P-wave parameters, readily obtainable from standard 12-lead ECGs, have been associated with atrial fibrillation (AF), ischemic stroke, and other cardiovascular conditions. Left atrial cardiomyopathy (AtCM), characterized by atrial fibrosis and functional impairment, is considered a central substrate in the development of AF and embolic stroke of undetermined source. This study examines the relationship between P-wave parameters and left atrial hemodynamics and evaluates their potential diagnostic utility in identifying AtCM.
We conducted a monocentric, prospective study in hospitalized patients. Inclusion criteria were sinus rhythm and age ≥ 18 years. P-wave parameters were assessed in conjunction with echocardiographic measures of left atrial function. Statistical analyses compared patients with and without pathological P-wave parameters.
A total of 416 patients were included. Pathological P-wave parameters were highly prevalent, with 55% of patients exhibiting ≥ 3 abnormalities. Advanced interatrial block (IAB) showed a robust association with impaired left atrial hemodynamics, whereas other parameters, such as PTFV1, demonstrated only weak correlations. Patients with advanced IAB exhibited significant alterations in left atrial size, function, and NT-proBNP levels.
Advanced IAB emerged as the most reliable P-wave parameter for detecting left atrial dysfunction in AtCM, whereas other P-wave indices, including PTFV1, were less informative. These findings highlight the diagnostic value of advanced IAB in identifying AtCM, particularly in patients with embolic stroke of undetermined source, and emphasize the need for more refined diagnostic criteria in future investigations.
Catheter ablation for atrial tachycardia (AT) in Budd-Chiari syndrome (BCS) presents unique challenges due to altered venous anatomy. This case demonstrates an innovative approach to overcome complete inferior vena cava (IVC) occlusion.
A 24-year-old female with BCS underwent catheter ablation via an innovative femoral vein–IVC–azygos–SVC approach, guided by preprocedural CT angiography and 3D electroanatomical mapping.
Successful ablation was achieved at the anterior interatrial septum with no arrhythmia recurrence during the 3-month follow-up.
This case demonstrates the successful use of an IVC-azygos-SVC approach guided by CT angiography and 3D mapping for atrial tachycardia ablation in Budd-Chiari syndrome, offering a viable solution for patients with complex venous obstruction.
Acute occlusive myocardial infarction (OMI) complicated by ventricular pre-excitation can present diagnostic challenges. This case describes a 78-year-old male with an 11-h history of chest tightness. A reduction was observed in the extent of localized ventricular pre-excitation, accompanied by secondary ST–T segment abnormalities in leads V1–V3. Emergency coronary angiography revealed occlusion of the left anterior descending artery. This case highlights that a decrease in the extent of local ventricular pre-excitation in R–wave–dominant leads, combined with inference of the accessory pathway location and its potential correlation with the occluded vessel, may facilitate early identification of OMI.
A 58-year-old man experienced a ventricular fibrillation storm with prominent inferolateral J waves and was diagnosed with early repolarization syndrome. Initial coronary angiography showed no significant stenosis and the other evaluations for ventricular fibrillation were unremarkable. Despite conventional therapy for ventricular fibrillation, it recurred. Isoproterenol infusion suppressed the J wave and successfully mitigated ventricular fibrillation episodes. This case highlights the role of isoproterenol in managing early repolarization syndrome-related ventricular fibrillation storms and the possible pathogenic link between SCN5A mutations and J wave syndromes.
Venous puncture failure during cardiac implantable electronic device (CIED) implantation is a significant procedural challenge, particularly in fasting patients. Pre-procedural intravenous normal saline (NS) infusion may enhance venous filling and improve procedural outcomes, but evidence in this setting is limited.
We conducted a retrospective cohort study at Abbas Institute of Medical Sciences, including 2852 patients undergoing CIED implantation. Patients were divided into two groups: those who received intravenous NS infusion prior to the procedure (n = 1130) and those who did not (n = 1722). Baseline demographics, procedural details, and outcomes—including venous puncture failure, arterial puncture, site change, and acute kidney injury (AKI)—were compared.
The NS group demonstrated a significantly lower rate of venous puncture failure (4.6% vs. 8.9%, p < 0.001) and arterial puncture failure (1.6% vs. 2.8%, p = 0.03). AKI occurred less frequently in the NS group, although this difference was not statistically significant (1.8% vs. 2.6%, p = 0.09). Predictors of venous puncture failure included absence of NS infusion (OR 2.1, 95% CI 1.5–3.0), BMI ≥ 30, and CKD. ROC analysis demonstrated good model discrimination (AUC = 0.81).
Pre-procedural NS infusion significantly improves venous puncture success in fasting patients undergoing CIED implantation.
Temporary pacemaker (TPM) implantation is a critical intervention for managing symptomatic bradyarrhythmias. While infraclavicular access via subclavian or internal jugular veins is commonly used, the supraclavicular approach has emerged as a promising alternative with potential benefits in safety and procedural efficiency. However, data comparing these approaches, particularly in resource-limited settings, remain limited.
We conducted a retrospective observational study at a tertiary care center, evaluating all patients who underwent TPM implantation via either supraclavicular or infraclavicular venous access between January 2020 and December 2024. Baseline characteristics, procedural success, complications, and outcomes were compared. Multivariate logistic regression identified predictors of complications. A ROC curve and Kaplan–Meier analysis were used to evaluate model performance and complication-free survival.
Of 3569 patients, 1644 received supraclavicular access and 1925 received infraclavicular access. The supraclavicular group had a significantly lower overall complication rate (9.3% vs. 14.8%, p < 0.001), including fewer arterial punctures, pneumothoraces, lead dislodgements, and hematomas. First-attempt success (89.4% vs. 83.2%, p < 0.001) and mean procedure time (24.6 ± 7.8 min vs. 29.1 ± 9.4 min, p < 0.001) were also better with supraclavicular access. On multivariate analysis, supraclavicular access was independently associated with fewer complications (adjusted OR 0.59, p < 0.001). Kaplan–Meier analysis showed longer complication-free survival in the supraclavicular group (log-rank p = 0.01).
Supraclavicular venous access for TPM implantation is associated with fewer complications, greater procedural efficiency, and improved patient outcomes compared to infraclavicular access. Wider adoption may improve safety in high-volume or resource-limited settings.
Implantable cardioverter-defibrillators (ICD) are first-line treatment to prevent sudden cardiac death due to recurrent ventricular tachycardia and fibrillation (VT/VF). However, some patients with organic heart disease (OHD) die without ever receiving appropriate ICD therapy. This study aimed to identify predictors of death without appropriate ICD therapy in patients with OHD who received ICD or cardiac resynchronization therapy with a defibrillator (CRT-D) for secondary prevention.
We analyzed consecutive patients who received ICD/CRT-D for secondary prevention between 2000 and 2022. Patients without OHD or those alive without appropriate ICD therapy were excluded. The “no-benefit group” included patients who died or developed severe disability without appropriate ICD therapy or those who died within 1 year after their first appropriate therapy. The “benefit group” included patients who survived > 1 year after appropriate therapy. Clinical characteristics were compared between the groups.
Of the 170 patients analyzed (median follow-up: 9.1 years), 43 (25%) were classified into the no-benefit group (30 died without appropriate therapy, 10 died within 1 year of first appropriate therapy, and 3 developed severe disability without appropriate therapy). Multivariate analyses identified age > 70 years and history of VF as independent predictors of “no benefit.” Among patients with VF aged ≥ 70 years, 71% were classified into the no-benefit group.
Although 75% of patients benefited from ICD therapy for secondary prevention, elderly patients with VF may gain limited benefits from ICD implantation.
Asynchronous pacing itself does not directly lead to the development of malignant ventricular arrhythmias. However, acute myocardial ischemia caused by acute reduction in coronary blood flow can result in a “vulnerable myocardium” and simultaneously impair pacemaker sensing function. Such a scenario may give rise to unintended asynchronous pacing, which can act as a trigger for malignant ventricular arrhythmias. We present a case illustrating how ischemia-induced pacemaker sensing failure contributed to life-threatening ventricular arrhythmias, highlighting the critical interplay between myocardial perfusion status and pacemaker behavior.
Ajmaline challenge (AC) is used for diagnosing suspected Brugada syndrome (BS) in patients with unexplained syncope, survived cardiac arrest, or for family screening.
To evaluate baseline ECG markers predicting a positive AC in the absence of a spontaneous diagnostic Brugada ECG.
Baseline ECGs of 221 consecutive patients undergoing AC (up to 1 mg/kg bodyweight) were analyzed. ECGs from positive and negative tests were compared, with Q-, R-, S-, J-, and T-wave amplitudes and intervals measured in all 12 leads.
221 patients underwent AC; the cohort was 71% male, and 7% had survived cardiac arrest. AC was positive in 93 patients (42%). Prominent S-waves in lead II and J-waves in V1 predicted a positive AC (S-wave duration: 36 vs. 22 ms, p < 0.01; J-wave amplitude V1: 0.06 vs. 0.01 mV, p < 0.001). ROC analysis confirmed discriminative value for S-wave duration in lead II (AUC 0.79) and J-wave amplitude in V1 (AUC 0.71). A cut off of ≥ 19 ms for S-wave duration in lead II showed 96% sensitivity for a positive test (OR 17.3, p < 0.001). J-wave amplitude in V1 ≥ 0.05 mV was also significantly associated (OR 5.4, p < 0.001).
In patients without a spontaneous diagnostic Brugada ECG, prominent S-waves in lead II and J-waves in V1 are subtle electrical abnormalities that help identify patients and family members with a higher likelihood of positive AC.
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