Hodge, David O.

Précis: Multiple systemic vascular-associated conditions including systemic hypertension and hypotension, diabetes mellitus, migraine headache, peripheral vascular disease, Raynaud syndrome, and anemia were associated with low-tension glaucoma. Purpose: The purpose of this study was to identify systemic risk factors associated with low-tension glaucoma. Patients and Methods: A retrospective case-control study design was employed to identify patients seen at the Mayo Clinic Department of Ophthalmology between 2005 and 2015 with low-tension glaucoma and an age-matched and sex-matched control group, each containing 277 patients. Results: The low-tension glaucoma group had more myopic refractive errors (−1.6 vs. −1.0 D, P <0.001), lower intraocular pressure (14.2 vs. 15.2 mm Hg, P <0.001), and a higher cup-to-disc ratio (0.7 vs. 0.3, P <0.001). The low-tension glaucoma group was significantly less likely to be obese (body mass index >30, P =0.03). This group had a significantly higher prevalence of systemic hypertension [odds ratio (OR): 1.64, P =0.004], diabetes mellitus (OR: 3.01, P <0.001), peripheral vascular disease (OR: 2.61, P =0.009), migraine headache (OR: 2.12, P =0.02), anemia (OR: 2.18, P =0.003), systemic hypotension (OR: 4.43, P <0.001), Raynaud syndrome (OR: 3.09, P =0.05), and angiotensin-converting enzyme inhibitor (OR: 1.64, P =0.01) or calcium channel blocker use (OR: 1.98, P =0.004). After adjusting for systemic hypertension, calcium channel blocker use remained significant (OR: 1.70, P =0.03). No significant difference was found between groups with respect to hyperlipidemia, obstructive sleep apnea, coronary artery disease, carotid stenosis, stroke, or statin, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, beta-blocker, or metformin use. Conclusions: Multiple vascular-associated conditions were associated with low-tension glaucoma including systemic hypertension, diabetes mellitus, peripheral vascular disease, migraine headache, Raynaud syndrome, anemia, systemic hypotension, and calcium channel blocker use. This study strengthens the evidence for the vascular hypothesis of low-tension glaucoma.

Purpose: The purpose of this study is to quantify cancer risk in patients with Fuchs endothelial corneal dystrophy (FECD). Methods: Using the 2014 to 2016 Medicare Limited 5% Data Sets—Carrier Line File, US Medicare fee-for-service beneficiaries (aged 65 years or older) with FECD and cancer were identified through International Classification of Diseases, ninth and 10th Revision diagnostic codes from January 1, 2014, to December 31, 2016. The main outcome measures were odds ratios (ORs) of cancer at various anatomic locations in patients with versus without FECD. Results: Of the 1,462,740 Medicare beneficiaries, 15,534 patients (1.1%) had an International Classification of Disease code for FECD. Compared with US Medicare beneficiaries without FECD, patients with FECD were at increased risk for the following malignancies: breast [OR: 1.32; 95% confidence interval (CI): 1.22–1.43; P < 0.001], cutaneous basal cell (OR: 1.42; 95% CI: 1.35–1.49; P < 0.001), cutaneous melanoma (OR: 1.20; 95% CI: 1.03–1.40; P = 0.02), cutaneous squamous cell (OR: 1.45; 95% CI: 1.38–1.53; P < 0.001), ovarian (OR: 1.84; 95% CI: 1.48–2.30; P < 0.001), and thyroid (OR: 1.32; 95% CI: 1.04–1.68; P = 0.02). By contrast, FECD cases were at lower odds of having lung (OR: 0.81; 95% CI: 0.71–0.93; P = 0.003) and prostate cancer diagnoses (OR: 0.88; 95% CI: 0.81–0.96; P = 0.002). Conclusions: Patients with FECD aged 65 years or older may be at increased risk for cancer at several anatomic locations. Follow-up studies are needed to further explore the association of FECD and malignancy, elucidate potential disease mechanisms, and identify genetic and/or environmental risk factors.

AbstractBackgroundAutomated wide complex tachycardia (WCT) differentiation into ventricular tachycardia (VT) and supraventricular wide complex tachycardia (SWCT) may be accomplished using novel calculations that quantify the extent of mean electrical vector changes between the WCT and baseline electrocardiogram (ECG). At present, it is unknown whether quantifying mean electrical vector changes within three orthogonal vectorcardiogram (VCG) leads (X, Y, and Z leads) can improve automated VT and SWCT classification.MethodsA derivation cohort of paired WCT and baseline ECGs was used to derive five logistic regression models: (i) one novel WCT differentiation model (i.e., VCG Model), (ii) three previously developed WCT differentiation models (i.e., WCT Formula, VT Prediction Model, and WCT Formula II), and (iii) one “all‐inclusive” model (i.e., Hybrid Model). A separate validation cohort of paired WCT and baseline ECGs was used to trial and compare each model's performance.ResultsThe VCG Model, composed of WCT QRS duration, baseline QRS duration, absolute change in QRS duration, X‐lead QRS amplitude change, Y‐lead QRS amplitude change, and Z‐lead QRS amplitude change, demonstrated effective WCT differentiation (area under the curve [AUC] 0.94) for the derivation cohort. For the validation cohort, the diagnostic performance of the VCG Model (AUC 0.94) was similar to that achieved by the WCT Formula (AUC 0.95), VT Prediction Model (AUC 0.91), WCT Formula II (AUC 0.94), and Hybrid Model (AUC 0.95).ConclusionCustom calculations derived from mathematically synthesized VCG signals may be used to formulate an effective means to differentiate WCTs automatically.

Introduction: Right ventricular apical (RVA) pacing appears to have detrimental effects on cardiac function and long term outcomes. Right ventricular non-apical (RVNA) pacing, especially in the septal position, has been postulated as an alternative that may lead to less morbidity and mortality. Prior studies have shown conflicting results and been limited by small numbers and short follow-up. We aimed to determine if right ventricular septal lead position was associated with a reduction in long-term mortality compared to RVA lead position. Methods: Patients who underwent dual-chamber pacemaker implantation from 2004 through 2013 were evaluated for right ventricular lead position based on chest radiographs. Lead positions were divided in to apical or non-apical. Non-apical lead positions were subdivided to isolate a septal lead position group. Mortality was compared between these groups. Results: During the study period, 3456 patients underwent dual-chamber pacemaker placement and had images appropriate for lead position evaluation. The group was 53.5% male with a mean age of 74 ± 13 years. RVNA lead position was found in 976 (28.2%) patients, including 243 (7.0%) with a septal position. There was no significant difference in age or prior heart failure diagnosis between groups. Kaplan-Meier survival analysis did not reveal a significant difference in mortality between patients with RVA versus RVNA lead position during 5 year follow-up (p = 0.82). However, septal lead position was associated with a significantly lower mortality compared with RVA position (p = 0.03) (figure). Conclusions: Right ventricular septal lead position is associated with a lower long-term mortality than RVA lead position. This has substantial implications regarding the preferred site for ventricular pacing lead placement.

Introduction: Percutaneous epicardial access (EAc) is increasingly performed as part of VT/PVC ablation, especially in those that have failed prior ablation. We aimed to delineate the outcomes of EAc. Methods: We retrospectively analyzed individuals undergoing EAc for arrhythmia ablation between June 2004 and July 2014. Acute procedural success was defined as elimination/non-inducibility of the clinical arrhythmia after ablation; clinical success was defined as absence of symptoms/arrhythmia. Results: Of 175 patients, 126 (72%) were male with a mean age of 52.8±15.7 years. Eighty-three (47.4%) patients had NICM, 25 (14.3%) had ICM and 34 (19.4%) had normal hearts. Baseline EF was 44±16%. Patients had failed an average of 1.7±1.2 antiarrhythmic drugs; 139 patients (79%) had failed prior endocardial (endo) ablation (average 1.3±1.1). Six (3.4%) had prior EAc and 18 (10.3%) prior cardiac surgery. The indication for ablation was VT or PVC in 113 (64.6%) and 60 (34.3%) patients, respectively. Successful access was obtained in 168 (98%) patients. Anterior access, inferior access, or both, was utilized in 89 (52.7%), 77 (45.6%) and 2 (1.2%) patients, respectively. There were an average of 2.7±2.2 VT/PVCs identified, and 1.6±1.1 ablated. Endo, epicardial (epi) or combined ablation was performed in 58 (33.1%), 14 (8%), and 100 (57.1%) patients, respectively; 3 did not undergo ablation. Procedural success was obtained in 158 of 173 (91.3%) patients for whom data was available. At 12 months, clinical success was maintained in 62% with no difference between endo, epi or combined ablation (figure). Cardiac tamponade requiring repeat EAc occurred in 12 (6.9%) patients. There were no procedural related deaths. Conclusion: Epicardial access is feasible in almost all patients with no prior cardiac surgery, and permits acute procedural success in 91.3% of patients, most of whom had failed previous ablation. Furthermore, complications are relatively infrequent in this complex cohort.

Introduction: Patients with congenital heart disease (CHD) frequently require implantable cardiac devices. Device infection or malfunction may necessitate lead extraction. Extraction may be challenging due to long lead dwell times, anatomic abnormalities, and prior cardiac surgery. Little is known about extraction outcomes in the CHD population. Methods and Results: This retrospective study included 41 CHD patients and 82 age and gender matched controls that underwent lead extractions at two centers between 2001-2014. Only patients with leads older than 12 months were included. There were 79 leads in CHD patients and 150 in controls. Patients with CHD had a mean age of 39±17 years at extraction and on average their leads had been implanted for 81±84 months, this was not significantly different from the control group. Eighty eight percent of CHD patients had 1 or more cardiac surgeries as compared to only 22% of controls (p<0.001). The number of abandoned leads was also significantly different with 16 abandoned leads in the CHD group and 3 in controls (p<0.001). There was no statistically significant difference in extraction techniques between the groups. Complete extraction was achieved in 94% of patients in both groups. There were no CHD group complications. Control group complications included 3 SVC lacerations requiring sternotomy (one was fatal), and 1 ventricular perforations with tamponade requiring sternotomy. None of these patients had a history of cardiac surgery. The average age of leads in patients with a complication was 15.3 years which was older than the mean lead age seen in the CHD and control populations which was 6.75 and 4.6 years respectively. Conclusions: Lead extraction can be safely performed in patients with CHD. Despite anatomic abnormalities and previous cardiac surgery, the outcome of lead extraction in patients with CHD is comparable to controls. Prior cardiac surgery may lower the risk for extraction complications.