Pulmonary vein isolation (PVI) is a cornerstone therapy for paroxysmal atrial fibrillation (PAF). The variations in nonlinear heart rate variability (HRV) between patients with and without recurrences remain unclear. We aimed to characterize the nonlinear HRV before and after PVI in patients with and without recurrence.
Twenty-five drug-refractory PAF patients (56.0 ± 9.1 years old, 20 males) who received PVI were enrolled. Holter electrocardiography were performed before, 1–3, and 6–12 months after PVI. After 8.2 ± 2.5 months of follow-ups after PVI, patients were divided into two groups: the recurrence (n = 8) and non-recurrence (n = 17) groups. Linear and nonlinear HRV variables were analyzed, including the Poincaré Plot analysis and the Detrended Fluctuation Analysis (DFA).
The non-recurrence group, but not the recurrence group, had decreased high-frequency component (HF), the root mean square of successive RR interval differences (RMSSD), and the Poincaré Plot index SD1 1–3 months after PVI and increased DFAslope2 6–12 months after PVI. The non-recurrence group's LF/HF ratio and DFAslope1 decreased significantly 1–3 and 6–12 months after PVI, respectively, whereas there was no significant change in the recurrence group after PVI.
Significantly reduced vagal tone 1–3 months after PVI, increased long-term fractal complexity 6–12 months after PVI, and decreased sympathetic tone as well as short-term fractal complexity 1–3 and 6–12 months after PVI led to a better AF-free survival after PVI. These findings suggest that neuromodulation and heart rate dynamics play crucial roles in AF recurrence following PVI.
The aim of the study was to assess the efficacy of cardiac resynchronization therapy (CRT) in patients with chemotherapy-induced cardiomyopathy (CIC).
With the increasing incidence of CIC, the association of CRT with improvement in clinical outcomes, echocardiographic parameters, and New York Heart Classification (NYHA) class was assessed through this qualitative systematic review.
The five studies included a total of 169 patients who underwent CRT after CIC, and of these, 61 (36.1%) patients were males. All studies showed an improvement in left ventricular ejection fraction (LVEF), among other echocardiographic parameters of LV volume. However, these findings are limited by short follow-up periods, small sample sizes, and the absence of a control group.
CRT was associated with improvement in all patient parameters with CIC.
To study the safety and electrical characteristics of various implanting sites of the Micra pacemaker.
A total of 15 patients from Beijing Anzhen Hospital, Capital Medical University, were included, who were implanted with Micra leadless pacemakers and allocated to either the high ventricular septum group (eight patients) or the low ventricular septum group (seven patients) based on their individual patient factors and clinical conditions. The baseline of the patients, the implanting area, the electrocardiogram change after implantation, the implantation data, the threshold, R wave, impedance, and the date of the 1-month follow-up were then analyzed. With all of the data, the characteristics of different implantation sites of the Micra pacemaker were determined.
Overall, the thresholds were low at implantation and remained stable over the 1-, 3-, 6-month, 1-, 2-, 3-, and 4-year follow-ups. On comparing the two groups, there was no difference in QRS duration at pacing (140.00 [40.00] ms vs. 179.00 [50.00] ms), threshold at implantation (0.38 [0.22] mV vs. 0.63 [1.00] mV), R wave at implantation ([10.85 ± 4.71] V vs. [7.26 ± 2.98] V), or impedance at implantation ([906.25 ± 162.39] Ω vs. [750.00 ± 173.40] Ω). While the difference in QRS duration between the two groups was not significant, the QRS duration of the high ventricular septum group exhibited a reduced tendency compared with that of the low ventricular group. The corrected QT interval during pacing exhibited a significant difference (440.00 [80.00] ms vs. 520.00 [100.00] ms; p < .05). For the 1-, 3-, 6-month, 1-, 2-, 3-, and 4-year follow-ups, there was no difference between the threshold of the high ventricular septum group and that of the low ventricular septum group (p > .05).
High ventricular septum pacing appears to be a safe site for implantation of the Micra pacemaker. It could entail a shorter QRS duration at pacing and could be more physiological than low ventricular septum pacing.
Premature ventricular contractions (PVCs) are a common form of arrhythmia associated with an unfavorable prognosis in patients with structural heart disease. It is unclear whether PVCs site of origin and QRS-width has a prognostic significance in patients without structural heart disease. The aim of this study was to assess the prognostic importance of PVCs morphology and duration in this patient group.
We included 511 consecutive patients without a history of previous heart disease. They were examined with echocardiography and exercise test with normal findings. We categorized the PVCs from a 12 lead ECG according to morphology and width of the QRS-complex and analyzed the outcome in terms of a composite endpoint of total mortality and cardiovascular morbidity.
During a median follow-up time of 5.3 years, 19 patients (3.5%) died and 61 (11.3%) met the composite outcome. Patients with PVCs originating from the outflow tracts had a significantly lower risk for the composite outcome compared to patients with non-OT-PVCs. Similarly, patients with PVC originating from the right ventricle had a better outcome than patients with left ventricular PCVs. No difference in outcome depending on QRS-width during PVCs was noticed.
In our cohort of consecutively included PVC patients without structural heart disease PVCs from the outflow tracts were associated with a better prognostic outcome than non-OT PVCs; the same was true for right ventricular PVCs when compared to left ventricular ones. The classification of the origin of the PVCs was based on 12-lead ECG morphology. QRS-width during PVC did not seem to have prognostic significance.
There is ongoing controversy regarding the prognostic value of PR prolongation among individuals free of cardiovascular diseases. It is necessary to risk-stratify this population according to other electrocardiographic parameters.
This study is based on the Third National Health and Nutrition Examination Survey. Cox proportional hazard models were constructed and Kaplan–Meier method was used.
A total of 6188 participants (58.1 ± 13.1 years; 55% women) were included. The median frontal QRS axis of the entire study population was 37° (IQR: 11–60°). PR prolongation was present in 7.6% of the participants, of whom 61.2% had QRS axis ≤37°. In a multivariable-adjusted model, mortality risk was highest in the group with concomitant prolonged PR interval and QRS axis ≤37° (hazard ratio [HR]: 1.20; 95% confidence interval [CI]: 1.04–1.39). In models with similar adjustment where population were reclassified depending on PR prolongation and QRS axis, prolonged PR interval and QRS axis ≤37° was still associated with increased risk of mortality (HR: 1.18; 95% CI: 1.03–1.36) compared with normal PR interval.
QRS axis is an important factor for risk stratification in population with PR prolongation. The extent to which this population with PR prolongation and QRS axis ≤37° is at higher risk of death compared with the population without PR prolongation.
Left ventricular (LV) lead position may be an important factor for delivering effective cardiac resynchronization therapy (CRT). We therefore aimed to evaluate the effects of LV lead position, stratified by native QRS morphology, regarding the clinical outcome.
A total of 1295 CRT-implanted patients were retrospectively evaluated. LV lead position was classified as lateral, anterior, inferior, or apical, and was determined using the left and right anterior oblique X-ray views. Kaplan Meier and Cox regression were performed to evaluate the effects on all-cause mortality and heart failure hospitalization, and the potential interaction between LV lead position and native ECG morphologies.
A total of 1295 patients were included. Patients were aged 69 ± 7 years, 20% were female, 46% received a CRT-Pacemaker (vs. CRT-Defibrillator), mean LVEF was 25% ± 7%, and median follow-up was 3.3 years [IQR 1.6–5–7 years]. Eight hundred and eighty-two patients (68%) had a lateral LV lead location, 207 (16%) anterior, 155 (12%) apical, and 51 (4%) inferior. Patients with lateral LV lead position had larger QRS reduction (−13 ± 27 ms vs. −3 ± 24 ms, p < .001). Non-lateral lead location was associated with a higher risk for all-cause mortality (HR 1.34 [1.09–1.67], p = .007) and heart failure hospitalization (HR 1.25 [1.03–1.52], p = .03). This association was strongest for patients with native left or right bundle branch block, and not significant for patients with prior paced QRS or nonspecific intraventricular conduction delay.
In patients treated with CRT, non-lateral LV lead positions (including apical, anterior, and inferior positions) were associated with worse clinical outcome and less reduction of QRS duration. This association was strongest for patients with native LBBB or RBBB.
In this issue of the Annals, ISHNE members Professors Bayes de Luna and Bacharova substantially contribute to our understanding of atrial pathology as revealed in the electrocardiographic P wave. In so doing, the extend the work that Professor Bayes de Luna began nearly 40 years ago.
In this remarkable paper, they taxonomize the three patterns of typical advanced inter-atrial block (A-IAB), as well as describe atypical patterns (i.e. with P wave durations less than 120 ms but positive–negative polarity in the inferior leads), explain the differentiation between A-IAB and atrial enlargement, and make the case that A-IAB may be as important a predictor of future stroke as atrial fibrillation.
For those unfamiliar with the phenomenon that has been dubbed “Bayes Syndrome” (the Professor modestly avoids this eponym), this paper is the perfect introduction.
In other important developments at Annals, we have added two important individuals to our masthead.
Professor Linda Johnson, MD, PhD Associate Professor, Cardiovascular Epidemiology, Lund University has joined us in the role of Associate Editor. Her work combines a profound understanding of cardiovascular epidemiology with an interest in ambulatory ECG monitoring for assessment of atrial fibrillation risk and autonomic dysfunction. I am very grateful that she has accepted our invitation and look to encourage submissions in her areas of expertise.
In a first for the Annals, we welcome our new Social Media Editor, Andrés Felipe Miranda-Arboleda, MD. Andres hails from Medellín, Colombia, but is currently finishing his electrophysiology fellowship at Queen's University, Kingston, Ontario. Please be sure to look out for his posts on Twitter, WeChat, and other platforms to keep you informed about important new Annals publications as well as throw-backs to classic papers that have stood the test of time.
Welcome aboard, Linda and Andres!
Ivabradine reduces the heart rate by selectively inhibiting the If current of the sinoatrial node, mainly for the treatment of chronic heart failure with decreased left ventricular systolic function and inappropriate sinus tachycardia, but the inhibitory effect on the atrioventricular node is rarely reported. The patient was admitted to hospital mainly because of intermittent chest pain for 7 years, which worsened for 10 days. Admission electrocardiogram (ECG) considered sinus tachycardia, with QS wave and T wave inversion in II, III, aVF, V3R-V5R, V4–V9 leads, and non-paroxysmal junctional tachycardia (NPJT) with interference atrioventricular dissociation. After treatment with ivabradine the ECG returned to normal conduction sequence. NPJT with interference atrioventricular dissociation is a fairly rare electrocardiographic phenomenon. This case reports for the first time that ivabradine is used in the treatment of NPJT with interference atrioventricular dissociation. It is speculated that ivabradine has a potential inhibitory effect on the atrioventricular node.
Wellen's syndrome, a STEMI equivalent, is associated with severe stenosis of the proximal left anterior descending (LAD) in a patient with chest pain who needs emergency coronary angiography with the possibility of intervention. Due to only T wave changes in the electrocardiograph (ECG), Wellen's syndrome was easily ignored. Moreover, it may progress to acute myocardial infarction or even cardiac arrest. Therefore, clinicians should improve their understanding of this ECG pattern and appropriately dilate the coronary angiography indication. In addition, more dangerous narrowing of a coronary artery, as in our case, the left main artery stenosis, should also be considered.
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