Powell, Brian D.

Background— Aspirin is beneficial in the setting of atherosclerotic cardiovascular disease. There are limited data evaluating preoperative aspirin administration preceding coronary artery bypass grafting and associated postoperative outcomes. Methods and Results— Using prospectively collected data from 1636 consecutive patients undergoing first-time isolated coronary artery bypass surgery at our institution from January 2000 through December 2002, we evaluated the association between aspirin usage within the 5 days preceding coronary bypass surgery and risk of adverse in-hospital postoperative events. A logistic regression model, which included propensity scores, was used to adjust for remaining differences between groups. Overall, there were 36 deaths (2.2%) and 48 adverse cerebrovascular events (2.9%) in the postoperative hospitalization period. Patients receiving preoperative aspirin (n=1316) had significantly lower postoperative in-hospital mortality compared with those not receiving preoperative aspirin [1.7% versus 4.4%; adjusted odds ratio (OR), 0.34; 95% CI, 0.15 to 0.75; P =0.007]. Rates of postoperative cerebrovascular events were similar between groups (2.7% versus 3.8%; adjusted OR, 0.67; 95% CI, 0.32 to 1.50; P =0.31). Preoperative aspirin therapy was not associated with an increased risk of reoperation for bleeding (3.5% versus 3.4%; P =0.96) or requirement for postoperative blood product transfusion (adjusted OR, 1.17; 95% CI, 0.88 to 1.54; P =0.28). Conclusions— Aspirin usage within the 5 days preceding coronary artery bypass surgery is associated with a lower risk of postoperative in-hospital mortality and appears to be safe without an associated increased risk of reoperation for bleeding or need for blood product transfusion.

Background: Effect of CRT on the timing of regional myocardial strain is not fully described. We aimed to explore the effect of CRT on the timing of regional myocardial strain using speckle tracking echocardiography (STE). Methods: STE and tissue Doppler imaging were performed in 91 patients before and 6 month after CRT. Time to peak longitudinal strain (Tϵ) from the onset of QRS was measured in 16 segments from three apical views. Time to peak systolic tissue velocity (Tv) was also measured in 12 basal and mid segments. Reverse remodeling was defined as 10% reduction in end-systolic volume. Results: At baseline, Tϵ and Tv demonstrated specific pattern with earlier septal and delayed lateral contraction (Figure ). Tϵ in responders showed significantly earlier timing in mid inferoseptal (p=0.003) and anteroseptal segments (base, P=0.005, mid P=0.007) than in nonresponders, whereas the timing of free wall did not differ between responders and non-responders. After CRT, Tϵ in earlier segments (inferoseptal, anteroseptal and inferior wall) prolonged significantly (p<0.001), whereas other segments did not change timing. Accordingly, SD of Tϵ in 12 segments reduced after CRT (110±46 ms vs. 81±36 ms, p<0.001). Tv did not change in all segments and SD of Tv did not improve after CRT (43±16 vs. 46±16 ms, p=0.20). Conclusions: Simultaneous electrical activation of LV free wall and septum with CRT achieves mechanical synchronization by delaying the timing of earlier contracting segment rather than directly shortening the timing in lateral wall. This could be explained by the increased wall stress on the septum as it contracts simultaneously with the opposing LV free wall. Figure. Change in Regional Timing in Strain and Peak Velocity

ICD Characteristics and Survival in Young PatientsIntroductionIndications for implantable cardioverter defibrillators (ICDs) in young patients have expanded and differ from those in older adults. We sought to provide descriptive characteristics and data regarding ICD therapy and outcomes among younger and older ICD recipients.Methods and ResultsDemographics, device type and programming, remotely transmitted data, shock events, and survival were compared among younger (≤30 years) and older (>30 years) cohorts with ICDs from a single manufacturer followed on a remote network. The younger cohort included 904 patients (1.6% of all implants). This group had more females (46% vs. 25%; P < 0.01), single‐coil leads (21% vs. 4%; P < 0.01), and single‐chamber devices (46% vs. 34%; P < 0.01). Shock incidence was higher (40% younger vs. 32% older at 4 years; P < 0.01) and survival was better over comparable follow‐up (88% vs. 72%; P < 0.01). Remote monitoring was associated with improved survival in both groups (93% vs. 86% ≤ 30 years, P < 0.01; 73% vs. 66% > 30 years, P < 0.01). Shock for polymorphic ventricular tachycardia/fibrillation (VT/VF) was more frequent in younger patients (12% vs. 5%; P < 0.01); 39% of all shocks were inappropriate. A 10‐fold increased risk of mortality was seen among young patients with shocks for atrial fibrillation/flutter (AF/AFL).ConclusionsDifferences in survival, shock incidence, and prognostic significance of VT/VF and AF/AFL exist between younger and older ICD recipients. These suggest distinct differences in myocardial substrates and diseases that ultimately impact ICD management.

IntroductionAdjudication of thousands of implantable cardioverter defibrillator (ICD)‐treated arrhythmia episodes is labor intensive and, as a result, is most often left undone. The objective of this study was to evaluate an automatic classification algorithm for adjudication of ICD‐treated arrhythmia episodes.MethodsThe algorithm uses a machine learning algorithm and was developed using 776 arrhythmia episodes. The algorithm was validated on 131 dual‐chamber ICD shock episodes from 127 patients adjudicated by seven electrophysiologists (EPs). Episodes were classified by panel consensus as ventricular tachycardia/ventricular fibrillation (VT/VF) or non‐VT/VF, with the resulting classifications used as the reference. Subsequently, each episode electrogram (EGM) data was randomly assigned to three EPs without the atrial lead information, and to three EPs with the atrial lead information. Those episodes were also classified by the automatic algorithm with and without atrial information. Agreement with the reference was compared between the three EPs consensus group and the algorithm.ResultsThe overall agreement with the reference was similar between three‐EP consensus and the algorithm for both with atrial EGM (94% vs 95%, P = 0.87) and without atrial EGM (90% vs 91%, P = 0.91). The odds of accurate adjudication, after adjusting for covariates, did not significantly differ between the algorithm and EP consensus (odds ratio 1.02, 95% confidence interval: 0.97–1.06).ConclusionsThis algorithm performs at a level comparable to an EP panel in the adjudication of arrhythmia episodes treated by both dual‐ and single‐chamber ICDs. This type of algorithm has the potential for automated analysis of clinical ICD episodes, and adjudication of EGMs for research studies and quality analyses.

Introduction Pulmonary vein isolation is an effective therapy for curing symptomatic atrial fibrillation (AF). While it is known the severity of left atrial (LA) enlargement affect the success of AF ablation, little is known the impact of intracardiac pressure on the ablation outcome. Methods This prospective study consisted of 63 patients (mean age 57±9 years, 73% male) who underwent catheter-based pulmonary vein isolation for drug refractor symptomatic AF (48% paroxysmal, 52% persistent). All patients underwent simultaneous echocardiography and haemodynamic measurements including left ventricular end systolic pressure (LVEDP), mean left atrial pressure (LAP) and dP/dtmax using Millar catheter at the time of procedure during AF. Left atrial volume (LAV) was measure by biplane area length method. Recurrence of AF was defined as episodes of AF more than 5 min documented in 24h ambulatory ECG or event monitor. Results After a mean follow-up duration of 16±7 months, AF elimination off anti-arrhythmic drugs was achieved in 70 % (44/63) of patients. Among the echographic and haemodynamic measurements, the baseline LAV and mean LAP were 57.62±25.39 ml and 12.19±4.57 mm Hg in AF free patients compared to 81.20±40.88 ml (p=0.02) and 16.46±4.14 mm Hg (p=0.01) in AF recurrence groups. Univariate and multivariate analysis showed LAP was the only independent predictor of the recurrence with an adjusted odd ratio of 1.27 (95% CI 1.04 to 1.54, p=0.03, table). Conclusion LAP is a determinant of AF recurrence after AF ablation. Therapies towards reduction of LA filling pressure, especially in patients with elevated LAP, may improve the outcome of ablation. Table Baseline clinical characters in the recurrence group and non-recurrence group Non-recurrence (N=44) recurrence (N=19) Univariate Multivariate P 95% CI P 95% CI Age (ys) 57.39±9.92 59.26±10.47 0.49 0.97, 1.08 – – AF type, persistent AF no. (%) 23 (53%) 10 (50%) 0.97 0.34, 2.98 – – AF duration (ys) 5.84±5.43 8.08±7.66 0.20 0.99, 1.05 – – LA volume (mL) 57.62±25.39 81.20±40.88 0.02 1.01, 1.05 0.30 0.99, 1.05 LVEDP (mm Hg) 10.25±14.54 11.25±5.75 0.81 0.96, 1.06 – – dP/dt max (mm Hg/s) 1294.02±337.13 1211.77±225.36 0.47 0.99, 1.02 – – Mean LAPmean (mm Hg) 12.19±4.57 16.46±4.14 0.01 1.06, 1.50 0.02 1.04, 1.54 Pulmonary vein isolation is an effective therapy for curing symptomatic atrial fibrillation (AF) but the success rate ranged wide. This study aimed to investigate the effect of LAP on AF recurrence.

Introduction Lateral or posteriolateral coronary vein has been considered the optimal location of left ventricular (LV) lead placement for cardiac resynchronisation therapy (CRT). However, the long-term clinical outcomes of CRT based on LV lead location have not been sufficiently addressed. Methods Seven hundred and eighteen CRT-P/CRT-D recipients from Jan 2002 to Dec 2008 were studied. At the CRT implant, the LV lead placement was prioritised as posterolateral/lateral (PL, 50%), anterior lateral (AL, 31%), anterior interventricular (AI, 12%) or middle cardiac veins (MC, 7%). NYHA class and echocardiography were assessed before and after CRT. Clinical outcomes of CRT were compared among 4 LV lead locations. Results Patient baseline demographics, except the gender (P=0.03), were similar among four groups. After CRT, the improvement in NYHA class, LV ejection fraction (EF), and LV diastolic diameter were significantly improved comparably across four LV lead locations (table). The increase in LVEF by >5% were 46%, 47%, 41% and 42% in PL, AL, AI and MC groups (p=0.87). Conclusion The present study suggests that LV lead positioned in the alternative coronary veins, other than posteriolateral or lateral location, achieve comparable benefit in improvement of HF symptoms, and LV function after CRT. Table Comparison of clinic outcomes before and after CRT in different LV lead locations Lateral vein (N=359) Anterolateral vein (N=226) middle cardiac vein (N=49) anterior interventricular vein (N=84) Pre-CRT Post-CRT Pre-CRT Post-CRT Pre-CRT Post-CRT Pre-CRT Post-CRT NYHA 3.02±0.46 2.34±0.81* 2.92±0.53 2.34±0.89* 3.10±0.45 2.70±0.85* 2.98±0.52 2.43±0.86* LVEF (%) 23.57±7.28 30.82±11.67* 24.19±7.96 30.44±12.06* 24.97±7.62 30.72±11.43* 22.45±7.25 28.40±11.73* LVEDD (mm) 65.71±9.12 63.00±9.73* 65.79±8.87 63.88±9.88* 65.39±9.32 62.61±10.25* 68.48±8.92 64.86±9.67* LVESD (mm) 57.91±9.89 52.83±11.68* 56.69±10.23 53.03±12.01* 56.18±11.56 52.24±13.11* 59.09±10.04 55.32±13.30 RVD (mm) 0.90±0.86 0.82±0.85 0.85±0.92 0.82±0.85 0.86±0.83 1.01±0.84 0.56±0.77 0.78±0.91 RV dysfunction 1.05±0.92 0.88±0.92* 1.03±0.93 0.93±0.91 1.06±0.97 1.06±0.90 0.74±0.86 0.79±0.96 MR (m/s) 1.54±0.78 1.30±0.75* 1.57±0.83 1.35±0.75* 1.53±0.71 1.15±0.70* 1.36±0.69 1.19±0.68 * P<0.05 compared to pre-CRT.

BackgroundPatients with preexisting mild cognitive impairment or dementia may be at increased risk for developing cardiac device complications due to an impaired ability to follow postimplant care instructions. We sought to determine whether rates of infection, lead dislodgement, or appropriate or inappropriate implantable cardioverter defibrillator (ICD) shocks are increased in this population.MethodsMedical charts of 561 patients with mild cognitive impairment or dementia who underwent pacemaker (PM) or ICD implantation between January 2002 and October 2009 at Mayo Clinic were identified. A total of 134 patients who were diagnosed with cognitive impairment or dementia before device implantation or within 1 year of implantation were compared with 134 matched controls. Information was collected on patient characteristics, comorbid medical conditions, ejection fraction, complications, device type, device therapy, and mortality. Device information was prospectively entered into a database and retrospectively reviewed.ResultsOf the 134 patients with mild cognitive impairment and dementia, 99 underwent PM implantation and 35 underwent ICD implantation. Compared to controls, there was no difference in patient characteristics, ejection fraction, or comorbidities except for diabetes, which was more prevalent in the cognitively impaired and demented group (18.7% vs 30.6%, P = 0.02). There was no difference in device therapy and complications (14.4% vs 5.8%, P = 0.268). However, there was a decreased survival in patients with cognitive impairment and dementia when compared to the control group (42% vs 67% at 5 years, P = 0.007).ConclusionPatients with cognitive impairment and standard device indications are not at increased risk for device complications and therapy but their survival is much lower than in matched controls. The cause of this lower survival is unknown but may be related to the underlying neurological disease. Presence of cognitive impairment should therefore be considered when contemplating implantation of a cardiac device.

We present the case of a patient who underwent repeated ablations for atrial fibrillation and presented with recurrent dyspnea, elevated left atrial pressure with large V waves in the absence of mitral regurgitation. This case provides an example of “stiff left atrial syndrome” as has been described in patients with mitral valve replacement and only recently in patients with radiofrequency ablations for atrial fibrillation. © 2012 Wiley Periodicals, Inc.

Abstract Aims This study aimed to evaluate the predictive value of a baseline speckle tracking strain rate imaging-derived discoordination index for response to cardiac resynchronization therapy (CRT). Methods and results Ninety-seven patients with QRS ≥120 ms and left ventricular (LV) ejection fraction ≤35% were prospectively followed after CRT in the Mayo CRT Registry. The LV discoordination index (stretch/shortening or thinning/thickening during ejection) was calculated from three types of deformation, radial, circumferential, and longitudinal, using two-dimensional speckle tracking strain rate imaging. The benefit of CRT was evaluated by reverse remodelling (i.e. reduction of LV end-systolic volume ≥15% at 6-month follow-up) and survival. The optimal cut-off value of the baseline discoordination index in discriminating responders from non-responders was determined by receiver operating characteristic curve analysis. Significant differences in baseline indices between responders and non-responders were noted for radial and circumferential discoordination indices. A mid-ventricular radial discoordination index (RDI-M) &gt;38% best predicted responders, especially in patients with ischaemic cardiomyopathy (area under the curve 0.86 for all patients, sensitivity 80%, and specificity 91%). Death occurred in 28 patients over a median follow-up of 3.2 years. When adjusted for confounding variables, lack of significant discoordination (RDI-M &lt;38%) before CRT was associated with a particularly high mortality (hazard ratio 7.05, 95% confidence interval 2.45–26.0). Conclusion LV discoordination assessed by speckle tracking RDI-M imaging was able to predict reverse remodelling at 6 months and survival of patients who received CRT.