Critical arrhythmia in postoperative cardiac children: Recognition and management.
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ABSTRACT:
SUBMITTER: Kabbani MS
PROVIDER: S-EPMC5525472 | biostudies-other | 2017 Jul-Sep
REPOSITORIES: biostudies-other
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Project description:Cardiovascular diseases i are the most common cause of loss of flying licence globally, and cardiac arrhythmia is the main disqualifier in a substantial proportion of aircrew. Aircrew ii often operate within a demanding physiological environment, that potentially includes exposure to sustained acceleration (usually resulting in a positive gravitational force, from head to feet (+Gz)) in high performance aircraft. Aeromedical assessment is complicated further when trying to discriminate between benign and potentially significant rhythm abnormalities in aircrew, many of whom are young and fit, have a resultant high vagal tone, and among whom underlying cardiac disease has a low prevalence. In cases where a significant underlying aetiology is plausible, extensive investigation is often required and where appropriate should include review by an electrophysiologist. The decision regarding restriction of flying activity will be dependent on several factors including the underlying arrhythmia, associated pathology, risk of incapacitation and/or distraction, the type of aircraft operated, and the specific flight or mission criticality of the role performed by the individual aircrew.
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Project description:Background: Hypothyroidism, the most common endocrine disease, induces cardiac electrical remodeling that creates a substrate for ventricular arrhythmias. Recent studies report that high thyrotropin (TSH) levels are related to cardiac electrical abnormalities and increased mortality rates. The aim of the present work was to investigate the direct effects of TSH on the heart and its possible causative role in the increased incidence of arrhythmia in hypothyroidism. Methods: A new rat model of central hypothyroidism (low TSH levels) was created and characterized together with the classical propylthiouracil-induced primary hypothyroidism model (high TSH levels). Electrocardiograms were recorded in vivo, and ionic currents were recorded from isolated ventricular myocytes in vitro by the patch-clamp technique. Protein and mRNA were measured by Western blot and quantitative reverse transcription polymerase chain reaction in rat and human cardiac myocytes. Adult human action potentials were simulated in silico to incorporate the experimentally observed changes. Results: Both primary and central hypothyroidism models increased the L-type Ca2+ current (ICa-L) and decreased the ultra-rapid delayed rectifier K+ current (IKur) densities. However, only primary but not central hypothyroidism showed electrocardiographic repolarization abnormalities and increased ventricular arrhythmia incidence during caffeine/dobutamine challenge. These changes were paralleled by a decrease in the density of the transient outward K+ current (Ito) in cardiomyocytes from animals with primary but not central hypothyroidism. In vitro treatment with TSH for 24 hours enhanced isoproterenol-induced spontaneous activity in control ventricular cells and diminished Ito density in cardiomyocytes from control and central but not primary hypothyroidism animals. In human myocytes, TSH decreased the expression of KCND3 and KCNQ1, Ito, and the delayed rectifier K+ current (IKs) encoding proteins in a protein kinase A-dependent way. Transposing the changes produced by hypothyroidism and TSH to a computer model of human ventricular action potential resulted in enhanced occurrence of early afterdepolarizations and arrhythmia mostly in primary hypothyroidism, especially under β-adrenergic stimulation. Conclusions: The results suggest that suppression of repolarizing K+ currents by TSH underlies most of the electrical remodeling observed in hypothyroidism. This work demonstrates that the activation of the TSH-receptor/protein kinase A pathway in the heart is responsible for the cardiac electrical remodeling and arrhythmia generation seen in hypothyroidism.
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Project description:Background: Preoperative detection of high-/low-risk postoperative ventricular arrhythmia (POVA) patients using a noninvasive method is an important issue in the clinical setting. This study mainly aimed to determine the usefulness of several preoperative electrocardiographic (ECG) markers in the risk assessment of POVA with cardiac surgery. Method: We enrolled 1024 consecutive patients undergoing cardiac surgery, and a total of 823 patients were included in the study. Logistic regression analysis determined preoperative ECG markers. A new risk predicting model were developed to predict occurrence of POVA, and the receiver operating characteristic curve (ROC) was used to validate this model. Results: Of these, 337 patients experienced POVA, and 485 patients did not experience POVA in this retrospective study. Among 15 ECG markers, a univariate analysis found a strong association between POVA and preoperative VA, the R-wave in lead aVR, the QRS wave, index of cardiac electrophysiological balance (iCEB), QT interval corrected (QTc), Tpeak-Tend interval (Tpe) in lead V2, the J wave in the inferolateral leads, pathological Q wave, and SV1+RV5>35 mm. Multivariate analysis showed that a preoperative J wave [adjusted odds ratio (AOR): 3.80; 95% CI: 1.88-7.66; p < 0.001], Tpe >112.5-ms (AOR: 2.80; 95% CI: 1.57-4.99; p < 0.001), and SV1+RV5 >35 mm (AOR: 2.92; 95% CI: 1.29-6.60; p = 0.01) were independently associated with POVA. A new risk predicting model were developed in predicting POVA. Conclusion: The ECG biomarkers including J wave, Tpe >112.5 ms, and SV1+RV5 >35 mm were significantly predicted POVAs. A risk predicting model developed with electrocardiographic risk markers preoperatively predicted POVAs.
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Project description:BackgroundReduced biventricular pacing (BiVP) is a common phenomenon in cardiac resynchronization therapy (CRT) with impact on CRT-response and patients' prognosis. Data on treatment strategies for patients with ventricular arrhythmia and BiVP reduction is sparse. We sought to assess the effects of ventricular arrhythmia treatment on BiVP.MethodsIn this retrospective analysis, the data of CRT patients with a reduced BiVP ≤ 97% due to ventricular arrhythmia were analyzed. Catheter ablation or intensified medical therapy was performed to optimize BiVP.ResultsWe included 64 consecutive patients (73 ± 10 years, 89% male, LVEF 30 ± 7%). Of those, 22/64 patients (34%) underwent ablation of premature ventricular contractions (PVC) and 15/64 patients (23%) underwent ventricular tachycardia (VT) ablation while 27/64 patients (42%) received intensified medical treatment. Baseline BiVP was 88.1% ± 10.9%. An overall increase in BiVP percentage points of 8.8% (range - 5 to + 47.6%) at 6-month follow-up was achieved. No changes in left ventricular function were observed but improvement in BiVP led to an improvement in NYHA class in 24/64 patients (38%). PVC ablation led to a significantly better improvement in BiVP [9.9% (range 4 to 22%) vs. 3.2% (range - 5 to + 10.7%); p = < 0.001] and NYHA class (12/22 patients vs. 4/27 patients; p = 0.003) than intensified medical therapy. All patients with VT and reduced BiVP underwent VT ablation with an increase of BiVP of 16.3 ± 13.4%.ConclusionIn this evaluation of ventricular arrhythmia treatment aiming for CRT optimization, both medical therapy and catheter ablation were shown to be effective. Compared to medical therapy, a higher increase in BiVP was observed after PVC ablation, and more patients improved in NYHA class.Clinical trial registrationThe study was registered at clinical trials.org in August 2019: NCT04065893.
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Project description:Conduction disorders and arrhythmias remain difficult to treat and are increasingly prevalent owing to the increasing age and body mass of the general population, because both are risk factors for arrhythmia. Many of the underlying conditions that give rise to arrhythmia - including atrial fibrillation and ventricular arrhythmia, which frequently occur in patients with acute myocardial ischaemia or heart failure - can have an inflammatory component. In the past, inflammation was viewed mostly as an epiphenomenon associated with arrhythmia; however, the recently discovered inflammatory and non-canonical functions of cardiac immune cells indicate that leukocytes can be arrhythmogenic either by altering tissue composition or by interacting with cardiomyocytes; for example, by changing their phenotype or perhaps even by directly interfering with conduction. In this Review, we discuss the electrophysiological properties of leukocytes and how these cells relate to conduction in the heart. Given the thematic parallels, we also summarize the interactions between immune cells and neural systems that influence information transfer, extrapolating findings from the field of neuroscience to the heart and defining common themes. We aim to bridge the knowledge gap between electrophysiology and immunology, to promote conceptual connections between these two fields and to explore promising opportunities for future research.
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Project description:Objectives:Inherited cardiac arrhythmia syndromes are life-threatening conditions. There is a paucity of research examining the psychological impact of these conditions in children. This study had three main aims. The first was to explore how the Cardiac Anxiety Questionnaire (CAQ) performs in a child population. The second aim was to compare the level of anxiety of children with an inherited cardiac arrhythmia syndrome and children being screened due to a family history of an inherited cardiac arrhythmia syndrome to control children. The third aim was to examine associations between a sudden cardiac death in the immediate family and levels of anxiety. Method:47 children with an inherited cardiac arrhythmia syndrome, 78 children with a family history and 75 control children completed the Revised Child Anxiety and Depression Scale (RCADS), the Cardiac Anxiety Questionnaire for Children (CAQ-C) and the Childhood Anxiety Sensitivity Index. Children were between the age of 8 and 16 years. Results:The study found the CAQ-C had promising psychometric properties. There were no significant differences in total anxiety scores (as measured by the RCADS) between the three groups. There were significant differences in cardiac-focused anxiety scores between the three groups. Conclusions:The CAQ has promising psychometric properties in a child population. However, further research is needed. Children attending specialist inherited cardiac arrhythmia clinics should be targeted for routine psychological screening and offered psychological intervention where necessary.
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Project description:BackgroundCardiovascular and arrhythmic events have been reported in hospitalized COVID-19 patients. However, arrhythmia manifestations and treatment strategies used in these patients have not been well-described. We sought to better understand the cardiac arrhythmic manifestations and treatment strategies in hospitalized COVID-19 patients through a worldwide cross-sectional survey.MethodsThe Heart Rhythm Society (HRS) sent an online survey (via SurveyMonkey) to electrophysiology (EP) professionals (physicians, scientists, and allied professionals) across the globe. The survey was active from March 27 to April 13, 2020.ResultsA total of 1197 respondents completed the survey with 50% of respondents from outside the USA, representing 76 countries and 6 continents. Of respondents, 905 (76%) reported having COVID-19-positive patients in their hospital. Atrial fibrillation was the most commonly reported tachyarrhythmia whereas severe sinus bradycardia and complete heart block were the most common bradyarrhythmias. Ventricular tachycardia/ventricular fibrillation arrest and pulseless electrical activity were reported by 4.8% and 5.6% of respondents, respectively. There were 140 of 631 (22.2%) respondents who reported using anticoagulation therapy in all COVID-19-positive patients who did not otherwise have an indication. One hundred fifty-five of 498 (31%) reported regular use of hydroxychloroquine/chloroquine (HCQ) + azithromycin (AZM); concomitant use of AZM was more common in the USA. Sixty of 489 respondents (12.3%) reported having to discontinue therapy with HCQ + AZM due to significant QTc prolongation and 20 (4.1%) reported cases of Torsade de Pointes in patients on HCQ/chloroquine and AZM. Amiodarone was the most common antiarrhythmic drug used for ventricular arrhythmia management.ConclusionsIn this global survey of > 1100 EP professionals regarding hospitalized COVID-19 patients, a variety of arrhythmic manifestations were observed, ranging from benign to potentially life-threatening. Observed adverse events related to use of HCQ + AZM included prolonged QTc requiring drug discontinuation as well as Torsade de Pointes. Large prospective studies to better define arrhythmic manifestations as well as the safety of treatment strategies in COVID-19 patients are warranted.
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Project description:Implantable loop recorders (ILRs) are conventionally utilized to elucidate the mechanism of atypical syncope. The objective of this study was to assess the impact of these devices on management of pediatric patients with known or suspected inherited arrhythmia syndromes.A retrospective chart review was undertaken of all pediatric patients with known or suspected inherited arrhythmia syndromes in whom an ILR was implanted from 2008 to 2015. Captured data included categorization of diagnosis, treatment, transmitted tracings, and the impact of ILR tracings on management. Transmissions were categorized as symptomatic, autotriggered, or routine. Actionable transmissions were abnormal tracings that directly resulted in a change of medical or device therapy. A total of 20 patients met the stated inclusion criteria (long QT syndrome, n=8, catecholaminergic polymorphic ventricular tachycardia,n=9, Brugada syndrome, n=1, arrhythmogenic right ventricular cardiomyopathy, n=2), with 60% of patients being genotype positive. Primary indication for implantation of ILR included ongoing monitoring +/- symptoms (n=15, 75%), suspicion of noncompliance (n=1, 5%), and liberalization of recommended activity restrictions (n=4, 25%). A total of 172 transmissions were received in patients with inherited arrhythmia syndromes, with 7% yielding actionable data. The majority (52%) of symptom events were documented in the long QT syndrome population, with only 1 tracing (5%) yielding actionable data. Automatic transmissions were mostly seen in the catecholaminergic polymorphic ventricular tachycardia cohort (81%), with 21% yielding actionable data. There was no actionable data in routine transmissions.ILRs in patients with suspected or confirmed inherited arrhythmia syndromes may be useful for guiding management. Findings escalated therapies in 30% of subjects. As importantly, in this high-risk population, the majority of symptom events represented normal or benign rhythms, reassuring patients and physicians that no further intervention was required.
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Project description:BackgroundNo data are currently available regarding the current clinical practice in postoperative care of cardiac surgical patients in Austria.ObjectiveThe study investigated the current intensive care management concerning hemodynamic monitoring and strategies to treat common perioperative disorders of patients after cardiac surgery in Austria.MethodsA survey consisting of 31 questions was sent to intensivists at all 9 hospitals offering cardiac surgery in Austria.ResultsThe response rate was 100%. The mean number of procedures on cardiopulmonary bypass per centre was 722 ± 223. In the majority of cases postoperative critical care is performed by anesthesiologists. Blood gas analysis, pulse oximetry, electrocardiogram, temperature, central venous pressure, arterial pressure and hourly urine output are de facto standard monitoring in all centers. Transesophageal echocardiography is available in all centers and is frequently used. Crystalloids are the first choice for volume replacement, whereas levosimendan and adrenaline are employed for the treatment of low cardiac output syndrome.ConclusionsThis study provides insights into the current state of postoperative management of cardiac surgical patients in Austria. Standard monitoring as proposed by international guidelines is well established in Austrian intensive care units. Echocardiography is widely seen as a very important tool in the postoperative care of cardiac surgical patients. Knowledge about the status quo of postoperative intensive care management of cardiac surgical patients enables further development of patient care.
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Project description:Arrhythmia is an extremely common finding in patients receiving cardiac resynchronisation therapy (CRT). Despite this, in the majority of randomised trials testing CRT efficacy, patients with a recent history of arrhythmia were excluded. Most of our knowledge into the management of arrhythmia in CRT is therefore based on arrhythmia trials in the heart failure (HF) population, rather than from trials dedicated to the CRT population. However, unique to CRT patients is the aim to reach as close to 100% biventricular pacing (BVP) as possible, with HF outcomes greatly influenced by relatively small changes in pacing percentage. Thus, in comparison to the average HF patient, there is an even greater incentive for controlling arrhythmia, to achieve minimal interference with the effective delivery of BVP. In this review, we examine both atrial and ventricular arrhythmias, addressing their impact on CRT, and discuss the available evidence regarding optimal arrhythmia management in this patient group. We review pharmacological and procedural-based approaches, and lastly explore novel ways of harnessing device data to guide treatment of arrhythmia in CRT.
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