2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry.

Sudden cardiac death (SCD) remains a high priority public health problem necessitating a multi-pronged approach for treatment and prevention. Tachyarrhythmic sudden cardiac death (SCD-VT/VF; ie, death attributable to potentially reversible ventricular tachyarrhythmias [ventricular tachycardia (VT) or fibrillation (VF)]), is a major cause of SCD. Accurate assessment of risk for SCD-VT/VF is of critical importance to assist clinical decision-making regarding prescription of preventive therapies that reduce mortality. These therapeutic decisions include adherence to standard medical therapies, often in conjunction with tailored medications, implantable devices, catheter ablation, or heretofore untested treatments, such as spinal cord stimulation.1 In cases in which the therapy is invasive or carries its own risk, such as these latter interventions, each should be based on reliable demonstration of added benefit to the patient.

Pre-emptive risk stratification for SCD-VT/VF has substantial implications to public health for the following reasons: (1) Heart disease remains the number 1 cause of death in the United States, with >600 000 deaths attributable to heart disease annually reported by the National Center for Health Statistics (http://www.cdc.gov/nchs/fastats/deaths.htm); (2) Approximately half of these deaths are estimated to be sudden; (3) Approximately 50% of all SCDs are the first recognized cardiac event; and (4) Only a minority of those who suffer out-of-hospital cardiac arrest will ultimately survive. Although the incidence of VF as a cause of out-of-hospital cardiac arrest is declining, it remains a leading cause.2 The introduction of the implantable cardioverter-defibrillator (ICD)—an effective, but costly therapy—has had meaningful, but limited, population impact on SCD2; thus, there are opportunities for new approaches (Figure) to address SCD. In particular, improved risk stratification techniques that identify individuals at high risk for SCD-VT/VF could have substantial impact,3 saving lives while stewarding medical resources for cases in which they are most effective. Since 2005, annual meetings …

Risk Stratification for Sudden Cardiac Death A Plan for the Future

Ambulatory ECG (AECG) is very commonly employed in a variety of clinical contexts to detect cardiac arrhythmias and/or arrhythmia patterns which are not readily obtained from the standard ECG. Accurate and timely characterization of arrhythmias is crucial to direct therapies that can have an important impact on diagnosis, prognosis or patient symptom status. The rhythm information derived from the large variety of AECG recording systems can often lead to appropriate and patient-specific medical and interventional management. The details in this document provide background and framework from which to apply AECG techniques in clinical practice, as well as clinical research.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/anec.12447

/pdf/erratum-hrs-ehra-expert-consensus-statement-on-the-state-of-1b0h17vl5u.pdf

Erratum: HRS/EHRA expert consensus statement on the state of genetic testing for the channelopathies and cardiomyopathies (Europace (2011) 13 (1077-1109) DOI: 10.1093/europace/eur245)

Objectives

We evaluated immediate and midterm results of transcatheter closure of atrial septal defects (ASDs) and patent foramen ovale (PFO) using various closure devices



Materials and Methods

The study included four hundred fourteen patients (one hundred eighty-two men, two hundred thirty-two women; mean age 39 ± 123 years; range 17–67 years) who underwent transcatheter closure of secundum ASD (n = 193) or PFO (n = 221) All the patients were evaluated by transthoracic echocardiography and transesophageal echocardiography before the procedure Transcatheter closure was performed by using Amplatzer (n = 184), Occlutech Figulla (n = 209), or BioSTAR (n = 21) devices Closure of ASDs was performed under general anesthesia with transesophageal echocardiography guidance, and closure of PFOs was performed under local anesthesia with transthoracic echocardiography guidance Follow-up controls were at 1, 6, and 12 months and annually thereafter The median follow-up periods of ASD and PFO patients were 43 and 30 months



Results

The mean device size was 193 ± 62 mm for ASD patients and 246 ± 26 mm for PFO patients The mean procedural and fluoroscopy times were 223 ± 47 and 41 ± 19 minutes for ASD closure and 124 ± 32 and 31 ± 12 minutes for PFO closure, respectively Procedural device embolization occurred in only two patients (048%) During follow-up, recurrent embolic events occurred in four patients (18%) after PFO closure, and no residual shunts were seen after ASD closure Device thrombosis developed in two ASD patients during the procedure and in one PFO patient at 12th month of the follow-up (072%)



Conclusion

Transcatheter closure of PFOs and secundum-type ASDs using the Amplatzer, Occlutech Figulla, and BioSTAR devices is an efficacious and safe therapeutic option

Transcatheter interatrial septal defect closure in a large cohort: midterm follow-up results.

The clinical goals of risk stratification of sudden death are to identify subjects who are at high risk of, and eventually to reduce the incidence of, sudden death. Numerous studies have described risk stratification techniques for serious cardiac events in patients following myocardial infarction. However, relatively little information is available regarding nonischemic dilated cardiomyopathy. A number of diagnostic methods have been used for risk stratification of patients with nonischemic dilated cardiomyopathy, including presence of syncope, ambulatory electrocardiographic monitoring, programmed ventricular stimulation, QRS duration, QT interval dispersion, QT interval dynamicity, signal-averaged ECG, heart rate variability, heart rate turbulence, baroreflex sensitivity, heart rate recovery, exercise recovery ventricular ectopy, fragmented QRS and cardiac magnetic resonance imaging. In this review, existing data regarding risk stratification of sudden cardiac death in nonischemic dilated cardiomyopathy will be summarized and its implications in clinical practice will be reviewed.

/pdf/risk-stratification-in-nonischemic-dilated-cardiomyopathy-4nhxqjs8ou.pdf

Risk stratification in nonischemic dilated cardiomyopathy: Current perspectives.

Percutaneous closure of an ostium secundum-type atrial septal defect is typically a safe and effective therapeutic option in the presence of significant shunting or paradoxical em -bolism. Infrequently, however, periprocedural sequelae occur.Herein, we report the cases of 2 patients, each of whom underwent transcatheter clo-sure of an atrial septal defect with the use of an Amplatzer Septal Occluder under trans- esophageal echocardiographic guidance. In both patients, acute thrombi formed peripro-cedurally, despite preprocedural anticoagulation. In patient 1, the infusion of unfractionated heparin for 24 hours prevented the recurrence of thrombus; in patient 2, the thrombus was isolated under the arm of the occluder, and unfractionated heparin was infused. Both patients were asymptomatic and without detectable thrombus after the procedure and at follow-up. These reports highlight a rare early sequela and the importance of transesopha -geal echocardiographic monitoring during the percutaneous closure of an atrial septal de-fect.

Thrombus Formation during Percutaneous Closure of an Atrial Septal Defect

Hypertrophic cardiomyopathy (HCM) is defined as myocardial hypertrophy in the absence of another cardiac or systemic disease capable of producing the magnitude of present hypertrophy. In about 70% of patients with HCM, there is left ventricular outflow tract (LVOT) obstruction (LVOTO) and this is known as obstructive type of hypertrophic cardiomyopathy (HOCM). Cases refractory to medical treatment have had two options either surgical septal myectomy or alcohol septal ablation (ASA) to alleviate LVOT gradient. ASA may cause some life-threatening complications including conduction disturbances and complete heart block, hemodynamic compromise, ventricular arrhythmias, distant and massive myocardial necrosis. Glue septal ablation (GSA) is a promising technique for the treatment of HOCM. Glue seems to be superior to alcohol due to some intrinsic advantageous properties of glue such as immediate polymerization which prevents the leak into the left anterior descending coronary artery and it is particularly useful in patients with collaterals to the right coronary artery in whom alcohol ablation is contraindicated. In our experience, GSA is effective and also a safe technique without significant complications. GSA decreases LVOT gradient immediately after the procedure and this reduction persists during 12 months of follow-up. It improves New York Heart Association functional capacity and decrease interventricular septal wall thickness. Further studies are needed in order to assess the long-term efficacy and safety of this technique.

https://journals.sagepub.com/doi/pdf/10.1177/2048004016636313

Glue septal ablation: A promising alternative to alcohol septal ablation:

Dear Editor, We would like to thank the authors for the letter regarding with our manuscript entitled ‘‘P-wave dispersion: What we know till now?’’ previously published in your distinguished journal. In that paper, we summarized the measurement methods, current use in different clinical situations, strengths and limitations of the of P-wave dispersion (Pd). Pd is a non-invasive electrocardiographic (ECG) marker for atrial remodeling and predictor for atrial fibrillation (AF). Pd is simply calculated as the difference between the widest and the narrowest P-wave duration recorded from the 12-lead ECG. In the letter entitled ‘‘The role of P wave dispersion in Dystrophic and Thalassemic Cardiomyopathy,’’ the authors shared their notable experiences with Pd in different clinical situations. Among these studies, Russo et al. evaluated Pd in beta Thalassemia major (b-TM) patients with preserved systolic and diastolic functions. Pd was measured from 12-lead ECG. Cardiac iron levels were measured by cardiac magnetic resonance T2 star (CMR T2*) imaging. This study showed a significant increase of Pd in b-TM patients with conserved systolic and diastolic cardiac functions. Furthermore, there was a significant correlation between Pd and CMR T2* values. In another study, Russo et al. investigated the role of maximum P-wave duration (P max) and Pd, calculated through a manually performed measurement with the use of computer software from all 12-lead ECG, as predictors of AF in b-TM patients during one-year follow-up. In this study, b-TM patients presented increased P-max and Pd. A cut-off value of 35.5ms for PD had a sensitivity of 90% and a specificity of 85% in identifying b-TM patients at risk for AF. Paroxysmal AF frequently occurs in Emery-Dreifuss muscular dystrophy (EDMD). Russo et al. evaluated the P-wave duration and Pd in patients with EDMD with preserved systolic and diastolic cardiac function. P-wave dispersion measured by using 12-lead ECG. There was a significant increase of maximum P-wave duration and Pd in patients with EDMD. In another study, Russo et al. disclosed that myotonic dystrophy type 1 (MD1) patients had higher maximum P-wave duration and Pd, compared to ageand sex-matched healthy controls. P max and Pd were higher in MD1 patients subgroup with AF compared to MD1 patients without arrhythmia. These studies, as summarized above, are examples for the expanding use of Pd in various clinical situations. Increased P-wave duration and Pd reflect prolongation of intraatrial and interatrial conduction time with lack of a well-coordinated conduction system within the atrial muscles. Despite different clinical situations can alter Pd, main mechanistic logic behind them were similar. Increased Pd reflects inhomogeneous, asynchronic and discontinuous propagation of sinus impulses mainly between the left and right atria, interstitial/extracellular fibroblast activation and collagen deposition with fibrosis in atrial tissue, insufficient blood supply, significant not isotropic myoelectric activity, and thin wall thickness and consequent expansion tendency all well-known electrophysiological characteristics in patients with atrial arrhythmias and especially paroxysmal AF. As a conclusion, Pd has been applied in a wide range of clinical conditions. P-wave duration and Pd reflect prolongation of intraatrial and interatrial conduction time and the inhomogeneous propagation of sinus impulses which are well-known electrophysiologic characteristics in patients with atrial arrhythmias and especially paroxysmal AF. Pd has been used in the assessment of the risk for AF in patients without apparent heart disease, coronary artery disease, hypertension, valvular heart diseases, heart failure, congenital heart diseases, rheumatologic diseases and various clinical conditions with expanding list. Prediction of the AF

P-wave dispersion in different clinical situations: Expanding list with resembling mechanisms.

Interpreting ECGs in Clinical Practice

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