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Radiology Apr 2021History A 46-year-old woman was admitted to our hospital with decompensated congestive heart failure and pericardial effusion diagnosed at echocardiography. She had no...
History A 46-year-old woman was admitted to our hospital with decompensated congestive heart failure and pericardial effusion diagnosed at echocardiography. She had no family history of sudden cardiac death. She was born at term and experienced no cardiac events until 4 years of age, at which point she was hospitalized because of three syncopal episodes that were not related to exercise. Over the next 10 years, she experienced two additional episodes of syncope not related to exercise. She had another hospital admission at 12 years of age. Clinical examination did not reveal cyanosis or clubbing, peripheral pulses were normal, and blood pressure was 90/60 mmHg. Her venous pressure was elevated, but the liver was not enlarged, and the lung fields were clear. Electrocardiography showed sinus rhythm, right bundle branch block, T-wave inversion in V6, and evidence of right atrial dilatation. Two-dimensional echocardiography showed normal intracardiac connections, with the tricuspid valve in the normal position and normal size of the left atrium and left ventricle with a normal ejection fraction. The right ventricle (RV) was dilated, without evidence of RV outflow tract obstruction. Implantation of an implantable cardioverter-defibrillator was considered but was ultimately contraindicated because of RV anatomy. Thus, the patient received conservative care and was started on digoxin and diuretics. At 32 years of age, she experienced an episode of atrial flutter that was treated with electrical cardioversion. As stated earlier, at 46 years of age, she was admitted to our hospital with decompensated heart failure to be evaluated for a heart transplant. She underwent electrocardiography, echocardiography, cardiac MRI with and without administration of contrast media, and non-cardiac-gated multidetector CT (MDCT) with and without contrast media to rule out pulmonary embolism. The following quantitative results were obtained with MRI: Left ventricular end-diastolic volume (LVDV) was 40 mL (LVDV per body surface area [BSA], 25 mL/m); left ventricular end-systolic volume (LVSV), 21 mL (LVSV/BSA, 13 mL/m); left ventricular stroke volume (SV), 19 mL (SV/BSA, 12 mL/m); and left ventricular ejection fraction, 47%. RV end-diastolic volume (RVDV) was 262 mL (RVDV/BSA, 164 mL/m); RV end-systolic volume (RVSV), 198 mL (RVSV/BSA, 124 mL/m); RV stroke volume (SV), 64 mL (SV/BSA, 40 mL/m); and RV ejection fraction, 24%. Phase contrast sequences in the aorta and pulmonary artery showed systemic output of 20 mL and pulmonary output of 18 mL. Tricuspid regurgitation was massive (46 mL).
Topics: Cardiomyopathy, Dilated; Diagnosis, Differential; Electrocardiography; Female; Heart Defects, Congenital; Humans; Magnetic Resonance Imaging, Cine; Middle Aged; Multidetector Computed Tomography; Radiography, Thoracic
PubMed: 33750225
DOI: 10.1148/radiol.2021192475 -
Advances in Anesthesia Dec 2022The number of electrophysiology (EP) procedures being performed has dramatically increased in recent years. This escalation necessitates a full understanding by the... (Review)
Review
The number of electrophysiology (EP) procedures being performed has dramatically increased in recent years. This escalation necessitates a full understanding by the general anesthesiologist as to the risks, specific considerations, and comorbidities that accompany these now common procedures. Procedures reviewed in this article include atrial fibrillation and flutter ablation, supraventricular tachycardia ablation, ventricular tachycardia ablation, electrical cardioversion, pacemaker insertion, implantable cardioverter-defibrillator (ICD) insertion, and ICD lead extraction. General anesthetic considerations as well as procedure-specific concerns are discussed. Knowledge of these procedures will add to the anesthesiologist's armamentarium in safely caring for patients in the EP laboratory.
Topics: Humans; Catheter Ablation; Defibrillators, Implantable; Atrial Fibrillation; Cardiac Electrophysiology; Anesthetics
PubMed: 36333043
DOI: 10.1016/j.aan.2022.06.004 -
Cardiovascular & Hematological... 2020Cardiac arrhythmias are associated with several cardiac diseases and are prevalent in people with or without structural and valvular abnormalities. Ventricular... (Review)
Review
Cardiac arrhythmias are associated with several cardiac diseases and are prevalent in people with or without structural and valvular abnormalities. Ventricular arrhythmias (VA) can be life threating and their onset require immediate medical attention. Similarly, atrial fibrillation and flutter lead to stroke, heart failure and even death. Optimal treatment of VA is variable and depends on the medical condition associated with the rhythm disorder (which includes reversible causes such as myocardial ischemia or pro-arrhythmic drugs). While an implanted cardioverter defibrillator is often indicated in secondary prevention of VA. This review highlights the newest advancements in these techniques and management of ventricular and atrial tachyarrhythmias, along with pharmacological therapy.
Topics: Animals; Atrial Fibrillation; Cardiac Resynchronization Therapy; Defibrillators, Implantable; Disease Management; Humans; Tachycardia, Ventricular; Treatment Outcome
PubMed: 33001020
DOI: 10.2174/1871529X20666201001143907 -
ESC Heart Failure Dec 2021While the interplay between heart failure (HF) and atrial fibrillation (AF) has been extensively studied, little is known regarding HF and atrial flutter (AFL), which... (Review)
Review
While the interplay between heart failure (HF) and atrial fibrillation (AF) has been extensively studied, little is known regarding HF and atrial flutter (AFL), which may be managed differently. We reviewed the incidence, prevalence, and predictors of HF in AFL and vice versa, and the outcomes of treatment of AFL in HF. A systematic literature review of PubMed/Medline and EMBASE yielded 65 studies for inclusion and qualitative synthesis. No study described the incidence or prevalence of AFL in unselected patients with HF. Most cohorts enrolled patients with AF/AFL as interchangeable diagnoses, or highly selected patients with tachycardia-induced cardiomyopathy. The prevalence of HF in AFL ranged from 6% to 56%. However, the phenotype of HF was never defined by left ventricular ejection fraction (LVEF). No studies reported the predictors, phenotype, and prognostic implications of AFL in HF. There was significant variation in treatments studied, including the proportion that underwent ablation. When systolic dysfunction was tachycardia-mediated, catheter ablation demonstrated LVEF normalization in up to 88%, as well as reduced cardiovascular mortality. In summary, AFL and HF often coexist but are understudied, with no randomized trial data to inform care. Further research is warranted to define the epidemiology and establish optimal management.
Topics: Atrial Flutter; Catheter Ablation; Heart Failure; Humans; Stroke Volume; Ventricular Function, Left
PubMed: 34505352
DOI: 10.1002/ehf2.13526 -
BMC Medicine Feb 2023The role of systemic inflammation in promoting cardiovascular diseases has attracted attention, but its correlation with various arrhythmias remains to be clarified. We...
BACKGROUND
The role of systemic inflammation in promoting cardiovascular diseases has attracted attention, but its correlation with various arrhythmias remains to be clarified. We aimed to comprehensively assess the association between various indicators of systemic inflammation and atrial fibrillation/flutter (AF), ventricular arrhythmia (VA), and bradyarrhythmia in the UK Biobank cohort.
METHODS
After excluding ineligible participants, a total of 478,524 eligible individuals (46.75% male, aged 40-69 years) were enrolled in the study to assess the association between systemic inflammatory indicators and each type of arrhythmia.
RESULTS
After covariates were fully adjusted, CRP levels were found to have an essentially linear positive correlation with the risk of various arrhythmias; neutrophil count, monocyte count, and NLR showed a non-linear positive correlation; and lymphocyte count, SII, PLR, and LMR showed a U-shaped association. VA showed the strongest association with systemic inflammation indicators, and it was followed sequentially by AF and bradyarrhythmia.
CONCLUSIONS
Multiple systemic inflammatory indicators showed strong associations with the onset of AF, VA, and bradyarrhythmia, of which the latter two have been rarely studied. Active systemic inflammation management might have favorable effects in reducing the arrhythmia burden and further randomized controlled studies are needed.
Topics: Male; Humans; Female; Bradycardia; Biological Specimen Banks; Arrhythmias, Cardiac; Inflammation; United Kingdom
PubMed: 36855116
DOI: 10.1186/s12916-023-02770-5 -
Cardiac Electrophysiology Clinics Sep 2019Knowledge of relevant cardiac anatomy is crucial in understanding the pathophysiology and treatment of arrhythmias, and helps avoid potential complications in mapping... (Review)
Review
Knowledge of relevant cardiac anatomy is crucial in understanding the pathophysiology and treatment of arrhythmias, and helps avoid potential complications in mapping and ablation. This article explores the anatomy, relevant to electrophysiologists, relating to atrial flutter and atrial fibrillation, ventricular tachycardia relating to the outflow tracts as well as endocardial structure, and also epicardial considerations for mapping and ablation.
Topics: Arrhythmias, Cardiac; Heart Atria; Heart Ventricles; Humans
PubMed: 31400867
DOI: 10.1016/j.ccep.2019.04.003 -
Current Treatment Options in... 2022A significant proportion of patients infected by the severe acute respiratory syndrome-coronavirus (SARS-CoV2) (COVID-19) also have disorders affecting the cardiac... (Review)
Review
PURPOSE OF REVIEW
A significant proportion of patients infected by the severe acute respiratory syndrome-coronavirus (SARS-CoV2) (COVID-19) also have disorders affecting the cardiac rhythm. In this review, we provide an in-depth review of the pathophysiological mechanisms underlying the associated arrhythmic complications of COVID-19 infection and provide pragmatic, evidence-based recommendations for the clinical management of these conditions.
RECENT FINDINGS
Arrhythmic manifestations of COVID-19 include atrial arrhythmias such as atrial fibrillation or atrial flutter, sinus node dysfunction, atrioventricular conduction abnormalities, ventricular tachyarrhythmias, sudden cardiac arrest, and cardiovascular dysautonomias including the so-called long COVID syndrome. Various pathophysiological mechanisms have been implicated, such as direct viral invasion, hypoxemia, local and systemic inflammation, changes in ion channel physiology, immune activation, and autonomic dysregulation. The development of atrial or ventricular arrhythmias in hospitalized COVID-19 patients has been shown to portend a higher risk of in-hospital death.
SUMMARY
Arrhythmic complications from acute COVID-19 infection are commonly encountered in clinical practice, and COVID-19 patients with cardiac complications tend to have worse clinical outcomes than those without. Management of these arrhythmias should be based on published evidence-based guidelines, with special consideration of the acuity of COVID-19 infection, concomitant use of antimicrobial and anti-inflammatory drugs, and the transient nature of some rhythm disorders. Some manifestations, such as the long COVID syndrome, may lead to residual symptoms several months after acute infection. As the pandemic evolves with the discovery of new SARS-CoV2 variants, development and use of newer anti-viral and immuno-modulator drugs, and the increasing adoption of vaccination, clinicians must remain vigilant for other arrhythmic manifestations that may occur in association with this novel but potentially deadly disease.
PubMed: 35462637
DOI: 10.1007/s11936-022-00964-3 -
Herz Jun 2023Arrhythmic manifestations of COVID-19 include atrial arrhythmias such as atrial fibrillation or atrial flutter, sinus node dysfunction, atrioventricular conduction... (Review)
Review
Arrhythmic manifestations of COVID-19 include atrial arrhythmias such as atrial fibrillation or atrial flutter, sinus node dysfunction, atrioventricular conduction abnormalities, ventricular tachyarrhythmias, sudden cardiac arrest, and cardiovascular dysautonomias including the so-called long COVID syndrome. Various pathophysiological mechanisms have been implicated, such as direct viral invasion, hypoxemia, local and systemic inflammation, changes in ion channel physiology, immune activation, and autonomic dysregulation. The development of atrial or ventricular arrhythmias in hospitalized COVID-19 patients has been shown to portend a higher risk of in-hospital death. Management of these arrhythmias should be based on published evidence-based guidelines, with special consideration of the acuity of COVID-19 infection, concomitant use of antimicrobial and anti-inflammatory drugs, and the transient nature of some rhythm disorders. In view of new SARS-CoV‑2 variants that may evolve, the development and use of newer antiviral and immunomodulator drugs, and the increasing adoption of vaccination, clinicians must remain vigilant for other arrhythmic manifestations that may occur in association with this novel but potentially deadly disease.
Topics: Humans; Atrial Fibrillation; Incidence; Post-Acute COVID-19 Syndrome; Hospital Mortality; COVID-19; SARS-CoV-2; Death, Sudden, Cardiac
PubMed: 37277617
DOI: 10.1007/s00059-023-05186-2 -
CMAJ : Canadian Medical Association... May 2023Few studies have explored the relationship between air pollution and arrhythmia onset at the hourly level. We aimed to examine the association of exposure to air...
BACKGROUND
Few studies have explored the relationship between air pollution and arrhythmia onset at the hourly level. We aimed to examine the association of exposure to air pollution with the onset of acute symptomatic arrhythmia at an hourly level.
METHODS
We conducted a nationwide, time-stratified, case-crossover study in China between 2015 and 2021. We obtained hourly information on the onset of symptomatic arrhythmia (including atrial fibrillation, atrial flutter, atrial and ventricular premature beats and supraventricular tachycardia) from the Chinese Cardiovascular Association Database - Chest Pain Center (including 2025 certified hospitals in 322 cities). We obtained data on hourly concentrations of 6 air pollutants from the nearest monitors, including fine particles (PM), coarse particles (PM), nitrogen dioxide (NO), sulfur dioxide (SO), carbon monoxide (CO) and ozone. For each patient, we matched the case period to 3 or 4 control periods during the same hour, day of week, month and year. We used conditional logistic regression models to analyze the data.
RESULTS
We included a total of 190 115 patients with acute onset of symptomatic arrhythmia. Air pollution was associated with increased risk of onset of symptomatic arrhythmia within the first few hours of exposure; this risk attenuated substantially after 24 hours. An interquartile range increase in PM, NO, SO and CO in the first 24 hours after exposure (i.e., lag period 0-24 h) was associated with significantly higher odds of atrial fibrillation (1.7%-3.4%), atrial flutter (8.1%-11.4%) and supraventricular tachycardia (3.4%-8.9%). Exposure to PM was associated with significantly higher odds of atrial flutter (8.7%) and supraventricular tachycardia (5.4%), and exposure to ozone was associated with higher odds of supraventricular tachycardia (3.4%). The exposure-response relationships were approximately linear, without discernible concentration thresholds.
INTERPRETATION
Exposure to air pollution was associated with the onset of symptomatic arrhythmia shortly after exposure. This finding highlights the importance of further reducing air pollution and taking prompt protective measures for susceptible populations during periods of elevated levels of air pollutants.
Topics: Humans; Cross-Over Studies; Atrial Fibrillation; Cities; Atrial Flutter; Nitrogen Dioxide; Particulate Matter; Air Pollution; Air Pollutants; Ozone; China; Environmental Exposure
PubMed: 37127306
DOI: 10.1503/cmaj.220929 -
World Journal of Cardiology Sep 2023Cardiac magnetic resonance (CMR) imaging could enable major advantages when guiding in real-time cardiac electrophysiology procedures offering high-resolution anatomy,... (Review)
Review
Cardiac magnetic resonance (CMR) imaging could enable major advantages when guiding in real-time cardiac electrophysiology procedures offering high-resolution anatomy, arrhythmia substrate, and ablation lesion visualization in the absence of ionizing radiation. Over the last decade, technologies and platforms for performing electrophysiology procedures in a CMR environment have been developed. However, performing procedures outside the conventional fluoroscopic laboratory posed technical, practical and safety concerns. The development of magnetic resonance imaging compatible ablation systems, the recording of high-quality electrograms despite significant electromagnetic interference and reliable methods for catheter visualization and lesion assessment are the main limiting factors. The first human reports, in order to establish a procedural workflow, have rationally focused on the relatively simple typical atrial flutter ablation and have shown that CMR-guided cavotricuspid isthmus ablation represents a valid alternative to conventional ablation. Potential expansion to other more complex arrhythmias, especially ventricular tachycardia and atrial fibrillation, would be of essential impact, taking into consideration the widespread use of substrate-based strategies. Importantly, all limitations need to be solved before application of CMR-guided ablation in a broad clinical setting.
PubMed: 37900261
DOI: 10.4330/wjc.v15.i9.415