Giselle A. Baquero

Surface 12 lead electrocardiogram recordings using smart phone technology

IMPORTANCE AliveCor ECG is an FDA approved ambulatory cardiac rhythm monitor that records a single channel (lead I) ECG rhythm strip using an iPhone. In the past few years, the use of smartphones and tablets with health related applications has significantly proliferated. OBJECTIVE In this initial feasibility trial, we attempted to reproduce the 12 lead ECG using the bipolar arrangement of the AliveCor monitor coupled to smart phone technology. METHODS We used the AliveCor heart monitor coupled with an iPhone cellular phone and the AliveECG application (APP) in 5 individuals. RESULTS In our 5 individuals, recordings from both a standard 12 lead ECG and the AliveCor generated 12 lead ECG had the same interpretation. CONCLUSIONS This study demonstrates the feasibility of creating a 12 lead ECG with a smart phone. The validity of the recordings would seem to suggest that this technology could become an important useful tool for clinical use. This new hand held smart phone 12 lead ECG recorder needs further development and validation.

Dofetilide Reduces the Frequency of Ventricular Arrhythmias and Implantable Cardioverter Defibrillator Therapies

Dofetilide Reduces VT/VF and ICD Therapies. Background: Patients with an implanted cardioverter defibrillator (ICD) and ventricular arrhythmias leading to ICD therapies have poor clinical outcomes and quality of life. Antiarrhythmic agents and catheter ablation are needed to control these arrhythmias. Dofetilide has only been approved for the treatment of atrial fibrillation. The role of dofetilide in the control of ventricular arrhythmias in patients with an ICD has not been established.

Clinical Efficacy of Dofetilide for the Treatment of Atrial Tachyarrhythmias in Adults with Congenital Heart Disease

BACKGROUND Atrial tachyarrhythmias (AT) including atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia represent a clinical challenge in the adult with congenital heart disease (CHD). Dofetilide (D) is a rapidly activating delayed rectifier potassium channel (IKr) blocker effective in pharmacological conversion and maintenance of normal sinus rhythm in patients with AF and AFL. There is limited knowledge regarding the role of D in adults with CHD. METHODS Safety and efficacy of D was evaluated in a consecutive group of thirteen adult patients (age 40 ± 11; six women) with CHD and refractory AT. RESULTS Ten patients had persistent (four AFL, one AF, and five atrial tachycardia) and three paroxysmal (one AF and two atrial tachycardia) AT. All patients were symptomatic during tachycardia, 12 patients had previously failed 2 ± 1 antiarrhythmic drugs. Mean systemic ventricular ejection fraction was 55 ± 9%; baseline QRS complex duration was 129 ± 45 ms (>120 ms in six patients). Patients were followed on D for 33 ± 39 months (median 16). Among 10 patients with persistent AT, seven patients (70%) pharmacologically converted to sinus rhythm on D and three patients (30%) required direct current cardioversion. Two patients (15.4%) experienced complete arrhythmia suppression, and seven (53.8%) experienced significant clinical improvement with sporadic recurrences; average time to recurrence was 5.5 ± 3.5 months. One patient developed torsade de pointes during loading, and the drug was discontinued. D was discontinued in five (38.5%) other patients due to recurrence of AT (n = 4) and renal failure (n = 1). Corrected QT interval (QTc) increased from 452 ± 61 to 480 ± 49 ms (P = .04) and corrected JT interval (JTc) from 323 ± 39 to 341 ± 33 ms (P = .09). CONCLUSIONS D should be considered a pharmacologic alternative when adult patients with CHD develop AT. D does not depress conduction, sinus node, or ventricular function but needs close monitoring for potential ventricular pro-arrhythmia.

Fatal malignant metastastic epithelioid angiomyolipoma presenting in a young woman: case report and review of the literature

Epithelioid angiomyolipomas (EAMLs) are rare mesenchymal tumors whose malignant variant is extremely uncommon and highly aggressive. Treatment strategies include chemo radiation, transcatheter arterial embolization and surgical resection, which has remained the mainstay treatment. Targeted therapies including mammalian target of rapamycin (mTOR) inhibitors such as Temsirolimus may offer some hope for progressive malignant EAMLs that are not amenable to other treatment modalities. We report a fatal case in a young female who presented with rapidly progressive metastatic EAML that did not respond to mTOR therapy. The literature has shown reduction in tumor burden with the use of mTOR inhibitors, but unfortunately due to the rarity of malignant EAML, a meaningful approach to treatment remains challenging.

Tricuspid Valve Incompetence Following Implantation of Ventricular Leads

Most cardiovascular implantable electronic devices (CIEDs) require a ventricular lead to be placed across the tricuspid valve. Tricuspid regurgitation (TR) is an understudied clinical complication of right ventricular lead implantation and its clinical significance is unknown. We review the incidence, predictors, and current management of TR as a complication of ventricular lead implantation. Emerging technologies, including leadless pacing devices and subcutaneous systems, offer the benefit of little or none tricuspid valve disruption.

Incidence, predictors and clinical outcomes of residual stenosis after aortic valve-in-valve

Objective We aimed to analyse the incidence of prosthesis–patient mismatch (PPM) and elevated gradients after aortic valve in valve (ViV), and to evaluate predictors and associations with clinical outcomes of this adverse event. Methods A total of 910 aortic ViV patients were investigated. Elevated residual gradients were defined as ≥20 mm Hg. PPM was identified based on the indexed effective orifice area (EOA), measured by echocardiography, and patient body mass index (BMI). Moderate and severe PPM (cases) were defined by European Association of Cardiovascular Imaging (EACVI) criteria and compared with patients without PPM (controls). Results Moderate or greater PPM was found in 61% of the patients, and severe in 24.6%. Elevated residual gradients were found in 27.9%. Independent risk factors for the occurrence of lower indexed EOA and therefore severe PPM were higher gradients of the failed bioprosthesis at baseline (unstandardised beta −0.023; 95% CI −0.032 to –0.014; P<0.001), a stented (vs a stentless) surgical bioprosthesis (unstandardised beta −0.11; 95% CI −0.161 to –0.071; P<0.001), higher BMI (unstandardised beta −0.01; 95% CI −0.013 to –0.007; P<0.001) and implantation of a SAPIEN/SAPIEN XT/SAPIEN 3 transcatheter device (unstandardised beta −0.064; 95% CI −0.095 to –0.032; P<0.001). Neither severe PPM nor elevated gradients had an association with VARC II-defined outcomes or 1-year survival (90.9% severe vs 91.5% moderate vs 89.3% none, P=0.44). Conclusions Severe PPM and elevated gradients after aortic ViV are very common but were not associated with short-term survival and clinical outcomes. The long-term effect of poor post-ViV haemodynamics on clinical outcomes requires further evaluation.

Perioperative care in older adults.

1 Background Over the last 20 years, the number of older adults requir- ing surgical interventions has substantially increased and will continue to escalate as the population ages. Periopera- tive management of older patients poses challenges not en- countered in younger individuals. People over 70 years of age are more likely to have multiple comorbidities, physical and cognitive impairments, and reduced cardiac, pulmonary, and renal reserve. These factors predispose older patients to increased risk for perioperative complications and pro- longed length of hospital stay, which in turn increase risk for iatrogenesis, nosocomial infections, and perioperative mortality. Current recommendations for perioperative assessment and management for older patients are derived from data collected in predominantly younger cohorts. Given the pau- city of evidence-based guidelines for this patient population, it is vital to understand the pathophysiologic changes that occur in the older patient in order to reduce their periopera- tive risk. The objectives of this review are to briefly summarize age-related effects on organ system reserve, identify comor- bidities and geriatric conditions that pose increased risk for perioperative complications, and increase awareness of the essentials of perioperative evaluation and therapy in the older surgical patient. The overall goals are to ensure ap- propriate perioperative assessment and medical manage- ment and to minimize the risk of complications in older patients undergoing surgical procedures. ogic reserve of all organ systems, even in the absence of any underlying pathology, and these changes predispose to the development of perioperative adverse events. In addition, older patients often have multiple comorbidities requiring complex medical regimens that may further complicate pe- rioperative management. In this context, age-related changes in gastrointestinal physiology, kidney function, body com- position (such as reduction in muscle mass and intravascular volume) and metabolism lead to alterations in the pharma- codynamics and pharmacokinetics of most drugs. As a re- sult, older patients are often more sensitive to anesthetic and analgesic agents administered during the perioperative period. Other age-related physiologic alterations increase the li- kelihood of postoperative cardiac (e.g., atrial fibrillation, heart failure) and non-cardiac (e.g., delirium, pneumonia) complications. For these reasons, older patients undergoing major surgery require a comprehensive preoperative evalua- tion that should include assessment of functional status, cognition, and frailty. Combining these factors with conven- tional perioperative risk assessments facilitates the identifi- cation of older patients at risk for specific postoperative complications, and may enable implementation of manage- ment strategies designed to reduce perioperative risk and minimize delays in recovery.

Safety and Feasibility of Transradial Catheterization in Breast Cancer Survivors: A 2-Center International Experience.

The technical feasibility of transradial access (TRA) in breast cancer survivors is usually not a concern; even so, the perceived fear of lymphedema, both on the part of the survivor and medical staff, is the limiting factor. Cardiac catheterization and percutaneous coronary intervention using TRA

High dose statins prior to PCI—change our modus operandis and start guideline therapy earlier?

The meta-analysis examines the efficacy of high dose preloading of statin prior to PCI and demonstrate its association with lower PMI and cardiovascular events at short-term. Results from this analysis should encourage highdose pretreatment with statins prior to PCI, especially in patients with NSTE-ACS. A large randomize clinical trial would be desirable but not entirely necessary to initiate adoption of this novel strategy.

The role of multivessel coronary intervention in ST-segment elevation myocardial infarction complicated by cardiogenic shock: have we reached a verdict?

192 www.ccmjournal.org Cardiogenic shock (CS) complicates 7–10% of ST-segment elevation myocardial infarctions (STEMI). In the last decade, increased availability of percutaneous coronary intervention (PCI) has decreased the prevalence of CS in STEMI; despite this, mortality in these patients remains above 50%. It has been demonstrated that prompt PCI can improve outcomes among patients with STEMI complicated by CS (1, 2). A majority of these patients have associated multivessel disease (MVD) (3, 4) that is an independent predictor of mortality (5, 6). Optimal revascularization strategies in these patients remain controversial (7–13). Guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology state that only the infarctrelated artery (IRA) should be treated during the initial intervention for patients not in CS (14, 15). There are exceptions, although present guidelines do not explicitly recommend it. The Role of Multivessel Coronary Intervention in ST-Segment Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Have We Reached a Verdict?*