Follow-Up Study of Electrocardiographic Indices in 252 Children with Ventricular Septal Defect after Minimally Invasive Transthoracic Closure

Objective: The aim of this study was to explore the efficacy and safety of minimally invasive transthoracic closure (MITC) in treating ventricular septal defect (VSD). Methods: A total of 252 children with VSD were investigated between August 2013 and March 2015. Their electrocardiographic indices were monitored at different time points (before surgery [T0], immediately after surgery [T1], and 3 days/7 days/1 month/3 months/6 months after surgery [T2–6]) and followed up every year. Related adverse events also were recorded. Results: All children with VSD successfully underwent MITC. The average follow-up time was 5 years, during which no changes in the heart rate or corrected QT interval were found. The PR and QRS intervals were prolonged in the early postoperative period (T3); the SV1+RV5 amplitude decreased significantly at T6, and the left axis deviation significantly recovered at T6 (P < 0.05). A total of 32 patients developed arrhythmia within 3 days after surgery; however, no severe arrhythmia, including ventricular tachycardia, ventricular fibrillation, second-and third-degree atrioventricular block, complete left or right bundle branch block, and delayed arrhythmia, occurred during the follow-up period. Binary multivariate logistic regression revealed that the longer the surgery time and the larger the VSD diameter, the higher the risk of arrhythmia. Conclusions: The incidence of long-term arrhythmia after MITC is low, and the outcomes are good.

Androgen Deprivation Therapy, Hypogonadism and Cardiovascular Toxicity in Men with Advanced Prostate Cancer

Androgen deprivation therapy (ADT) is successfully used in patients with advanced prostatic cancer, but there are many concerns about its systemic side effects, especially due to advanced age and frequent comorbidities in most patients. In patients treated with ADT there are metabolic changes involving the glycaemic control and lipid metabolism, increased thrombotic risk, an increased risk of myocardial infarction, severe arrhythmia and sudden cardiac death. Still, these adverse effects can be also due to the subsequent hypogonadism. Men with heart failure or coronary artery disease have a lower level of serum testosterone than normal men of the same age, and hypogonadism is related to higher cardiovascular mortality. Many clinical studies compared the cardiovascular effects of hypogonadism post orchiectomy or radiotherapy with those of ADT but their results are controversial. However, current data suggest that more intensive treatment of cardiovascular risk factors and closer cardiological follow-up of older patients under ADT might be beneficial. Our paper is a narrative review of the literature data in this field.

The Long-Term Change of Arrhythmias after Transcatheter Closure of Perimembranous Ventricular Septal Defects

Objectives. To observe and analyze the long-term change of different types of arrhythmias after transcatheter closure of perimembranous ventricular septal defect (pmVSD). Methods. We retrospectively collected the data of patients who underwent pmVSD closure in our institution from March 2002 to December 2010. Results. One hundred thirty-nine patients met the inclusion criteria, of which 265 (25.5%) had early arrhythmia. They were classified into two categories: conduction abnormality (191/1039; 18.4%) and origin abnormality (94/1039; 9.0%), including 20 patients with both types of arrhythmias. The median follow-up time was 84.5 months, and 103 patients (103/191; 53.9%) with early conduction block got permanent arrhythmias, while only three patients (3/94; 3.2%) with early anomalous origin arrhythmias still had an abnormal electrocardiogram. Serious arrhythmias (28/1039; 2.7%), including II° atrioventricular block (AVB), III° AVB, and complete left bundle branch block (CLBBB), can appear immediately in the early postoperative period (21 patients) or in the late outset (seven patients) after several months or even years (6 months to 8.3 years). Twenty patients (20/21; 95.2%) with serious arrhythmia in the early postoperative period improved after early treatment, but six patients relapsed or worsened during follow-up. At the endpoint, severe arrhythmia persisted in 13 patients, of which four patients got permanent pacemaker implanted, and one patient with recurrent CLBBB died from heart failure. Conclusions. The probability of delayed CAVB or bundle branch block after VSD closure is low but often occurs several years after surgery. Therefore, long-term ECG follow-up should last for several years or even decades. Serious arrhythmias that appear early after transcatheter pmVSD closure may impose a risk of recurrence although they have been cured already. Close attention should be paid to the changes of cardiac function in patients with CLBBB after VSD closure, and the severity of such arrhythmia should be taken seriously and reexamined.

Predictive value of diabetes mellitus for freedom from arrhythmia recurrence after cryoballoon-guided pulmonary vein isolation

Funding Acknowledgements Type of funding sources: None. Background Diabetes mellitus (DM) has been identified to play an important role in the regulation of atrial fibrillation (AF). Data concerning the impact of DM on the development of individual arrhythmia substrates are still lacking. Purpose Therefore, the primary aim of this study was to examine the outcome of cryoballoon-guided pulmonary vein isolation (PVI) in patients (pts) suffering from DM and coexisting AF. Methods 523 consecutive pts undergoing initial PVI using the 2nd generation cryoballoon were analysed. 273 pts (52%) suffered from paroxysmal AF (PAF) (51 ± 23.2 years old, 26% female), 250 pts (48%) from persistent AF (PERS) (63.9 ± 10.0 years old, 30% female) and 69 pts (13%) were diagnosed with DM (68 ± 19.6 years old, 30% female). Follow-up (FU) visits were performed at 3, 6 and 12 months including 7-day Holter ECGs. Primary endpoint was the first documented recurrence of any atrial arrhythmia after a 3 months blanking period (&gt; 30 sec.). Results Within the observation period of 12 months AF recurrence occurred in 29% (n = 151 pts). Regardless of the coincidence of DM, PAF pts were significantly younger than those with PERS (p = 0.001). PAF pts additionally suffering from DM presented with a significantly higher risk for arrhythmia recurrence (p = 0.047). Multivariate analyses verified DM as a strong independent predictor for arrhythmia recurrence associated with a &gt; 4 fold higher risk for recurrence after ablation (p = 0.009, hazard ratio (HR) 4.363, confidence interval (CI) 1.46-13.07). PERS pts showed a slightly increased rate of arrhythmia recurrence when additional DM was diagnosed. In these patients multivariate analyses revealed that DM was associated with a 43% higher risk for arrhythmia recurrence (p = 0.321, HR 1.143, CI 0.59-2.22). Beyond that, severe gender disparities were observed with female gender as independent predictor for arrhythmia recurrence (p = 0.027*, HR 1.927, CI 1.079-3.440). Conclusions DM has relevant implication for arrhythmia recurrence after PVI. More distinct effects were observed in PAF patients following AF ablation. This could be related to more severe arrhythmia substrates in PAF pts suffering from DM compared to PAF pts without additional DM and even more substantial structural changes in PERS. Thus, individual paths in ablation management are required in these pts with AF and coexisting DM.

Epinephrine versus tramazoline to reduce nasal bleeding during nasotracheal intubation. A double-blind randomized trial

BACKGROUNDː Nasal bleeding is the most common complication during nasotracheal intubation (NTI). To reduce nasal bleeding, the nasal cavity is treated with vasoconstrictors (epinephrine [E] or tramazoline [T]) prior to NTI. This study aimed to determine whether E or T is more effective and safe for reducing nasal bleeding during NTI.METHODSː This study was preregistered on UMIN-CTR after being approved by the IRB of the School of Dentistry at Aichi Gakuin University. Written consent was received from all the patients. Total 206 patients aged 20–70 years and classified as 1–2 on American Society of Anesthesiologists-physical status were scheduled to undergo general anesthesia with NTI. Patients with a narrowed nasal cavity observed during preoperative CT test (n = 3), patients with hypertension (n = 3), patients undergoing antithrombotic therapy, and patients who did not give consent (n = 3) were excluded from the study. At last, 197 patients were randomly divided into two groups and treated with either E (n = 99; 3 patients were discontinued) or T (n = 98; 2 patient were discontinued). After induction of general anesthesia, each patient’s nasal cavity was treated using either E or T. Next, NTI was performed via the right nostril. Primary outcome was the presence of nasal bleeding. If bleeding was recognized at the posterior pharyngeal wall via nasal cavity during intubation, it was defined as bleeding. Secondary outcomes were the degree of bleeding (classified as none, mild, moderate, or severe), arrhythmia, and hemodynamic (mean atrial pressure and heart rate) changes associated with vasoconstrictors.RESULTSː The presence of bleeding was comparable in both groups (12.5%, E; 14.5%, T; P = 0.63). No significant difference between the groups regarding the degree of bleeding (P = 0.78) was observed, with most patients having no bleeding (n = 84, E; n = 82, T).No severe bleeding and no arrhythmias induced by vasoconstrictor were observed in the two groups.CONCLUSIONSː Nasal treatment with E or T shows no difference in nasal bleeding during NTI. Although no arrhythmia associated with E was observed in this study, it has been reported in literature. Therefore, as frequency and degree of nasal bleeding were comparable, nasal treatment with T could reduce the risk of NTI.Trial RegistrationUMIN-CTR (Registration No. UMIN000037907)

Ablation of small conductance calcium-activated potassium type-2 channel (SK2) delays occurrence of bupivacaine-induced cardiotoxicity in isolated mouse hearts

Bupivacaine is frequently used for conducting regional anesthesia. When accidentally injected or excessively absorbed into circulation, bupivacaine can induce severe arrhythmia and potentially lead to cardiac arrest. The specific mechanisms underlying this cardiotoxicity, however, remain to be clarified. We transfected HEK-293 cells to express the small conductance calcium-activated potassium type-2 channel (SK2), and used a whole-cell patch clamp method in order to explore how bupivacaine affected these channels. We subsequently used SK2 knockout mice to explore the relevance of SK2 channels in bupivacaine-induced cardiotoxicity in isolating mouse hearts, mounting them on a Langendorff apparatus, and perfusing them with bupivacaine. Using this system, arrhythmia, asystole, and cardiac functions were monitored. We observed dose-dependent inhibition of SK2 channels by bupivacaine: half-maximal inhibitory concentration (IC50) value = 18.6 μM (95% CI 10.8–32.1). When SK2 knockout (SK2 −/−) or wild-type (WT) mice were perfused with Krebs-Henseleit buffer (KHB), we did not observe any instances of arrhythmia. When SK2 −/− mice or WT were perfused with KHB containing bupivacaine (40 μM), the time to arrhythmia (Tarrhythmia) and time to asystole (Tasystole) were both significantly longer in SK2 −/− mice relative to WT mice ( P < 0.001). Similarly, SK2 −/− mice exhibited a significantly longer time to 25%, 50%, and 75% reductions in heart rate (HR) and rate-pressure product (RPP) relative to WT mice following bupivacaine perfusion ( P < 0.001). These results reveal that bupivacaine was able to mediate a dose-dependent inhibition of SK2 channels in HEK-293 cells, and deletion of SK2 channels can delay bupivacaine-induced cardiotoxicity in isolated mouse hearts.

Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study Database: Neuroanesthesia

Background: The incident report in neurosurgical anesthesia was part of the Perioperative and Anesthetic Adverse Events in Thailand Study (PAAd Thai) of the Royal College of Anesthesiologists of Thailand in 2015. There were scarce reports of perioperative anesthetic adverse events in neurosurgical cases. Objective: To investigate anesthetic complications and causes, and contributing factors including corrective strategies for the prevention of adverse events in neurosurgical cases. Materials and Methods: A prospective descriptive study was conducted in 22 hospitals across Thailand. Perianesthetic adverse incidents were reported by a standardized incident report form during 12 months period (between January and December 2015). Adverse events of neurosurgical cases were reviewed to demonstrate the causes. Descriptive statistics were used. Results: Among the first 2,000 incident reports from the PAAd Thai study, 228 critical incidents from the 157 incident report forms of neurosurgical cases were reported. The incidents commonly occurred in male patients (56.0%). The major age range was 40 to 70 years. The common adverse events included cardiac arrest within 24 hours (36.3%), death (33.1%), reintubation (15.3%), desaturation (10.8%), severe arrhythmia (10.2%), and difficult intubation (6.4%). Anesthesia was considered as part of the contributing factors in 70 reports while it was considered as the sole factor in 26 reports. Conclusion: Cardiac arrests, death, and reintubation were common incidents in neurosurgical anesthesia. Common factors contributing to the incidents were inexperience, severe increased intracranial pressure, inadequate preanesthetic evaluation, emergency condition, inappropriate decision, and communication. Factors minimizing the incidents were vigilance, having experience, experienced assistant, improvement of training, comply to practice guidelines, and effective communication. Suggested corrective strategies were quality assurance activity, improvement of supervision, additional training, improvement of communication, compliance with guidelines, and more equipment. Keywords: Adverse events, Anesthesia, Multicentered study, Incident report, Neuroanesthesia

650The arrhythmic mitral valve prolapse: presentation and outcome

Background The majority of patients with of Mitral-valve-prolapse (MVP) have a excellent prognosis. Until recently most cases of mortality were thought to be related to mitral regurgitation and left ventricular dysfunction. The concept of the arrhythmic MVP emerged to describe cases of sudden cardiac death (SCD) in the presence of isolated MVP yet it’s phonotype remains incompletely and inconsistently defined. Purpose To analyze the prevalence, severity and characteristics of ventricular-arrhythmia (VA), to determine it’s phenotypical context and independent impact on outcome in patients with MVP. Methods A cohort of 595 (65 ± 16 years, 278 female) consecutive patients with MVP and comprehensive clinical, arrhythmia (24hour-Holter) and Doppler-echocardiographic characterization, was identified and long-term outcome analyzed. Results VA was frequent, present in 43% of patients with at least ventricular ectopy≥5%, but was most often moderate (ventricular-tachycardia—VT 120-179bpm) in 27% and rarely severe (VT≥180/min) in 8.6%. Presence of VA was associated with older age, male sex, bileaflet-prolapse, marked leaflet redundancy, mitral-annulus-disjunction (MAD), larger left-atrium and left ventricular end-systolic diameter, and T-wave-inversion/ST-depression (all P ≤ 0.001). Severe VA was independently associated with presence of MAD, leaflet-redundancy and T-wave-inversion/ST-depression (all P &lt; 0.0001) but not with mitral regurgitation severity or ejection-fraction. Outcome primary endpoint of overall survival after arrhythmia diagnosis (8-year 87 ± 2%) was strongly associated with arrhythmia-severity (8-year 90 ± 2% for no/trivial arrhythmia, 85 ± 3% for mild/moderate and 76 ± 7% for severe arrhythmia. P = 0.02, Figure). Excess-mortality was substantial for severe-arrhythmia (univariate-hazard-ratio 2.70[1.27-5.77], P = 0.01 vs. no/trivial arrhythmia), even adjusted comprehensively including for MVP-characteristics (adjusted-hazard-ratio 2.94[1.36-6.36], P = 0.006) ). Conclusions This large cohort of isolated consecutive MVP characterized with 24-hour-Holter monitoring, clinical and Echocardiographic assessment, demonstrates that VA are frequent with MVP but rarely severe. The arrhythmic MVP was independently and strongly associated with specific ECG and morphologic patterns, particularly ST-T changes, MAD presence and marked leaflet redundancy, suggestive of a specific arrhythmic MVP phenotype, independently of MR-severity. Arrhythmia, particularly severe, is associated with long-term excess-mortality, independently of any other characteristics, including MR severity and LVEF. These findings lay the foundation for novel risk-stratification of MVP for the conduct of prospective controlled studies evaluating the management of MVP high-risk patients. Figure – Impact on survival of ventricular arrhythmia Overall survival of MVP stratified by ventricular arrhythmia (Panel A) or ventricular arrhythmia severity (Panel B) throughout follow-up. Abstract Figure.

Heart defibrillation: relationship between pacing threshold and defibrillation probability

Background Considering the clinical importance of the ventricular fibrillation and that the most used therapy to reverse it has a critical side effect on the cardiac tissue, it is desirable to optimize defibrillation parameters to increase its efficiency. In this study, we investigated the influence of stimuli duration on the relationship between pacing threshold and defibrillation probability. Results We found out that 0.5-ms-long pulses had a lower ratio of defibrillation probability to the pacing threshold, although the higher the pulse duration the lower is the electric field intensity required to defibrillate the hearts. Conclusion The appropriate choice of defibrillatory shock parameters is able to increase the efficiency of the defibrillation improving the survival chances after the occurrence of a severe arrhythmia. The relationship between pulse duration and the probability of reversal of fibrillation shows that this parameter cannot be underestimated in defibrillator design since different pulse durations have different levels of safety.