Ameeta Yaksh

Demographic and medical parameters in the development of complex regional pain syndrome type 1 (CRPS1): Prospective study on 596 patients with a fracture

Summary An intra‐articular fracture, ankle fracture, and dislocation are risk factors for complex regional pain syndrome type 1, and none of the patients were free of symptoms 1 year after trauma. ABSTRACT Limited data are available on the incidence of complex regional pain syndrome type 1 (CRPS1) and on demographic and medical risk factors for the development of CRPS1. The objective of this study was to investigate the incidence of CRPS1 in patients with a fracture using 3 sets of diagnostic criteria and to evaluate the association between demographic/medical factors and the development of CRPS1 diagnosed with the Harden and Bruehl criteria. A prospective multicenter cohort study of 596 patients (ages 18 years and older) with a single fracture of the wrist, scaphoid, ankle, or metatarsal V, recruited patients from the emergency rooms of 3 Dutch hospitals. Of the 596 participants, 42 (7.0%) were diagnosed with CRPS1 according to the Harden and Bruehl criteria, 289 (48.5%) according to the International Association for the Study of Pain criteria, and 127 (21.3%) according to the criteria of Veldman. An analysis of the medical and demographic differences revealed that patients in whom CRPS1 later developed more often had intra‐articular fractures, fracture dislocations, rheumatoid arthritis, or musculoskeletal comorbidities. An ankle fracture, dislocation, and an intra‐articular fracture contributed significantly to the prediction of the development of CRPS1. No CRPS1 patients were symptom free at 12 months (T3). At baseline, patients with CRPS1 had significantly more pain than patients without CRPS1 (P < .001). The incidence of the diagnosis of CRPS1 after a single fracture depends to a large extent on the diagnostic criteria used. After a fracture, 7% of the patients developed CRPS1 and none of the patients were free of symptoms at 1‐year follow‐up.

Atrial fibrillation: to map or not to map?

Isolation of the pulmonary veins may be an effective treatment modality for eliminating atrial fibrillation (AF) episodes but unfortunately not for all patients. When ablative therapy fails, it is assumed that AF has progressed from a trigger-driven to a substrate-mediated arrhythmia. The effect of radiofrequency ablation on persistent AF can be attributed to various mechanisms, including elimination of the trigger, modification of the arrhythmogenic substrate, interruption of crucial pathways of conduction, atrial debulking, or atrial denervation. This review discusses the possible effects of pulmonary vein isolation on the fibrillatory process and the necessity of cardiac mapping in order to comprehend the mechanisms of AF in the individual patient and to select the optimal treatment modality.

Unexpected finding in an adult with ventricular fibrillation and an accessory pathway: non-compaction cardiomyopathy

IntroductionIn this report, we demonstrate a patient presenting with anout-of-hospital cardiac arrest due to ventricular fibrillation(VF). At the hospital the presence of an accessory path-way could be seen on the surface electrocardiogram(ECG). Surprisingly, cardiac imaging also showed thepresence of isolated left ventricular non-compaction car-diomyopathy (INVM).INVMwasfirstdescribedin1984byEngberdingetal.as an unclassified cardiomyopathy [1]. It is assumed to bethe result of an arrest of the compaction process duringthe normal development of the heart (week 5–8). InINVM, the spaces within the intertrabeculated meshworkpersist with deep recesses and no other cardiac abnormal-ities [1, 2]. Clinical presentation of INVM includesheart failure, thromboembolic events and arrhythmias[1, 3, 5, 7]. Conduction abnormalities and arrhythmiasobserved in INVM patients are left or right bundlebranch block, supraventricular tachycardia and ventric-ular tachycardia [1–3, 5–10].However,thepresenceofanaccessorypathwayandINVMin one patient with VF has never been described before.Case reportA 19-year-old female presented to the emergency depart-ment after an out-of-hospital cardiac arrest due to VF.After alcohol consumption she jumped off a 1 m highpier into the water. While dressing she complained ofdizziness, palpitations and breathlessness. She collapsednear her car and lost consciousness. The paramedics ar-rived within 7 min and provided cardiopulmonary resus-citation. VF was documented on arrival (Fig. 1). Afterthree DC shocks sinus rhythm resumed and due to a lowGlasgow Coma Score she was intubated. At the intensivecardiac care unit therapeutichypothermia was induced for24 h. She regained consciousness without any signs ofpersistent neurological injury. Anamnestic there were noprevious palpitations or (near) collapses. The patient hadnoted that she was relatively quickly exhausted duringphysical exercise. Despite this, she played field hockeywithout any restraints. Her family history was negative forcardiovascular diseases, arrhythmias or sudden cardiacdeath. The 12-lead ECG after defibrillation showed pre-

Spatial distribution of conduction disorders during sinus rhythm

BACKGROUND Length of lines of conduction block (CB) during sinus rhythm (SR) at Bachmanns bundle (BB) is associated with atrial fibrillation (AF). However, it is unknown whether extensiveness of CB at BB represents CB elsewhere in the atria. We aim to investigate during SR 1) the spatial distribution and extensiveness of CB 2) whether there is a predilection site for CB and 3) the association between CB and incidence of post-operative AF. METHODS During SR, epicardial mapping of the right atrium (RA), BB and left atrium was performed in 209 patients with coronary artery disease. The amount of conduction delay (CD, Δlocal activation time ≥7ms) and CB (Δ≥12ms) was quantified as % of the mapping area. Atrial regions were compared to identify potential predilection sites for CD/CB. Correlations between CD/CB and clinical characteristics were tested. RESULTS Areas with CD or CB were present in all patients, overall prevalence was respectively 1.4(0.2-4.0) % and 1.3(0.1-4.3) %. Extensiveness and spatial distribution of CD/CB varied considerably, however occurred mainly at the superior intercaval RA. Of all clinicalcharacteristics, CD/CB only correlated weakly with age and diabetes (P<0.05). A 1% increase in CD or CB caused a 1.1-1.5ms prolongation of the activation time (P<0.001). There was no correlation between CD/CB and post-operative AF. CONCLUSION CD/CB during SR in CABG patients with electrically non-remodeled atria show considerable intra-atrial, but also inter-individual variation. Despite these differences, a predilection site is present at the superior intercaval RA. Extensiveness of CB at the superior intercaval RA or BB does not reflect CB elsewhere in the atria and is not associated with post-operative AF.

Endovascular catheter ablation of ventricular tachycardia in a patient with a surgically repaired congenital left ventricular aneurysm.

We present a patient with a congenital left ventricular aneurysm who visited our outpatient clinic for a routine check-up and, during this visit, lost consciousness due to sustained ventricular tachycardia. In our patient, endocardial mapping revealed extensive conduction abnormalities, and successful ablation was accomplished at the endocardial surface.

Impact of Ischemic and Valvular Heart Disease on Atrial Excitation:A High‐Resolution Epicardial Mapping Study

Background The influence of underlying heart disease or presence of atrial fibrillation (AF) on atrial excitation during sinus rhythm (SR) is unknown. We investigated atrial activation patterns and total activation times of the entire atrial epicardial surface during SR in patients with ischemic and/or valvular heart disease with or without AF. Methods and Results Intraoperative epicardial mapping (N=128/192 electrodes, interelectrode distances: 2 mm) of the right atrium, Bachmanns bundle (BB), left atrioventricular groove, and pulmonary vein area was performed during SR in 253 patients (186 male [74%], age 66±11 years) with ischemic heart disease (N=132, 52%) or ischemic valvular heart disease (N=121, 48%). As expected, SR origin was located at the superior intercaval region of the right atrium in 232 patients (92%). BB activation occurred via 1 wavefront from right‐to‐left (N=163, 64%), from the central part (N=18, 7%), or via multiple wavefronts (N=72, 28%). Left atrioventricular groove activation occurred via (1) BB: N=108, 43%; (2) pulmonary vein area: N=9, 3%; or (3) BB and pulmonary vein area: N=136, 54%; depending on which route had the shortest interatrial conduction time (P<0.001). Ischemic valvular heart disease patients more often had central BB activation and left atrioventricular groove activation via pulmonary vein area compared with ischemic heart disease patients (N=16 [13%] versus N=2 [2%]; P=0.009 and N=86 [71%] versus N=59 [45%]; P<0.001, respectively). Total activation times were longer in patients with AF (AF: 136±20 [92–186] ms; no AF: 114±17 [74–156] ms; P<0.001), because of prolongation of right atrium (P=0.018) and BB conduction times (P<0.001). Conclusions Atrial excitation during SR is affected by underlying heart disease and AF, resulting in alternative routes for BB and left atrioventricular groove activation and prolongation of total activation times. Knowledge of atrial excitation patterns during SR and its electropathological variations, as demonstrated in this study, is essential to further unravel the pathogenesis of AF.

Early ventricular tachyarrhythmias after coronary artery bypass grafting surgery: Is it a real burden?

BACKGROUND The prevalence of ventricular dysrhythmias (VD) [ventricular premature beats (VPBs), ventricular couplets (Vcouplets), ventricular runs (Vruns)] after coronary artery bypass grafting (CABG) has so far not been examined. The goal of this study is to examine characteristics of VD and whether they precede ventricular tachyarrhythmias (VTA) during a postoperative follow-up period of 5 days using continuous rhythm registrations. In addition, we determined predictive factors of VD/VTA. METHODS Incidences and burdens of VD/VTA were calculated in patients (N=105, 83 male, 65±9 years) undergoing primary, on-pump CABG. Independent risk factors were examined using multivariate analysis. RESULTS VPBs, Vcouplets, and Vruns occurred in respectively 100%, 82.9%, and 48.6% with corresponding burdens of 0.05%, 0%, and 0%. Sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) did not occur in our cohort. Independent risk factors for VD included male gender, mitral valve insufficiency, hyperlipidemia, and age ≥60 years. CONCLUSIONS VD are common in patients with coronary artery disease after CABG. Despite high incidences of these dysrhythmias, corresponding burdens are low and sustained VT or VF did not occur. Incidences were highest on the first postoperative day and diminished over time.

Early, de novo atrial fibrillation after coronary artery bypass grafting: Facts and features

Introduction Knowledge of the mechanism underlying post‐operative atrial fibrillation (PoAF) is essential for development of preventive measures. The incidence and characteristics of both PoAF and supraventricular premature beats triggering PoAF, their interrelationship and alterations over time have never been examined. The goal of this study is therefore to examine the correlation between the incidence and characteristics of supraventricular premature beats (SVPBs) and PoAF episodes in patients undergoing CABG in the first five post‐operative days. Methods PoAF episodes (N = 327) and SVPBs (N = 141,873) were characterized in 29 patients (63 ± 9 years; 22 (76%) male) undergoing coronary artery bypass grafting and compared with a control group of patients without PoAF by using continuous cardiac rhythm monitoring during the first 5 days after surgery. Results Most patients (N = 18, 62%) had multiple PoAF episodes; the median number of PoAF episodes per patient was 3 and varied between 1 and 139. The majority of PoAF episodes developed on the second and third post‐operative day (55%). The averaged median duration of PoAF episodes per patient was 469 ± 1085 min. Patients with PoAF had a higher SVPBs burden compared to subjects without PoAF (0.9% vs 0.2%, P < .001). SVPBs initiating PoAF had shorter coupling intervals than SVPBs which did not initiate PoAF episodes (58% vs 64% (P < .001) and were preceded by heart rate acceleration. Conclusion PoAF episodes are mainly repetitive though transient in nature. There was a considerable inter‐individual variation in both AF and SVPB characteristics, despite a similar underlying clinical profile. The SVPB burden is higher in patients with PoAF and the mode of onset is characterized by short coupled SVPBs. Determination of individual post‐operative dysrhythmia profiles enables identification of patients at risk for developing PoAF.

Hemodynamic deterioration precedes onset of ventricular tachyarrhythmia after Heartmate II implantation

BackgroundEarly postoperative ventricular tachyarrhythmia (PoVT) after left ventricular assist device (LVAD) implantation are common and associated with higher mortality-rates. At present, there is no data on initiation of these PoVT and the role of alterations in cardiac hemodynamics. Case PresentationA LVAD was implanted in a patient with end-stage heart failure due to a ischemic cardiomyopathy. Alterations in cardiac rhythm and hemodynamics preceding PoVT-episodes during the first five postoperative days were examined by using continuous recordings of cardiac rhythm and various hemodynamic parameters. All PoVT (N=120) were monomorphic, most often preceded by short-long-short-sequences or regular SR and initiated by ventricular runs. Prior to PoVT, mean arterial pressure decreased; heart rate and ST-segments deviations increased. ConclusionsPoVT are caused by different underlying electrophysiological mechanisms. Yet, they are all monomorphic and preceded by hemodynamic deterioration due to myocardial ischemia.

Intraoperative Inducibility of Atrial Fibrillation Does Not Predict Early Postoperative Atrial Fibrillation

Background Early postoperative atrial fibrillation (EPoAF) is associated with thromboembolic events, prolonged hospitalization, and development of late PoAF (LPoAF). It is, however, unknown if EPoAF can be predicted by intraoperative AF inducibility. The aims of this study are therefore to explore (1) the value of intraoperative inducibility of AF for development of both EPoAF and LPoAF and (2) the predictive value of de novo EPoAF for recurrence of LPoAF. Methods and Results Patients (N=496, 75% male) undergoing cardiothoracic surgery for coronary and/or valvular heart disease were included. AF induction was attempted by atrial pacing, before extracorporeal circulation. All patients were on continuous rhythm monitoring until discharge to detect EPoAF. During a follow‐up period of 2 years, LPoAF was detected by ECGs and Holter recordings. Sustained AF was inducible in 56% of patients. There was no difference in patients with or without AF before surgery (P=0.159), or between different types of surgery (P=0.687). In patients without a history of AF, incidence of EPoAF and LPoAF was 37% and 2%, respectively. EPoAF recurred in 58% patients with preoperative AF, 53% developed LPoAF. There were no correlations between intraoperative inducibility and EPoAF or LPoAF (P>0.05). EPoAF was not correlated with LPoAF in patients without a history of AF (P=0.116), in contrast to patients with AF before surgery (P<0.001). Conclusions Intraoperative AF inducibility does not predict development of either EPoAF or LPoAF. In patients with AF before surgery, EPoAF is correlated with LPoAF recurrences. This correlation is absent in patients without AF before surgery.