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Anselmino M, Ballatore A, Giaccardi M, Agresta A, Chieffo E, Floris R, Racheli M, Scaglione M, Casella M, Maines M, Marini M, De Ferrari GM, De Ponti R, Del Greco M. X-ray management in electrophysiology: a survey of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC). J Cardiovasc Med (Hagerstown) 2021; 22:751-758. [PMID: 34009182 DOI: 10.2459/jcm.0000000000001210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Radiation use in medicine has significantly increased over the last decade, and cardiologists are among the specialists most responsible for X-ray exposure. The present study investigates a broad range of aspects, from specific European Union directives to general practical principles, related to radiation management among a national cohort of cardiologists. METHODS AND RESULTS A voluntary 31-question survey was run on the Italian Arrhythmology and Pacing Society (AIAC) website. From June 2019 to January 2020, 125 cardiologists, routinely performing interventional electrophysiology, participated in the survey. Eighty-seven (70.2%) participants are aware of the recent European Directive (Euratom 2013/59), although only 35 (28.2%) declare to have read the document in detail. Ninety-six (77.4%) participants register the dose delivered to the patient in each procedure, in 66.1% of the cases both as fluoroscopy time and dose area product. Years of exposition (P = 0.009) and working in centers performing pediatric procedures (P = 0.021) related to greater degree of X-ray equipment optimization. The majority of participants (72, 58.1%) did not recently attend radioprotection courses. The latter is related to increased awareness of techniques to reduce radiation exposure (96% vs. 81%, P = 0.022), registration of the delivered dose in each procedure (92% vs. 67%, P = 0.009), and X-ray equipment optimization (50% vs. 36%, P = 0.006). CONCLUSION Italian interventional cardiologists show an acceptable level of radiation awareness and knowledge of updated European directives. However, there is clear space for improvement. Comparison to other health professionals, both at national and international levels, is needed to pursue proper X-ray management and protect public health.
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Affiliation(s)
- Matteo Anselmino
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Andrea Ballatore
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Marzia Giaccardi
- Cardiology and Electrophysiology Unit, Department of Medicine, 'Santa Maria Nuova' Hospital, Florence
| | | | | | - Roberto Floris
- Ospedale di Nostra Signora di Bonaria, San Gavino Monreale
| | | | - Marco Scaglione
- Division of Cardiology, 'Cardinal Massaia' Hospital, Asti, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital, Ancona
| | | | | | - Gaetano Maria De Ferrari
- Division of Cardiology, 'Città della Salute e della Scienza di Torino' Hospital, Department of Medical Sciences, University of Turin
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo-University of Insubria, Varese, Italy
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Sarkozy A, De Potter T, Heidbuchel H, Ernst S, Kosiuk J, Vano E, Picano E, Arbelo E, Tedrow U. Occupational radiation exposure in the electrophysiology laboratory with a focus on personnel with reproductive potential and during pregnancy: A European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS). Europace 2018; 19:1909-1922. [PMID: 29126278 DOI: 10.1093/europace/eux252] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/07/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Andrea Sarkozy
- University Antwerp and University Hospital of Antwerp, Cardiology department, Antwerp, Belgium
| | - Tom De Potter
- Cardiology Department, OLV Hospital, Moorselbaan, 164 Aalst B-9300, Belgium
| | - Hein Heidbuchel
- University Antwerp and University Hospital of Antwerp, Cardiology department, Antwerp, Belgium
| | - Sabine Ernst
- Cardiology Department, Royal Brompton And Harefield Hospital Sydney Street Chelsea Wing, Level 4 London, SW3 6NP, UK
| | - Jedrzej Kosiuk
- Cardiology Department, University Hospital of Leipzig, Leipzig, Germany
| | - Eliseo Vano
- Department Radiology, Medical School and San Carlos University Hosp Radiology, Madrid 28040, Spain
| | | | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona. IDIBAPS, Institut d'Investigació August Pi i Sunyer, Hospital Clínic de Barcelona Villarroel, 17008036 Barcelona, Spain
| | - Usha Tedrow
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street Boston, MA 02115, USA
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Rodríguez-Mañero M, Valderrábano M, Baluja A, Kreidieh O, Martínez-Sande JL, García-Seara J, Saenen J, Iglesias-Álvarez D, Bories W, Villamayor-Blanco LM, Pereira-Vázquez M, Lage R, Álvarez-Escudero J, Heidbuchel H, González-Juanatey JR, Sarkozy A. Validating Left Atrial Low Voltage Areas During Atrial Fibrillation and Atrial Flutter Using Multielectrode Automated Electroanatomic Mapping. JACC Clin Electrophysiol 2018; 4:1541-1552. [PMID: 30573117 DOI: 10.1016/j.jacep.2018.08.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/17/2018] [Accepted: 08/16/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES This study aimed: 1) to determine the voltage correlation between sinus rhythm (SR) and atrial fibrillation (AF)/atrial flutter (AFL) using multielectrode fast automated mapping; 2) to identify a bipolar voltage cutoff for scar and/or low voltage areas (LVAs); and 3) to examine the reproducibility of voltage mapping in AF. BACKGROUND It is unclear if bipolar voltage cutoffs should be adjusted depending on the rhythm and/or area being mapped. METHODS High-density mapping was performed first in SR and afterward in induced AF/AFL. In some patients, 2 maps were performed during AF. Maps were combined to create a new one. Points of <1 mm difference were analyzed. Correlation was explored with scatterplots and agreement analysis was assessed with Bland-Altman plots. The generalized additive model was also applied. RESULTS A total of 2,002 paired-points were obtained. A cutoff of 0.35 mV in AFL predicted a sinus voltage of 0.5 mV (95% confidence interval [CI]: 0.12 to 2.02) and of 0.24 mV in AF (95% CI: 0.11 to 2.18; specificity [SP]: 0.94 and 0.96; sensitivity [SE]: 0.85 and 0.75, respectively). When generalized additive models were used, a cutoff of 0.38 mV was used for AFL for predicting a minimum value of 0.5 mV in SR (95% CI: 0.5 to 1.6; SP: 0.94, SE: 0.88) and of 0.31 mV for AF (95% CI: 0.5 to 1.2; SP: 0.95, SE: 0.82). With regard to AF maps, there was no change in the classification of any left atrial region other than the roof. CONCLUSIONS It is possible to establish new cutoffs for AFL and/or AF with acceptable validity in predicting a sinus voltage of <0.5 mV. Multielectrode fast automated mapping in AFL and/or AF seems to be reliable and reproducible when classifying LVAs. These observations have clinical implications for left atrial voltage distribution and in procedures in which scar distribution is used to guide pulmonary vein isolation and/or re-isolation.
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Affiliation(s)
- Moisés Rodríguez-Mañero
- Cardiology Department, Hospital Universitario Santiago de Compostela, Santiago de Compostela, IDIS, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain.
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Department of Cardiology Houston Methodist Hospital, Houston, Texas
| | - Aurora Baluja
- Critical Patient Translational Research Group, Department of Anesthesiology, Intensive Care and Pain Management, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Omar Kreidieh
- Cardiology Department, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Jose Luis Martínez-Sande
- Cardiology Department, Hospital Universitario Santiago de Compostela, Santiago de Compostela, IDIS, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
| | - Javier García-Seara
- Cardiology Department, Hospital Universitario Santiago de Compostela, Santiago de Compostela, IDIS, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
| | - Johan Saenen
- Cardiology Department, Cardiac Electrophysiology Section, University Hospital of Antwerp, Antwerp, Belgium
| | - Diego Iglesias-Álvarez
- Cardiology Department, Hospital Universitario Santiago de Compostela, Santiago de Compostela, IDIS, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
| | - Wim Bories
- Cardiology Department, Cardiac Electrophysiology Section, University Hospital of Antwerp, Antwerp, Belgium
| | | | - María Pereira-Vázquez
- Cardiology Department, Hospital Universitario Santiago de Compostela, Santiago de Compostela, IDIS, Spain
| | - Ricardo Lage
- Cardiology Department, Hospital Universitario Santiago de Compostela, Santiago de Compostela, IDIS, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
| | - Julián Álvarez-Escudero
- Critical Patient Translational Research Group, Department of Anesthesiology, Intensive Care and Pain Management, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Hein Heidbuchel
- Cardiology Department, Cardiac Electrophysiology Section, University Hospital of Antwerp, Antwerp, Belgium
| | - José Ramón González-Juanatey
- Cardiology Department, Hospital Universitario Santiago de Compostela, Santiago de Compostela, IDIS, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
| | - Andrea Sarkozy
- Cardiology Department, Cardiac Electrophysiology Section, University Hospital of Antwerp, Antwerp, Belgium
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Wilkoff BL, Fauchier L, Stiles MK, Morillo CA, Al-Khatib SM, Almendral J, Aguinaga L, Berger RD, Cuesta A, Daubert JP, Dubner S, Ellenbogen KA, Estes NAM, Fenelon G, Garcia FC, Gasparini M, Haines DE, Healey JS, Hurtwitz JL, Keegan R, Kolb C, Kuck KH, Marinskis G, Martinelli M, Mcguire M, Molina LG, Okumura K, Proclemer A, Russo AM, Singh JP, Swerdlow CD, Teo WS, Uribe W, Viskin S, Wang CC, Zhang S. 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing. Europace 2015; 18:159-83. [PMID: 26585598 DOI: 10.1093/europace/euv411] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Zipes DP, Calkins H, Daubert JP, Ellenbogen KA, Field ME, Fisher JD, Fogel RI, Frankel DS, Gupta A, Indik JH, Kusumoto FM, Lindsay BD, Marine JE, Mehta LS, Mendes LA, Miller JM, Munger TM, Sauer WH, Shen WK, Stevenson WG, Su WW, Tracy CM, Tsiperfal A, Williams ES, Halperin JL, Arrighi JA, Awtry EH, Bates ER, Brush JE, Costa S, Daniels L, Desai A, Drachman DE, Fernandes S, Freeman R, Ijioma N, Khan SS, Kuvin JT, Marine JE, McPherson JA, Mendes LA, Sivaram CA, Spicer RL, Wang A, Weitz HH. 2015 ACC/AHA/HRS Advanced Training Statement on Clinical Cardiac Electrophysiology (A Revision of the ACC/AHA 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion). Circ Arrhythm Electrophysiol 2015; 8:1522-51. [PMID: 26386016 DOI: 10.1161/hae.0000000000000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Haines DE, Beheiry S, Akar JG, Baker JL, Beinborn D, Beshai JF, Brysiewicz N, Chiu-Man C, Collins KK, Dare M, Fetterly K, Fisher JD, Hongo R, Irefin S, Lopez J, Miller JM, Perry JC, Slotwiner DJ, Tomassoni GF, Weiss E. Heart Rythm Society expert consensus statement on electrophysiology laboratory standards: process, protocols, equipment, personnel, and safety. Heart Rhythm 2014; 11:e9-51. [PMID: 24814989 PMCID: PMC7106221 DOI: 10.1016/j.hrthm.2014.03.042] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Indexed: 01/08/2023]
Affiliation(s)
| | - Salwa Beheiry
- California Pacific Medical Center, San Francisco, California
| | - Joseph G. Akar
- Yale University School of Medicine, New Haven Connecticut
| | | | | | | | | | | | | | | | | | | | - Richard Hongo
- Sutter Pacific Medical Foundation, San Francisco, California
| | | | | | - John M. Miller
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - David J. Slotwiner
- Hofstra School of Medicine, North Shore-Long Island Jewish Health System, New Hyde Park, New York
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Papaioannou VE, Verkerk AO, Amin AS, de Bakker JMT. Intracardiac origin of heart rate variability, pacemaker funny current and their possible association with critical illness. Curr Cardiol Rev 2013; 9:82-96. [PMID: 22920474 PMCID: PMC3584310 DOI: 10.2174/157340313805076359] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 07/21/2012] [Accepted: 07/29/2012] [Indexed: 01/23/2023] Open
Abstract
Heart rate variability (HRV) is an indirect estimator of autonomic modulation of heart rate and is considered a risk marker in critical illness, particularly in heart failure and severe sepsis. A reduced HRV has been found in critically ill patients and has been associated with neuro-autonomic uncoupling or decreased baroreflex sensitivity. However, results from human and animal experimental studies indicate that intracardiac mechanisms might also be responsible for interbeat fluctuations. These studies have demonstrated that different membrane channel proteins and especially the so-called 'funny' current (If), an hyperpolarization-activated, inward current that drives diastolic depolarization resulting in spontaneous activity in cardiac pacemaker cells, are altered during critical illness. Furthermore, membrane channels kinetics seem to have significant impact upon HRV, whose early decrease might reflect a cellular metabolic stress. In this review article we present research findings regarding intracardiac origin of HRV, at the cellular level and in both isolated sinoatrial node and whole ex vivo heart preparations. In addition, we will review results from various experimental studies that support the interrelation between If and HRV during endotoxemia. We suggest that reduced HRV during sepsis could also be associated with altered pacemaker cell membrane properties, due to ionic current remodeling.
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Affiliation(s)
- Vasilios E Papaioannou
- Democritus University of Thrace, Alexandroupolis University Hospital, Intensive Care Unit, Alexandroupolis Medical School, Dragana 68100, Greece.
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Keller MW, Schuler S, Luik A, Seemann G, Schilling C, Schmitt C, Dössel O. Comparison of simulated and clinical intracardiac electrograms. Annu Int Conf IEEE Eng Med Biol Soc 2013; 2013:6858-6861. [PMID: 24111320 DOI: 10.1109/embc.2013.6611133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Intracardiac electrograms are the key in understanding, interpretation and treatment of cardiac arrhythmias. However, electrogram morphologies are strongly variable due to catheter position, orientation and contact. Simulations of intracardiac electrograms can improve comprehension and quantification of influencing parameters and therefore reduce misinterpretations. In this study simulated intracardiac electrograms are analyzed regarding tilt angles of the catheter relative to the propagation direction, electrode tissue distances as well as clinical filter settings. Catheter signals are computed on a realistic 3D catheter geometry using bidomain simulations of cardiac electrophysiology. Thereby high conductivities of the catheter electrodes are taken into account. For validation, simulated electrograms are compared with in vivo electrograms recorded during an EP-study with direct annotation of catheter orientation and tissue contact. Good agreement was reached regarding timing and signal width of simulated and measured electrograms. Correlation was 0.92±0.07 for bipolar, 0.92±0.05 for unipolar distal and 0.80 ± 0.12 for unipolar proximal electrograms for different catheter orientations and locations.
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Pantos I, Koukorava C, Nirgianaki E, Carinou E, Tzanalaridou E, Efstathopoulos EP, Katritsis DG. Radiation exposure of the operator during cardiac catheter ablation procedures. Radiat Prot Dosimetry 2012; 150:306-311. [PMID: 22234422 DOI: 10.1093/rpd/ncr414] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Radiation exposure of the operator during cardiac catheter ablation procedures was assessed for an experienced cardiologist adopting various measures of radiation protection and utilised electroanatomic navigation. Chip thermoluminescent dosemeters were placed at the eyes, chest, wrists and legs of the operator. The ranges of fluoroscopy time and air kerma area product values associated with cardiac ablation procedures were wide (6.3-48.3 min and 1.7-80.3 Gy cm(2), respectively). The measured median radiation doses per procedure for each monitored position were 23.6 and 21.3 μSv to the left and right wrists, respectively, 25.3 and 30.4 μSv to the left and right legs, respectively. The doses to the eyes were below the minimum detectable dose of 9 μSv. The estimated median effective dose was 22.5 μSv. Considering the actual workload of the operator, the calculated annual doses to the hands, legs and eyes, as well as the annual effective dose, were all below the corresponding limits. The findings of this study indicate that cardiac ablation procedures performed at a modern laboratory do not impose a high radiation hazard to the operator when radiation protection measures are routinely adopted.
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Affiliation(s)
- I Pantos
- Department of Cardiology, Athens Euroclinic, Athens, Greece
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Mikheev NN, Eliseeva LV. [Noninvasive radiodiagnosis of late coronary stent stenoses]. Vestn Rentgenol Radiol 2011:18-21. [PMID: 22288127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To study the diagnostic value of stress echocardiography (stress echoCG) in the early diagnosis of coronary stent stenoses in the late postoperative period. SUBJECTS AND METHODS The study enrolled 39 men aged 37 to 58 years with symptoms of cardialgia, who had previously (3 to 8 years earlier) undergone balloon angioplasty and coronary artery stenting to treat coronary heart disease. To exclude coronary stent stenoses, all the patients had dobutamine stress echoCG, transesophageal atrial electrostimulation, and further coronary angiographies (CAG). RESULTS Stress echoCG showed a lesion of the stented coronary artery in 34 patients and that of previously angiographically intact coronary arteries in 5 patients. According to CAG data, there was stenosis of > 70% in the coronary stent lumen in 16 patients and that of 40 to 70% in 12 patients. Six patients were found to have de novo stenoses in the previously stented coronary artery. Stress echoCG showed that the diagnostic accuracy and sensitivity of both stenoses of intracoronary stents and de novo ones in the stented artery and previously intact coronary arteries was 100%. CONCLUSION Stress echoCG is a highly informative method for the early topical diagnosis of both stenoses of coronary stents and a stenotic lesion of previously intact portions of coronary arteries. The early diagnosis of coronary stent stenoses permits mini-invasive endovascular treatment to be performed.
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Tatarinova AA, Treshkur TV, Parmon EV. [Microvolt T-wave alternans as a novel method of analysis of changes of repolarization phase and detection of latent electrical instability of the myocardium]. Kardiologiia 2011; 51:66-83. [PMID: 21878074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This review considers of modern concepts of microvolt T-wave alternans (TWA): its pathophysiological basis at cellular level, particulars of quantitative analysis of TWA, modulating effects of autonomic nervous system and drugs, prognostic efficacy in predicting susceptibility to ventricular arrhythmia in comparison with other modern prognostic factors of sudden cardiac death.
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MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmias, Cardiac/complications
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/drug therapy
- Arrhythmias, Cardiac/physiopathology
- Autonomic Nervous System/drug effects
- Autonomic Nervous System/physiopathology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Electrocardiography/classification
- Electrocardiography/drug effects
- Electrocardiography/standards
- Electrophysiologic Techniques, Cardiac/classification
- Electrophysiologic Techniques, Cardiac/standards
- Heart/physiopathology
- Heart Conduction System/drug effects
- Heart Conduction System/physiopathology
- Heart Rate/drug effects
- Humans
- Predictive Value of Tests
- Risk Assessment
- Sensitivity and Specificity
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Abstract
Procedures and interventions in the cardiac catheterization laboratory (CCL) and electrophysiology laboratory (EPL) are more complex and involve acutely ill patients. Safely caring for this growing patient population in the CCL and EPL is now a concern for all anesthesiologists and cardiologists. Anesthesiologists are uniquely trained to care for this complex patient population, allowing the cardiologist to focus on completing the interventional procedure successfully.
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Affiliation(s)
- Douglas C Shook
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Douglas PS, Hendel RC, Cummings JE, Dent JM, Hodgson JM, Hoffmann U, Horn RJ, Hundley WG, Kahn CE, Martin GR, Masoudi FA, Peterson ED, Rosenthal GL, Solomon H, Stillman AE, Teague SD, Thomas JD, Tilkemeier PL, Weigold WG. ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging. Endorsed by the Society of Nuclear Medicine [added]. Circulation 2008; 119:187-200. [PMID: 19064686 DOI: 10.1161/circulationaha.108.191365] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lin YJ, Higa S, Kao T, Tso HW, Tai CT, Chang SL, Lo LW, Wongcharoen W, Chen SA. Validation of the Frequency Spectra Obtained from the Noncontact Unipolar Electrograms During Atrial Fibrillation. J Cardiovasc Electrophysiol 2007; 18:1147-53. [PMID: 17711441 DOI: 10.1111/j.1540-8167.2007.00924.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Noncontact mapping (NCM) can record virtual unipolar electrograms (Egs) from multiple sites simultaneously; therefore, it has the potential to perform simultaneous frequency mapping during atrial fibrillation (AF). The aim of this study was to validate the frequency spectra of the noncontact unipolar Egs in both atria. METHODS This study enrolled 12 patients (age = 61 +/- 16 years) with paroxysmal or persistent AF who underwent catheter ablation guided by NCM. Noncontact and contact unipolar Egs were recorded simultaneously. The cross-correlation of the Eg morphology, activation time difference of the time-domain signals, and resultant frequency spectra were compared via dominant frequency (DF) and magnitude-squared coherence (MSC). RESULTS A total of 159 sites were analyzed during AF. The variables that independently predicted a higher correlation between the contact and noncontact electrogram morphology were a smaller activation timing difference P < 0.01), smaller distance of the mapping sites to the array center (P = 0.01), and higher atrial voltage (P = 0.03). However, the average MSC of the frequency band within the physiologic range of AF (2 to 15 Hz) was only affected by the activation timing difference (P = 0.002). The DF value between the contact and noncontact unipolar signals correlated well with each other throughout the right atria and left atria in 94% of the mapping sites (r = 0.87, P < 0.001). CONCLUSION The accuracy of the noncontact unipolar Eg morphology decreased when the mapping sites harbored a smaller atrial voltage and longer distance to the array center. The DF difference between the contact and noncontact unipolar Eg was not affected by the distance to the array center.
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Affiliation(s)
- Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taiwan
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Worley S, Ellenbogen KA. Application of Interventional Procedures Adapted for Device Implantation: New Opportunities for Device Implanters. Pacing Clin Electro 2007; 30:938-41. [PMID: 17669074 DOI: 10.1111/j.1540-8159.2007.00789.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Seth Worley
- Heart Center, Lancaster General Hospital, Lancaster, Pennsylvania, USA.
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Abstract
AIMS Recently, a discussion was carried out in Heart Rhythm on the specifications that could characterize implantable defibrillators. It is the intention of this paper to participate in this discussion on defibrillation characteristics and to give recommendations on how this problem could be solved. Theoretical considerations and results There are different defibrillation theories, all finding that the defibrillation's efficacy depends on the time constant RC which is output capacitance C times load resistance R. Efficacy decreases with increasing RC. This means that (i) the knowledge of C is of paramount importance, (ii) the energy is 'devalued' with increasing RC and that those parameter settings such as tilt or pulse duration should be adjusted to the time constant, and (iii) the energy values given without further specification are not meaningful. As there is always a voltage drop across an internal resistance within the ICD, the measured voltage across the output differs from the capacitor voltage and is reduced which determines the efficiency of the device. From the data given by Thammanomai et al., one can determine the parameters maximum voltage, capacitance, internal resistance, and tilt. These parameters are adequate and necessary to describe an ICD device and to derive the effective energy for device comparison. Discussion The 'high output devices' with their high nominal energy are reduced in their effective energies to a degree that they are comparable to the best 'standard output devices'. They do not offer that superiority which is promised by the nominal energy. Moreover, if the tilt is fixed and larger than optimal, the energy requirements are still higher or the effective energy will further drop. The term 'delivered energy' is not used by us because the delivered energy increases with increasing tilt. However, today's tilts are too large as judged by theories, which means that high delivered energies can be worse than lower ones. The delivered energy is, therefore, not a meaningful parameter in judging ICDs. CONCLUSION ICD devices should be characterized by: (i) voltage, (ii) capacitance, (iii) tilt or pulse duration (if not programmable), and (iv) internal resistance. All other parameters can be derived from them by simple calculations. Introduction of a 'devaluation factor' characterizes the decreasing efficacy with increasing time constant and renders the output characteristics transparent and comparable.
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Affiliation(s)
- Werner Irnich
- Justus-Liebig-University, University Hospital, Friedrichstr 18, 35392, Giessen, Germany.
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Buxton AE, Calkins H, Callans DJ, DiMarco JP, Fisher JD, Greene HL, Haines DE, Hayes DL, Heidenreich PA, Miller JM, Poppas A, Prystowsky EN, Schoenfeld MH, Zimetbaum PJ, Heidenreich PA, Goff DC, Grover FL, Malenka DJ, Peterson ED, Radford MJ, Redberg RF. ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology). J Am Coll Cardiol 2007; 48:2360-96. [PMID: 17161282 DOI: 10.1016/j.jacc.2006.09.020] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Abstract
Despite the multiple advances in the field of cardiovascular medicine, the incidence of sudden cardiac death (SCD) continues to rise. Of all SCDs, <25% occur in individuals deemed at high risk by current risk-stratification algorithms; hence, these risk-stratification algorithms are not satisfactory. Until better markers are identified to risk stratify patients, we will see an increasing use of implantable cardioverter defibrillators (ICDs). However, even with the increase in defibrillator use, the impact on overall incidence of SCD may only be modest, as many individuals experience SCD as the first manifestation of cardiovascular disease. Another important challenge is widespread availability of automated external defibrillators and effective utilization of public access defibrillation programs for timely and appropriate management of out-of-hospital victims with cardiac arrest. This review discusses the current understanding on SCD, risk stratification, and management aimed at reducing SCD, particularly with the use of ICDs.
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Affiliation(s)
- Rishi Sukhija
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Vimal Mehta
- Division of Cardiology, GB Pant Hospital, New Delhi, India
| | - Marino Leonardi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jawahar L. Mehta
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Buxton AE, Calkins H, Callans DJ, DiMarco JP, Fisher JD, Greene HL, Haines DE, Hayes DL, Heidenreich PA, Miller JM, Poppas A, Prystowsky EN, Schoenfeld MH, Zimetbaum PJ, Goff DC, Grover FL, Malenka DJ, Peterson ED, Radford MJ, Redberg RF. ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology). Circulation 2006; 114:2534-70. [PMID: 17130345 DOI: 10.1161/circulationaha.106.180199] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH, Creager MA, Holmes DR, Merli G, Rodgers GP. American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion. Circulation 2006; 114:1654-68. [PMID: 16987946 DOI: 10.1161/circulationaha.106.178893] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH, Creager MA, Holmes DR, Merli G, Rodgers GP, Tracy CM, Weitz HH. American College of Cardiology/American Heart Association 2006 Update of the Clinical Competence Statement on Invasive ElectrophysiologyStudies,CatheterAblation,andCardioversion. J Am Coll Cardiol 2006; 48:1503-17. [PMID: 17010821 DOI: 10.1016/j.jacc.2006.06.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Earley MJ, Abrams DJR, Sporton SC, Schilling RJ. Validation of the noncontact mapping system in the left atrium during permanent atrial fibrillation and sinus rhythm. J Am Coll Cardiol 2006; 48:485-91. [PMID: 16875973 DOI: 10.1016/j.jacc.2006.04.069] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2005] [Revised: 03/20/2006] [Accepted: 04/04/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to validate noncontact mapping (NCM) in the left atrium (LA) during sinus rhythm and atrial fibrillation (AF). BACKGROUND Understanding the mechanisms of AF is crucial to the development of novel and effective treatments. Noncontact mapping records global electrical activation simultaneously and therefore has the potential to elucidate these mechanisms. METHODS Patients underwent catheter ablation of permanent AF guided by NCM. Virtual and contact unipolar electrograms were recorded simultaneously during sinus rhythm and AF from sites spanning the LA and their morphology, amplitude, and timing were compared. The impact of distance from the array to the endocardial surface and electrogram amplitude were analyzed. RESULTS A total of 22 patients age 52 +/- 9 (mean +/- SD) years were studied. During sinus rhythm, the median (range) morphology correlation and timing difference between contact and virtual atrial electrograms were 0.81 (0.27 to 0.98) and 4.2 (0 to 18.3) ms, respectively. These results were significantly worse than the corresponding far field individual ventricular electrograms; 0.91 (0.53 to 1.0) and 1.7 (0 to 18.3) ms (p < 0.001). For endocardial sites >40 mm from the array, the correlation was significantly worse than sites <40 mm: 0.73 (0.48 to 0.95) versus 0.87 (0.27 to 0.98) (p < 0.001). The correlation during AF was 0.72 (0.24 to 0.98), which deteriorated with increasing distance from the array. In the presence of adenosine induced atrioventricular block the correlation deteriorated 0.67 +/- 0.16 versus 0.79 +/- 0.11 (p < 0.001). CONCLUSIONS Noncontact mapping can be performed in human LA; however, the accuracy of reconstructed electrograms is poor >40 mm from the center of the array, particularly during AF. Care must be taken interpreting isopotential maps if the entire endocardial surface of the LA is not close to the array.
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Affiliation(s)
- Mark J Earley
- Department of Cardiology, St. Bartholomew's Hospital, London, United Kingdom
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23
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Efstathopoulos EP, Katritsis DG, Kottou S, Kalivas N, Tzanalaridou E, Giazitzoglou E, Korovesis S, Faulkner K. Patient and staff radiation dosimetry during cardiac electrophysiology studies and catheter ablation procedures: a comprehensive analysis. ACTA ACUST UNITED AC 2006; 8:443-8. [PMID: 16690631 DOI: 10.1093/europace/eul041] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AIMS To perform a comprehensive analysis of all aspects of patient and in-room personnel radiation dosimetry in interventional electrophysiology. METHODS AND RESULTS Measurements were performed during 19 diagnostic electrophysiology studies and 24 catheter ablations. Kerma-area product and exposure time values were 48.7 (6.4-230) Gy cm2 and 25.5 (4.4-79.2) min for ablation, and 12.5 (4.5-117.2) Gy cm2 and 4.5 (1.2-31) min for diagnostic studies, respectively. Patient effective doses were 15.2 (2.1-59.6) mSv for ablation and 3.2 (1.3-23.9) mSv for diagnostic procedures. Radiation risk to the patient was estimated to be up to eight cases of fatal cancer in 10,000 procedures. The risk of development of fatal cancer was less than 3x10(-6) per procedure to the primary operator. The risk for the nurse and technician was much lower. The dose per procedure for the primary operator was 7.1 microGy at the eyes, 0.79 microGy at the chest under the lead apron, 13.68 microGy at the chest over the apron, 3.82 microGy at the thyroid, 17.76 microGy at the left hand, and 12.11 microGy at the left knee. CONCLUSION As far as radiation exposure is concerned, electrophysiology studies followed by radiofrequency ablation are safe procedures for both patient and personnel when performed in catheterization laboratories with modern equipment, experienced operators, and standard safety precautions.
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Hirshfeld JW, Balter S, Brinker JA, Kern MJ, Klein LW, Lindsay BD, Tommaso CL, Tracy CM, Wagner LK, Creager MA, Elnicki M, Hirshfeld JW, Lorell BH, Rodgers GP, Tracy CM, Weitz HH. ACCF/AHA/HRS/SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures. A report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. J Am Coll Cardiol 2004; 44:2259-82. [PMID: 15582335 DOI: 10.1016/j.jacc.2004.10.014] [Citation(s) in RCA: 171] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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25
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Kunihara T, Shiiya N, Matsui Y, Yasuda K. Preliminary report of transesophageal monitoring of spinal cord ischemia using near-infrared spectrophotometry. J Cardiovasc Surg (Torino) 2004; 45:95-6. [PMID: 15041949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Abstract
While noninvasive techniques, including esophageal recording and pacing, clearly have advantages in the pediatric population; they also have significant limitations. Invasive electrophysiology (EP) in children now encompasses the use of many advanced engineering applications, which contribute to the efficacy of such procedures. This is particularly true with respect to the performance of radiofrequency catheter ablation. First, microcatheters (eg, Cardima) offer advantages as diagnostic catheters in small hearts, and allow pacing and recording from both atrium and ventricle in even the smallest infants using limited venous access. In addition, there is the possibility of mapping the distal coronary sinus, and the right atrioventricular groove via the right coronary artery. Second, electroanatomic mapping using the CARTO system (Biosense Webster) allows complex maps to be constructed in patients with congenital heart disease and a history of cardiac surgery. Although somewhat laborious to construct, such maps offer great detail to guide ablation, and also provide voltage information to guide identification of patches and scars. Similarly, non-contact mapping systems (eg, EnSite, Endocardial Solutions) are available which record far-field potentials and employ solutions to the inverse problem to reconstruct endocardial potentials. Three-dimensional mapping based on a single beat is possible, and the success of ablation in creating conduction block in unique channels can be evaluated. Both of these three-dimensional mapping systems have the potential to improve outcomes in patients with complex disease undergoing ablation. Finally, patients are now undergoing combined procedures with interventional catheterization (eg, device closure, stenting) along with EP procedures (eg, ablation, device implant) in the same laboratory session. The state of the art in invasive pediatric EP increasingly involves the use of advanced technology adapted for use in pediatric and congenital heart disease applications.
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Affiliation(s)
- George F Van Hare
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
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Gura MT, Bubien RS, Belco KM, Taibi B, Schurig L, Wilkoff BL. North American Society of Pacing and Electrophysiology. Standards of professional practice for the allied professional in pacing and electrophysiology. Pacing Clin Electrophysiol 2003; 26:127-31. [PMID: 12685154 DOI: 10.1046/j.1460-9592.2003.00164.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The purpose of this article is to provide an introduction to electrophysiology (EP) testing. The history and evolution of EP testing will be reviewed briefly. The indications for electrophysiology studies (EPS) testing, EP definitions and terminology, components of a basic EP procedure, and potential complications will also be presented. To understand the principles of EPS, comprehension of the heart's electrical properties is imperative.
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Affiliation(s)
- Diane M Bosen
- St. John Hospital and Medical Center, 22101 Moross, Detroit, MI 48236, USA.
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Abstract
Various forms of extracellular recordings from the AV node (AVN) have been reported. However, lack of consistent validation have precluded the use of such recordings in experimental and clinical studies. In 14 Langendorff perfused dog hearts, the triangle of Koch (TOK) was exposed and an octapolar electrode catheter (2 mm rings, 2 mm spacing) was inserted under the endocardium so that the bipolar pairs recorded electrograms from the apex to the base of the TOK. All recording were filtered between 0.05 and 250 Hz, except for a His bundle (Hb) recording (30-250 Hz) made from another bipolar electrode catheter placed in the aortic root. Transmembrane action potentials (AP) were recorded close to the sites of extracellular electrograms. Pin electrodes at the periphery of the bath were arranged to register two ECG leads from the volume conductor. During recovery of electrical activity 11 of 14 preparations developed a junctional rhythm that initially manifested only an AV nodal extracellular and corresponding intracellular AV nodal potentials followed gradually by conduction to the Hb and ventricles but no retrograde atrial activation; 3 preparations initially produced Hb rhythms based on extracellular and transmembrane AP recordings from the AVN and Hb. The amplitude and duration of the AVN extracellular potentials (average: 97 +/- 26 microV and 92 +/- 25 msec, respectively) during AVN rhythms, significantly differed from those during atrial pacing (262 +/- 185 microV and 78 +/- 26 msec, p < 0.05). Histologic sections of the sites underlying the electrodes recording AVN potentials showed AVN tissue throughout. We conclude that extracellular AV nodal potentials are independent waveforms with specific qualitative and quantitative characteristics that distinguish them from adjacent atrial, transitional, Hb or ventricular potentials.
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Affiliation(s)
- Benjamin J Scherlag
- University of Oklahoma Health Sciences Center, Cardiac Arrhythmia Research Institute and Department of Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA.
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Washizuka T, Chinushi M, Tagawa M, Kasai H, Watanabe H, Hosaka Y, Yamashita F, Furushima H, Abe A, Watanabe H, Hayashi J, Aizawa Y. Inappropriate discharges by fourth generation implantable cardioverter defibrillators in patients with ventricular arrhythmias. Jpn Circ J 2001; 65:927-30. [PMID: 11716240 DOI: 10.1253/jcj.65.927] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The study prospectively investigated the incidence, cause and efficient management of inappropriate discharge by the fourth generation implantable cardioverter-defibrillator (ICD) system in 45 patients (mean age, 57+/-16 years). During the follow-up period of 27+/-17 months, 18 patients (40%) experienced one or more inappropriate therapies: sinus and supraventricular tachycardia (15 patients) and T wave oversensing (3 patients). In the 15 patients, re-programming of the tachycardia detection interval and/or additional treatment with beta-blocking agents were effective. In the 3 patients with T wave oversensing, the arrythmia was associated with an increase in T wave amplitude, change in T wave morphology and decreased R wave amplitude, and re-programming of the sensitivity of the local electrogram or changing the number of intervals to detect ventricular tachycardia decreased the number of inappropriate discharges in all 3 patients. In conclusion, inappropriate therapies are common problems in patients treated with the fourth generation ICD system, but most of them can be resolved using the dual-chamber ICD system. However, in patients with T-wave oversensing, it is difficult to avoid inappropriate discharge completely, even if the dual-chamber ICD system is implanted.
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Affiliation(s)
- T Washizuka
- First Department of Internal Medicine, Niigata University School of Medicine, Japan.
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Brembilla-Perrot B, Suty-Selton C, Houriez P, Claudon O, Beurrier D, de la Chaise AT. Value of non-invasive and invasive studies in patients with bundle branch block, syncope and history of myocardial infarction. Europace 2001; 3:187-94. [PMID: 11467459 DOI: 10.1053/eupc.2001.0174] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
UNLABELLED The prognosis of patients with bundle branch block (BBB) and myocardial infarction (MI) is poor, particularly for patients suffering from syncope. The purpose of this study was to investigate the diagnostic value of some techniques for the evaluation of the mechanism of syncope in patients with MI and BBB and their prognosis. METHODS We prospectively obtained the results of clinical history, 24 h Holter monitoring, left ventricular ejection fraction (LVEF), signal-averaged ECG (SAECG) and programmed ventricular stimulation in 130 patients with syncope, MI and BBB. 81 of them had right (R)BBB and 49-left (L)BBB. RESULTS Ventricular tachycardia (VT) was identified as the main cause of syncope in patients with MI and BBB: 68% of them had inducible VT. The sensitivity (se) and specificity (sp) of non sustained VT on Holter monitoring for the detection of VT were respectively 42.5 and 47% in patients with RBBB, 62 and 36% in those with LBBB; se and sp of LVEF <40% were 67.5% and 65% in patients with RBBB, 85 and 9% in those with LBBB; se and sp of the combination of 2 of the 3 SAECG criteria, QRS duration > 155 ms, LAS duration >30 ms and RMS 40 < 17 microV were respectively 50 and 57% in patients with RBBB; se and sp of the combination of 2 of the 3 criteria QRS duration >165 ms, LAS duration >40 ms and RMS 40 <17 microV were 73 and 55.5%) in patients with LBBB. During the follow-up (4.7 years +/- 2.5), 12 patients died suddenly and 12 patients died from heart failure. Univariate and multivariate analysis revealed than only the induction of VT was a significant predictor of sudden death. A long QRS duration (> 165 ms) and induction of VT were independent predictors of total cardiac mortality. CONCLUSION Among noninvasive studies, only the determination of filtered QRS duration was a significant predictor of cardiac mortality in the case of a prolongation (> 165 ms). Sudden death was only predicted by the induction of sustained VT. Because of the high incidence of inducible sustained VT, the low value of Holter monitoring and decreased LVEF for the prediction of ventricular arrhythmias and the poor prognosis of patients with inducible VT and low LVEF, systematic programmed ventricular stimulation is indicated in patients with MI, syncope and BBB, whatever the non-invasive studies results.
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Willems S, Weiss C, Shenasa M, Ventura R, Hoffmann M, Meinertz T. Optimized mapping of slow pathway ablation guided by subthreshold stimulation: a randomized prospective study in patients with recurrent atrioventricular nodal re-entrant tachycardia. J Am Coll Cardiol 2001; 37:1645-50. [PMID: 11345379 DOI: 10.1016/s0735-1097(01)01206-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This randomized prospective study sought to assess the value of slow pathway (SP) mapping and ablation guided by subthreshold stimulation (STS) in comparison with a strategy based on conventional criteria. BACKGROUND Previous studies have demonstrated that STS can be used as a highly specific and sensitive marker for successful SP ablation in the setting of atrioventricular nodal re-entrant tachycardia (AVNRT). Nonetheless, thus far this mapping strategy has not been investigated in contrast with the conventional approach. METHODS One hundred patients with sustained AVNRT were included. Fifty patients (group A) were randomly assigned to endocardial mapping and SP ablation using currently established criteria. In the other 50 patients (group B), SP ablation was guided by STS mapping. In group B patients, only radiofrequency current (RFC) was applied if additionally constant current STS (up to 5 mA) during AVNRT interrupted the tachycardia due to selective block within the SP. RESULTS Termination of AVNRT without apparent capture was observed during STS in 47 of 50 group B patients (94%). In all cases, this effect was indicative for successful subsequent SP ablation. The mean number of RFC pulses required for successful SP ablation was significantly lower in patients assigned to the STS-guided strategy (1.6 +/- 1.3 vs. 3.9 +/- 3.4; p = 0.0003). Similarly, the mean procedure duration was shorter in the STS group (156.9 +/- 33.5 vs. 173.2 +/- 49.7 min; p = 0.0221); the fluoroscopy time was comparable between both groups (14.1 +/- 8.7 vs. 16.9 +/- 10.6 min; p = 0.1278). CONCLUSIONS Subthreshold stimulation is an effective method for detection of target sites for selective SP ablation. This technique helps to minimize the number of RFC pulses without prolongation of the overall procedure and fluoroscopy time required for SP ablation.
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Affiliation(s)
- S Willems
- Department of Cardiology, University Hospital Eppendorf, Hamburg, Germany.
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Mouchawar G, Kroll M, Val-Mejias JE, Schwartzman D, McKenzie J, Fitzgerald D, Prater S, Katcher M, Fain E, Syed Z. ICD waveform optimization: a randomized, prospective, pair-sampled multicenter study. Pacing Clin Electrophysiol 2000; 23:1992-5. [PMID: 11139975 DOI: 10.1111/j.1540-8159.2000.tb07070.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The theoretical tissue model-based estimates of phase 1 and phase 2 duration of biphasic waveforms are considerably shorter than the pulse widths currently used in ICDs with standard tilt. This study used a tissue resistance/capacitance (RC) model to identify optimal biphasic pulse widths. By paired step-down defibrillation threshold (DFT) testing, the efficacy of standard versus "tuned" biphasic waveforms was evaluated in 91 patients. Standard waveforms consisted of a phase 1 set to 65% tilt and phase 2 = phase 1. The tuned waveform was based on an RC model of membrane characteristics with a time constant of 3.5 ms. The optimal phase 1 truncation point is at the peak of membrane response. The optimal phase 2 duration ends with a membrane response near or just below 0. In paired analysis, no significant differences were found in DFT or impedance between standard and tuned waveforms. In patients with DFTs > 400 V, the tuned waveform lowered the DFT by an average of 38 V (P < 0.05). Multivariate analyses showed a significant inverse relationship between DFT and impedance (P < 0.001). As impedance increased, the tuned waveform was associated with DFTs comparable to the standard waveform with shorter pulse duration and lower delivered energy. No single tilt value allowing an easy calculation of delivered energy was related to ICD waveform efficacy. The use of ICDs with tuned optimal pulse durations offer a greater flexibility of choice for patients with high DFTs.
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Affiliation(s)
- G Mouchawar
- St. Jude Medical, 15900 Valley View Court, Sylmar, CA 91342, USA.
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Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH, Winters WL, Achord JL, Boone AW, Hirshfeld JW, Lorell BH, Rodgers GP, Tracy CM, Weitz HH. American College of Cardiology/American Heart Association Clinical Competence Statement on invasive electrophysiology studies, catheter ablation, and cardioversion: A report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. Circulation 2000; 102:2309-20. [PMID: 11056109 DOI: 10.1161/01.cir.102.18.2309] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Brembilla-Perrot B, Blangy H, Holban I, Houriez P, Claudon O, Rizk J, Mauferon JB, Clavel A. [Value of transesophageal programmed atrial stimulation in the evaluation of unexplained cerebrovascular accidents]. Ann Cardiol Angeiol (Paris) 1999; 48:103-8. [PMID: 12555333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Certain embolic cerebrovascular accidents can be explained by the development of paroxysmal atrial fibrillation. When noninvasive complementary investigations are negative, programmed atrial stimulation can be proposed to detect increased atrial vulnerability. The objective of this study was to evaluate the reliability of this method performed via a transoesophageal approach in 59 subjects presenting with an embolic cerebrovascular accident and who were in sinus rhythm at the time of the accident. Seven of these patients had a history of paroxysmal atrial fibrillation (AF) or atrial tachycardia (AT) (group I). Three of these seven patients also presented AV nodal reentrant junctional tachycardia. The other 52 patients had no history of arrhythmia and their Holter recording did not reveal any episodes of sustained atrial tachycardia (group II). Transoesophageal programmed atrial stimulation used up to 2 extrastimuli under baseline conditions and during Isuprel infusion. The following results were obtained: sustained atrial tachycardia (> 1 min) was induced in all patients of group 1, 3 of them also presented inducible junctional tachycardias. 14 patients of group II (27%) presented inducible supraventricular tachycardia: atrial tachycardia in 7 cases. Patients in group II with inducible AT presented either heart disease (n = 3) or minor abnormalities on the Holter recording (runs of atrial premature complexes or sinus pauses (n = 3). Two of these patients subsequently developed sustained atrial fibrillation during follow-up. In 25 patients with normal Holter recording and no heart disease, programmed atrial stimulation induced junctional tachycardia in 4 cases. In conclusion, transoesophageal electrophysiological investigation is a useful way to identify various forms of supraventricular tachycardia able to explain an embolic cerebrovascular accident. The considerable incidence of inducible AV nodal reentrant junctional tachycardia must be emphasized, while the incidence of atrial fibrillation is much lower than during intracardiac investigations.
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