients with LBB capture (36±6 mV*ms) compared to patients without LBB capture (deep septal pacing; 46±12 mV*ms).

The reduction in QRS area between RVS and LVS pacing coincided with normalization of the QRS vector in the transverse plane (panel C), which is characterized electrocardiographically by predominantly negative-to-positive inversion of the QRS complex in the precordial leads (V1-V3).

Conclusions

Compared to RV septal pacing, LV septal pacing restores ventricular electrical synchrony, as determined by QRS area, and normalizes the activation vector in the transverse plane to a level comparable to intrinsic rhythm. Differences in resynchronization between left bundle branch pacing and deep septal pacing are small.

LBBAP restores ventricular synchrony

Funding Acknowledgement

Type of funding source: None

Obsessive-compulsive disorder: a critical review of therapeutic perspectives

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a chronic disabling disease with profound implications for social functioning. Thirty per cent of all patients with OCD show insufficient improvement with state-of-the-art treatment. Conventional treatment and alternative treatment options for this population were investigated.

METHOD

A selective review of the relevant scientific literature on OCD treatment and treatment resistance was conducted.

RESULTS

In addition to serotonin reuptake inhibitors (SRIs) and cognitive-behavioural therapy, alternative monotherapies, SRI augmentation strategies with a variety of drugs and electroconvulsive therapy have shown results in individual cases, but no conclusive evidence has been found in placebo-controlled trials. While studies investigating neurosurgery for refractory OCD show positive results, most of these studies have methodological shortcomings.

CONCLUSION

Novel approaches currently under investigation that have shown promising effects for treatment-resistant OCD include SRI augmentation with atypical antipsychotics and chronic deep brain stimulation, a new surgical technique. Placebo-controlled trials for both treatment options will be needed to confirm preliminary findings.

"Danger is lurking everywhere". the relation between anxiety and threat perception abnormalities in normal children

The present study examined the relation between anxiety and depression and threat perception abnormalities. Children were exposed to stories describing social situations. Some of the stories were ambiguous (i.e., these stories contained information that could be interpreted as threatening) whereas other stories were non-threatening (i.e., these stories contained no obvious trace of threat). From children's responses to the stories, several threat perception indices were derived. Children's level of anxiety and depression were assessed by means of self-report questionnaires. Results indicated that high levels of anxiety were accompanied by a high frequency of threat perception, high ratings of threat, a high frequency of threatening interpretations, high levels of negative feelings and cognitions, and an early detection of threat. Interestingly, significant associations between anxiety and threat perception abnormalities were not only observed in response to ambiguous stories but also in relation to non-threatening scenarios. Furthermore, depression was also connected with threat perception distortions. Even when controlling for anxiety levels, depression remained significantly related to threat frequency, threat ratings, and threat thresholds.