Assessment of short forms of recurrent atrial extra systoles by echocardiography with left atrial strain in ambulatory patients without organic cardiopathy / Evaluación de formas cortas de extrasístoles auriculares recurrentes mediante ecocardiografía con deformación auricular izquierda en pacientes ambulatorios sin cardiopatía orgánica

Abstract Aim: To analyse the potential usefulness and clinical relevance of the assessment by echocardiography with left atrial strain, based on the myocardial atrial deformation curves with speckle-tracking velocity vector imaging (VVI), in the analysis of short-form recurrent atrial extra systoles in ambulatory patients not suffering from organic cardiopathy. Methods: We designed a descriptive, prospective, and observational study including 270 patients between the ages of 18 and 75 assessed during an outpatient cardiology consultation attended due to palpitations over a period of two years. Using ambulatory electrocardiographic monitoring, we selected cases with short forms of repetitive atrial extrasystole, isolated or recurrentatrial fibrillation and a control group formed by those patients without repetitive ectopia. All patients underwent a thorough echocardiographic study during their first cardiological visit. Results: The analysis of the dynamic curves segmental deformation generated after an atrial extrasystole can reveal different points of origin of the extrasystole and detect specific anatomical alterations in the interatrial conduction at the level of the Bachmann's fascicle showing different models of electro anatomical activation possibly involved in the appearance of repetitive forms. Higher values of dyssynchrony between the septal and lateral wall and elongation in the time of interatrial electromechanical conduction could also be related to the existence of repetitive ectopic beats. Conclusions: Our ambulatory study employing the left atrial longitudinal strain, particularly in its segmental analysis, provides new insights into its the usefulness and potential clinical relevance.

Resumen Objetivo: Analizar la utilidad y relevancia clínica de la evaluación mediante ecocardiografía basada en las curvas de deformación auricular miocárdica con imágenes vectoriales de velocidad (VVI) de speckle-tracking, en el análisis de las extrasístoles auriculares recurrentes de corta duración en pacientes ambulatorios sin cardiopatía orgánica. Métodos: Se diseñó un estudio descriptivo, prospectivo y observacional que incluyó a 270 pacientes de entre 18 y 75 años evaluados durante una consulta externa de cardiología a la que acudieron por palpitaciones durante un periodo de dos años. Mediante el uso de monitorización electrocardiográfica ambulatoria, se seleccionaron casos con formas cortas de extrasistolia auricular repetitiva, fibrilación auricular aislada o repetitiva y un grupo control formado por aquellos pacientes sin ectopia repetitiva. Todos los pacientes se sometieron a un estudio ecocardiográfico exhaustivo durante su primera visita cardiológica. Resultados: El análisis de las curvas dinámicas de deformación segmentaria generadas tras un extrasístole auricular diferentes modelos de activación electroanatómica posiblemente implicados en la aparición de formas repetitivas. Valores mayores de disincronía entre la pared septal y lateral y el alargamiento en el tiempo de conducción electromecánica intraauricular pudieran también relacionarse con la existencia de latidos ectópicos repetitivos. Conclusiones: Nuestro estudio ambulatorio empleando la deformación longitudinal auricular izquierda, particularmente en su análisis segmentario, proporciona nuevas perspectivas sobre su utilidad y potencial relevancia clínica.

Viabilidade do Implante de Eletrodo Ventricular Esquerdo na Terapia de Ressincronização Cardíaca Guiada por Gated SPECT e Remodelamento Ventricular / Feasibility of Left Ventricle Lead Implantation in Cardiac Resynchronization Therapy Guided by Gated SPECT and Ventricular Remodeling

Resumo Fundamento A terapia de ressincronização cardíaca (TRC) pode beneficiar pacientes com insuficiência cardíaca (IC) avançada. O índice de excentricidade anormal por gated SPECT está relacionado a alterações estruturais e funcionais do ventrículo esquerdo (VE). Objetivo O objetivo do presente estudo foi avaliar a viabilidade do implante de eletrodos do VE guiado por análise de fase e sua relação com o remodelamento ventricular. Métodos Dezoito pacientes com indicação de TRC foram submetidos à cintilografia miocárdica para orientar o implante, avaliando-se os parâmetros de excentricidade e forma ventricular. P < 0,05 foi adotado como significância estatística. Resultados Na linha de base do estudo, a maioria dos pacientes foi classificada como NYHA 3 (n = 12). Após a TRC, 11 dos 18 pacientes foram reclassificados para um menor grau de limitação funcional. Além disso, a qualidade de vida dos pacientes melhorou após a TRC. Foram observadas reduções significativas na duração do QRS, intervalo PR, índice de forma diastólica final, índice de forma sistólica final, volume sistólico e massa miocárdica pós-TRC. O eletrodo do VE da TRC foi posicionado concordante, adjacente e discordante em 11 (61,1%), 5 (27,8%) e 2 (11,1%) pacientes, respectivamente. A excentricidade sistólica e diastólica final demonstrou remodelamento reverso após a TRC. Conclusões O implante de eletrodo do VE em TRC guiado por cintilografia gated SPECT é viável. A colocação do eletrodo concordante ou adjacente ao último segmento a se contrair foi um determinante do remodelamento reverso.

Abstract Background Cardiac resynchronization therapy (CRT) may benefit patients with advanced heart failure (HF). Abnormal eccentricity index by gated SPECT is related to structural and functional alterations of the left ventricle (LV). Objective The aim of this study is to evaluate the feasibility of LV lead implantation guided by phase analysis and its relationship to ventricular remodeling. Methods Eighteen patients with indication for CRT underwent myocardial scintigraphy for implant orientation, and eccentricity and ventricular shape parameters were evaluated. P < 0.05 was adopted as statistical significance. Results At baseline, most patients were classified as NYHA 3 (n = 12). After CRT, 11 out of 18 patients were reclassified to a lower degree of functional limitation. In addition, patients' quality of life was improved post-CRT. Significant reductions were observed in QRS duration, PR interval, end-diastolic shape index, end-systolic shape index, stroke volume, and myocardial mass post-CRT. The CRT LV lead was positioned concordant, adjacent, and discordant in 11 (61.1%), 5 (27.8%), and 2 (11.1%) patients, respectively. End-systolic and end-diastolic eccentricity demonstrated reverse remodeling post-CRT. Conclusions LV lead implantation in CRT guided by gated SPECT scintigraphy is feasible. The placement of the electrode concordant or adjacent to the last segment to contract was a determinant of reverse remodeling.

Evaluation of cardiac function and systolic dyssynchrony of fetuses exposed to maternal anti-SSA and anti-SSB antibodies using two-dimensional speckle tracking imaging / 中华超声影像学杂志

Objective:To evaluate the cardiac function and systolic dyssynchrony of fetuses exposed to maternal autoimmune antibodies (anti-SSA/Ro60, anti-SSA/Ro52 and anti-SSB/La) by using two-dimensional speckle tracking imaging (2D-STI).Methods:A total of 52 pregnant women with singleton pregnancy in the Affiliated Hospital of Inner Mongolia Medical University from July 2018 to November 2020 were selected. Eighteen fetuses of mothers with autoimmune antibodies were enrolled as autoimmune disease (AD) group and 34 fetuses of healthy mothers without antibodies were included as control group. Maternal baseline characteristics, fetoplacental Doppler parameters, and conventional echocardiographic data of two groups were prospectively collected. The systolic global and regional longitudinal strain of left and right ventricles (LV and RV) and the time to peak strain of regional myocardium were measured using 2D-STI. The differences in time to peak strain between the LV free wall and RV free wall (two-chamber dyssynchrony, 2C-DYS) and between the septum and LV free wall (one-chamber dyssynchrony, 1C-DYS) were also calculated.Results:There were no significant differences between the two groups in conventional systolic and diastolic functional parameters for the LV and RV(all P>0.05). The myocardial deformation parameters and 2C-DYS obtained by 2D-STI showed no statistical differences between two groups(all P>0.05). However, 1C-DYS was significantly more prolonged in the AD group than control group[28.50(13.50, 39.25)ms vs 19.50(8.00, 29.25)ms, P=0.042]. Conclusions:LV systolic mechanical dyssynchrony in fetuses of mothers with autoimmune antibodies suggests in-utero subclinical damage of the cardiac conduction system.

Disincronía ventricular inducida por fármacos y taquicardiomiopatía en un neonate / Drug-induced ventricular dissynchrony and tachycardiomyopathy in a newborn

Resumen La disfunción ventricular secundaria a disincronía eléctrica y mecánica es una complicación de la estimulación ventricular desde el ápex del ventrículo derecho. No existen informes de disincronía secundaria a los efectos de fármacos antiarrítmicos. Se presenta el caso de una niña de 10 días de vida con taquicardia supraventricular incesante que se internó en terapia intensiva neonatal. Se inició tratamiento con propranolol por vía oral y ante la persistencia de la taquicardia se agregó amiodarona endovenosa. La paciente estuvo predominantemente en taquicardia con frecuencias cardíacas entre 200 y 290 latidos por minuto durante una semana a pesar del tratamiento instaurado. La función ventricular fue normal en los ecocardiogramas realizados. Se agregó flecainida por vía oral al esquema de tratamiento y luego de 24 horas presentó una taquicardia más lenta con QRS ancho e imagen de bloqueo completo de rama izquierda. Un nuevo ecocardiograma evidenció deterioro de la función ventricular izquierda e insuficiencia mitral moderada lo que motivó la suspensión de la flecainida y el propranolol. A las 24 horas de la suspensión se observó la normalización de la función ventricular a pesar de la persistencia de episodios intermitentes de taquicardia. Se reinició el propranolol logrando el control de la taquicardia. La presencia de disincronía ventricular generada por el bloqueo de rama izquierda secundario al tratamiento farmacológico con flecainida constituye una novedosa explicación posible para el desarrollo de disfunción ventricular.

Abstract Ventricular dysfunction secondary to electrical and mechanical dyssynchrony in chronic right ventricular apical pacing is a well-recognized complication. There are no previous reports of pharmacologically induced dyssynchrony. A 10-day old infant with incessant supraventricular tachycardia was admitted to the neonatal intensive care unit. Therapy with oral propranolol was initiated and due to persistence of tachycardia intravenous amiodarone was administered. The patient remained predominantly in tachycardia with heart rates between 200-290 beats per minute for a week with serial echocardiograms showing preserved ventricular function. Oral flecainide was started. After 24 hours of treatment the patient developed a slower incessant wide QRS with a left bundle branch block pattern. The echocardiogram showed deterioration of left ventricular systolic function and moderate mitral regurgitation. Flecainide and propranolol were discontinued. The QRS complex narrowed and despite intermittent breakthroughs of supraventricular tachycardia, ventricular function normalized. Propranolol was restarted to achieve definitive control of the tachycardia. The presence of ventricular dyssynchrony generated by the left bundle branch block pattern secondary to pharmacological treatment with flecainide is a novel possible explanation for the development of ventricular dysfunction.

La asincronía ventricular izquierda como resultado de la estimulación apical permanente por dispositivos en el ventrículo derecho / Left ventricular dyssynchrony as result of right ventricular permanent apical pacing

Resumen La estimulación apical permanente del ventrículo derecho (VD) puede producir asincronía del ventrículo izquierdo (VI) desde los puntos de vista eléctrico y mecánico. Este fenómeno es efecto de una alteración de la activación normal del VI que lleva al deterioro de la función sistólica y la aparición de insuficiencia cardíaca y sus efectos deletéreos relacionados. Para el estudio de la asincronía eléctrica del VI se ha propuesto en fecha reciente el nuevo sistema electrocardiográfico no invasivo Synchromax, que puede cuantificar el grado de asincronía eléctrica que causa una subsecuente asincronía mecánica. Esta última se ha estudiado casi siempre mediante la ecocardiografía transtorácica bidimensional (ETT2D) a través del Doppler tisular y la deformación miocárdica y ahora con la ecocardiografía tridimensional transtorácica en tiempo real (E3DTR). La relación entre estos fenómenos ha sido motivo de estudio a fin de identificar a los pacientes que se benefician de la transición a un tratamiento de resincronización cardíaca. Conclusiones: La estimulación artificial permanente del VD produce asincronía eléctrica del VI que puede cuantificarse mediante el nuevo sistema electrocardiográfico Synchromax y desencadenar asincronía mecánica estudiada mediante la ecocardiografía transtorácica para reconocer a los pacientes que pueden beneficiarse de un tratamiento de resincronización cardíaca.

Abstract Permanent apical pacing of right ventricle (RV) can produce dyssynchrony of the left ventricle (LV) from an electrical and mechanical point of view. This phenomenon is caused by an alteration in the normal activation of LV leading to a deterioration of systolic function and the appearance of heart failure and its associated deleterious effects. For the study of the electrical asynchrony of the LV, a new noninvasive electrocardiographic system Synchromax has recently been proposed, being able to quantify the degree of electrical asynchrony that leads to a subsequent mechanical dyssynchrony. The latter has been traditionally studied by two-dimensional transthoracic echocardiography (2DTTE) through tissue Doppler and myocardial deformation and lately by real-time 3-dimensional echocardiography (RT3DE). The relationship between these phenomena has been the subject of study to predict those patients who benefit from an “upgrade” to cardiac resynchronization therapy. Conclusions: Permanent apical pacing of the RV produces electrical dyssynchrony of the LV that can be quantified using a new electrocardiographic system Synchromax and trigger mechanical asynchrony studied through transthoracic echocardiography allowing to predict those patients who benefit from cardiac resynchronization therapy.

Índice de varianza versus duración del complejo QRS para el diagnóstico de dispersión mecánica del ventrículo izquierdo

Introducción. En el complejo universo de la falla cardíaca, el pronóstico y el tratamiento de la misma sumaron un aspecto de valor durante la última década del siglo pasado, a partir del reconocimiento de la disincronía mecánica durante la sístole y las consiguientes propuestas de resincronización cardíaca. Desde los inicios la predicción de disincronía mecánica se ha fundamentado en la duración del complejo QRS, las imágenes y más recientemente el análisis del índice de varianza del QRS. Objetivo. Tomando como estándar la dispersión mecánica ventricular izquierda medida por ecocardiografía, valorar la concordancia entre duración promedio del QRS del electrocardiograma (ECG) versus el índice de varianza, en cuanto a sensibilidad, especificidad y valor predictivo de dispersión anormal. Métodos. Población de pacientes consecutivos citados para ecocardiografía strain, sin escara ventricular, para medir dispersión mecánica, duración promedio del QRS del ECG e índice de varianza espacial. Resultados. Se evaluaron 54 pacientes y 57 escenarios distintos. Edad promedio: 66,3±14,2 años; duración promedio del QRS fue de 119,7±31,5 mseg. El índice de varianza promedio fue 0,52±0,35. Un índice de varianza >0,4 demostró sensibilidad y especificidad de 82,6% y 64,7% respectivamente, para diagnóstico de dispersión mecánica anormal (e"56 mseg); valor predictivo positivo: 61,3%, negativo: 84,6%. La duración promedio de QRS e"130 mseg logró sensibilidad y especificidad de 52,6% y 71%, con valores predictivos positivo y negativo de 54,5% y 68,6%, respectivamente. La duración promedio del QRS no guarda dependencia con la disincronía mecánica (p=0,1458); la disincronía mecánica (>56 mseg) y la electrocardiografía de varianza, por otra parte, sí guardan dependencia muy significativa (p=0,0012). Los métodos no son comparables para diagnosticar disincronía (kappa=0,376). Conclusión. El ECG de varianza tiene mejor sensibilidad y valor predictivo negativo para el diagnóstico de dispersión mecánica ventricular izquierda valorada por ecocardiografía.

Introduction. The prediction of mechanical dyssynchrony has generally been based on the duration of the QRS complex, although other resources are available, such as the QRS variance index; these methods have not been compared with each other. Objective. Taking as a standard the left ventricular mechanical dispersion measured by speckle-tracking strain echocardiography, to assess the concordance between the average QRS duration of the standard electrocardiogram versus the spatial variance index in terms of sensitivity, specificity and predictive value of abnormal mechanical dispersion. Methods. Population of consecutive patients cited for strain echocardiography and without ventricular scar tissue, to measure mechanical dispersion, average QRS duration of the standard electrocardiogram and the variance index. Results. Fifty-four patients and 57 different scenarios were evaluated; the average age was 66.3±14.2 years, the QRS average duration on standard electrocardiogram was 119.7±31.5 ms. Average ID was 0.52±0.35. A spatial variation index >0.4 showed sensitivity and specificity of 82.6% and 64.7% respectively, for the diagnosis of abnormal mechanical dispersion (e"56 ms); positive predictive value: 61.3%, negative: 84.6%. The average duration of QRS e"130 ms achieved sensitivity and specificity of 52.6% and 71%, and the positive and negative predictive values were 54.5 and 68.6%, respectively. The average QRS duration are not interdependent with mechanical dyssynchrony (p=0.1458); mechanical dyssynchrony (>56 ms) and spatial variance electrocardiography are, nevertheless, clearly interdependent (p=0.0012). The methods are not comparable between them (kappa=0.376). Conclusion. The QRS variation electrocardiogram has better sensitivity and negative predictive value respect to the average QRS duration for the diagnosis of left ventricular mechanical dispersion prevalence, measured by echocardiography.

Introdução. No complexo universo da insuficiência cardíaca, seu prognóstico e tratamento agregaram valor durante a última década do século passado, com base no reconhecimento da dissincronia mecânica durante a sístole e nas propostas subsequentes de ressincronização cardíaca. Desde o início, a previsão da dissincronia mecânica tem sido baseada na duração do complexo QRS, nas imagens e, mais recentemente, na análise do índice de variância QRS. Objetivo. Tomando como padrão a dispersão mecânica do ventrículo esquerdo medida pelo ecocardiograma, avalie a concordância entre a duração média do QRS do eletrocardiograma (ECG) versus o índice de variância, em termos de sensibilidade, especificidade e valor preditivo de dispersão anormal. Métodos População de pacientes consecutivos citados para ecocardiograma de deformação, sem escara ventricular, para medir dispersão mecânica, duração média do QRS do ECG e índice de variância espacial. Resultados. Foram avaliados 54 pacientes e 57 cenários diferentes. Idade média: 66,3±14,2 anos; a duração média do QRS foi de 119,7±31,5 mseg. O índice de variância médio foi de 0,52±0,35. Um índice de variância >0,4 mostrou sensibilidade e especificidade de 82,6% e 64,7%, respectivamente, para diagnóstico de dispersão mecânica anormal (e"56 mseg); valor preditivo positivo: 61,3%, negativo: 84,6%. A duração média do QRS e"130 mseg alcançou sensibilidade e especificidade de 52,6% e 71%, com valores preditivos positivos e negativos de 54,5% e 68,6%, respectivamente. A duração média do QRS não depende de dissincronia mecânica (p=0,1458); dissincronia mecânica (>56 mseg) e eletrocardiografia de variância, por outro lado, têm dependência muito significativa (p=0,0012). Os métodos não são comparáveis para diagnosticar dissincronia (kappa=0,376). Conclusão. A variância do ECG apresenta melhor sensibilidade e valor preditivo negativo para o diagnóstico de dispersão mecânica do ventrículo esquerdo avaliada pelo ecocardiograma.

Estimulación parahisiana guiada por un índice de correlación cruzada con dos derivaciones electrocardiográficas / Parahisian stimulation guided by a cross-correlation index with two electrocardiographic leads

Introducción. La estimulación apical del ventrículo derecho (VD) produce un patrón de activación similar al bloqueo de rama izquierda, el cual retrasa la activación de la pared lateral del ventrículo izquierdo. El "índice de disincronía" (ID) correlaciona las derivadas DII y V6 como marcadores de la despolarización septal y lateral; en el presente reporte, se utilizó el ID para el implante del electrodo ventricular en la región "parahisiana". Métodos. Se incluyeron 6 pacientes a quienes se realizó un implante electivo de marcapasos bicameral, bajo indicaciones convencionales. En cada paciente se registró un electrocardiograma de 12 derivaciones en reposo, bajo estimulación apical en el (VD) y bajo estimulación septal "parahisiana"; en cada uno se obtuvo el ID. Resultados. Se analizaron 18 electrocardiogramas de 6 pacientes, edad promedio 72±16.7 años (48-91) 2 mujeres; en 4, la indicación del implante fue bloqueo atrioventricular completo y en 2, enfermedad del nodo sinusal. En todos los pacientes se observó mejoría del ID con estimulación parahisiana, con respecto al ápex del VD y en la mayoría también con respecto al ritmo de base. No se observó correlación entre la duración del complejo QRS y el ID. Conclusión. El uso del ID utilizando las derivaciones II/V6 permite valorar la disincronía eléctrica, en forma sencilla, no invasiva y en tiempo real.

Introduction. Right ventricle (RV) apical stimulation produces an activation pattern similar to the left bundle Branch block, which delays the lateral wall of the left ventricle activation. The "dyssynchrony index" (ID) correlates DII and V6 leads as surrogate markers of septal and lateral depolarization; in this report, the ID for the ventricular electrode implantin the "parahisian" region was used. Methods. Six patients were included who underwent an elective dual chamber pacemaker implant, under conventional indications. In each patient, a 12-lead electrocardiogram was recorded at rest, under RV apical stimulation and under "parahisian" septal stimulation; in each one, the ID was obtained. Results. Eighteen electrocardiograms of 6 patients were analysed, average age 72 ± 16.7 years (48-91) 2 women; in 4, the indication of the implant was complete atrioventricular block and in 2, sinus node disease. In all patients, improvement of the ID with parahisian stimulation was observed, with respect to the RV apex, and in most of them, also with respect to the base rhythm. No correlation was observed between the QRS complex duration and the ID. Conclusión The use of the ID using leads II/V6 allows the evaluation of electrical dyssynchrony, in a simple, non-invasive way and in real time.

Evaluación del deterioro contráctil en pacientes sometidos a estimulación eléctrica en punta de ventrículo derecho / Evaluation of contractile deterioration in patients undergoing electrical stimulation on the right ventricular tip

Introducción: A pesar de los indiscutibles beneficios en cuanto a calidad y expectativa de vida en los pacientes con indicaciones precisas de marcapasos, existen un grupo de ellos con efectos deletéreos en la función y geometría ventricular izquierda. Objetivo: Identificar modificaciones ecocardiográficas en pacientes con estimulación cardíaca permanente realizada desde punta de ventrículo derecho. Métodos: Se realizó estudio descriptivo longitudinal prospectivo a 84 pacientes que requirieron implantación de marcapasos permanente con estimulación desde punta del ventrículo derecho. Se recolectaron datos ecocardiográficos antes y después del implante. Resultados: El 53,65 por ciento fueron del sexo masculino, edad media 68,25. Las medias de las variables ecocardiográficas incrementaron sus valores, excepto, la fracción de eyección del ventrículo izquierdo que disminuyó, el grupo con estimulación secuencial presentó 4 casos más con disfunción diastólica grado II que al inicio, el grupo con estimulación no secuencial tuvo 5 casos con disfunción diastólica grado III, la fracción de eyección del ventrículo izquierdo disminuye un 6 por ciento en pacientes con estimulación secuencial y 9 por ciento para el modo no secuencial. Conclusiones: Las modificaciones ecocardiográficas durante el estudio mostraron una tendencia grupal al aumento excepto la fracción de eyección del ventrículo izquierdo que disminuyó(AU)

Introduction: Despite their indisputable benefits for the quality of life and life expectancy of patients with precise pacemaker indications, a number of these devices have shown to have deleterious effects in terms of left ventricular function and geometry. Objective: Identify echocardiographic changes in patients with permanent cardiac stimulation applied from the right ventricular tip. Methods: A prospective longitudinal descriptive study was conducted of 84 patients requiring permanent pacemaker implantation with stimulation from the right ventricular tip. Echocardiographic data were collected before and after implantation. Results: Of the total patients, 53.65 percent were male. Mean age was 68.25 years. An increase was observed in all the means of echocardiographic values except for the left ventricular ejection fraction, which decreased. The sequential stimulation group presented 4 more cases with grade II diastolic dysfunction than at baseline, whereas the group with non-sequential stimulation included 5 grade III diastolic dysfunction cases. Left ventricular ejection fraction lowered 6 percent in patients with sequential stimulation and 9% in patients with non-sequential stimulation. Conclusions: Echocardiographic changes during the study showed a group tendency to increase, except for the left ventricular ejection fraction, which decreased(AU)

Very Early (<2 h) Versus Early (12 h) Administration of Caffeine Citrate for Reducing Need for Mechanical Ventilation within 24 h of Life in Preterm Infants on Continuous Positive Airway Pressure

Background: Auditory neuropathy, auditory dys-synchrony, and auditory neuropathy spectrum disorder (ANSD) are variableterms used to describe an auditory disorder seen in patients ranging in age from infants to adults. The prevalence of ANSD indeaf schoolchildren is 2.46% within the age range of 6–12 years. In children, they are detected by the presence of otoacousticemissions (OAEs) in the absence of ABRs. In older age group, difficulty hearing in noise, fluctuating hearing, and speechperception performance not predict ed by the level of residual hearing have been reported. The multitude of etiologies forANSD results in heterogeneous group of patients – making the management strategies even more challenging. The commonetiologies put forward are – prematurity, neonatal insult, genetic abnormality, ototoxic drugs, and head injury.Aim of the Study: This study aims to study the audiological profile in ANSD in a tertiary care hospital and to study the etiologyof ANSD cases.Materials and Methods: A total of 42 patients attending the ENT Outpatient Department of Government Medical College,Kozhikode, with ANSD were included in the study. An ethical committee clearance was obtained before the commencement ofthe study. An ethical committee cleared consent form was used for the study. All ANSD patients were evaluated with a detailedhistory including perinatal and development history, ototoxic drug exposure, head trauma, neurodegenerative conditions, andfamily history. Following clinical evaluation which included general examinations, ENT examination, and central nervous systemexamination, an audiological evaluation, which included pure tone audiometry, speech audiometry, immittance evaluation, OAE,and auditory brainstem response, was done. Radiological investigation (magnetic resonance imaging brain with inner ear – focusingon any structural anomalies; cochlea, vestibulocochlear nerve, and internal auditory canal) was done. Patients were counseledregarding the rehabilitation options based on their audiological and radiological results and the need for follow-up was explained.Observation and Results: A total of 42 patients attending the ENT Outpatient Department (OPD) of Government MedicalCollege, Kozhikode, with ANSD were included in the study. Among the 42 patients, 21 (50%) were in the age group of 11–20 yearsfollowed by 13 patients who were between 0 and 10 years (30.95%). The remaining 8 were aged above 20 years (19.04%).The youngest patient was 10 months old and the oldest was aged 38 years with a mean age of 10.35 ± 2.10 years. Therewere 29 (69.04%) females and 13 (30.95%) males. 3/42 (7.14%) patients gave a history of exposure to ototoxic drugs suchas streptomycin, gentamicin, and kanamycin, but never had a history of loss of hearing before that. History of premature birthwas noted in 10 (23.80%) patients and the remaining patients did not show premature birth history. Among the 42 patients ofthis study group, 23 (54.76%) had low birth weight, of which 2/42 (4.76%) were <1.5 kg. 21/42 (50%) patients had birth weightabove 1.5 kg. 10/42 patients (23.80%) gave a history of neonatal intensive care unit (NICU) admissions at the time of their birth.Conclusions: The major risk factor identified in this study for ANSD was low birth weight with prematurity, NICU admissions,and viral infections having significant contributions. On audiological evaluation, hearing loss was of mild-to-moderate rangewith a low-frequency loss. There was no statistical correlation between pure audiometry values and speech audiometry whichwas a characteristic observation. OAEs were present in the majority of patients with absent cochlear microphonics (reversepolarity) and acoustic reflexes.

Comparison of three-dimensional echocardiography and speckle tracking echocardiography in quantification and mapping of intraventricular mechanical dyssynchrony

Objectives The aim of the study is to compare two advanced methods of evaluation of left ventricular mechanical dyssynchrony (LVMD), the speckle tracking echocardiography (STE) and the three-dimensional echocardiography (3DE). Methods One hundred thirty-six subjects, with or without LV dysfunction and with or without bundle branch block (BBB), were included in this study, designed to investigate agreement between magnitude and spatial pattern of LVMD as assessed by 3DE and STE. The frequency and severity of LVMD and localization of most asynchronous segments were compared. Results Both 3DE and STE revealed progressive rise in frequency and magnitude of LVMD with increasing disease severity. Dyssynchrony was dependent on left ventricle ejection fraction rather than the QRS duration. The frequency and magnitude of dyssynchrony were maximum in patients having LV dysfunction with left BBB. Compared with STE, 3DE diagnosed LVMD more frequently in patients having LV dysfunction with narrow QRS (17.6% vs 60.3%, respectively; P < 0.001). When the two methods were compared for localization of most asynchronous segments, the results matched only in about 50% cases. Conclusions Both 3DE and STE provided consistent results with progressive rise in magnitude of LVMD, correlating with disease severity. 3DE diagnosed more patients as having LVMD in those having LV dysfunction with narrow QRS. The most delayed segment assessed by two methods matched only in about half the cases. Correlation with clinical CRT responsiveness is needed to conclude which method is more accurate in dyssynchrony mapping for targeted lead placement.

Estimulación del ventrículo derecho como causante y agravante de disincronía ventricular / Stimulation of the right ventricle as a cause and aggravating ventricular dyssynchrony

Resumen Introducción y objetivos . La activación eléctrica artificial del corazón en pacientes con arcapasos implantados en el ventrículo derecho es causante de disincronía ventricular. Synchromax® es un monitor de electrocardiografía que com prueba de manera no invasiva e instantánea el grado de sincronía intraventricular, analizando simultáneamente las derivaciones antípodas DII y V6; se dispone de valores de corte para definir su severidad. El presente estudio buscó medir con Synchromax® el índice de disincronía generado por la estimulación apical o septal del ventrículo derecho en pacientes con marcapasos, comparando con el índice durante el ritmo nativo. Métodos . Entre septiembre 2018 y enero 2019 se estu diaron 18 pacientes de ambos sexos que tenían cita para revisión de sus dispositivos: marcapasos unicameral, bicameral, cardiodesfibrilador o resincronizador. Se obtuvieron registros con Synchromax® en ritmo nativo y durante la estimula ción artificial. Resultados . Trece de dieciocho pacientes deterioraron su sincronía (72.2%) por efecto de la estimulación artificial, los cinco restantes no presentaron variaciones y se mantuvieron en el mismo rango de ID. En 7 de los 13 casos la disincronía llegó a nivel severo (ID > 0.7, 53.8%). El test de ANOVA confirmó diferencia estadísticamente significativa entre los valores pre y post estimulación (p <0.01); también se confirmó que el implante apical generaba más disincronía que el septal (p=0.036). Conclusiones . Synchromax® permite la detección instantánea de disincronía eléctrica inducida por estimulación de cámaras derechas. Se recomienda que los implantes sean guiados con esta tecnología fácil de usar, reproducible y no operador dependiente.

Abstract Stimulation of the right ventricle as a cause and aggravating ventricular yssynchrony Introduction and objectives : Artificial electrical activation of the heart in patients with permanent right ventricular stimulation is responsible for ventricular dyssynchrony. Synchromax® is an electrocardiogram monitor that allows an instantaneous and noninvasive verification of intraventricular synchrony, making a comparative analysis of the antipode leads DII and V6; cut values for a resulting index are available to diagnose dyssynchrony and define its severity. The present study objective is to measure with Synchromax® the dyssynchrony index generated by right ventricular stimulation in patients with implanted pacemakers, comparing with the index during native rhythm. Methods : Between September 2018 and January 2019, 18 patients of both genders with unicameral, bicameral, cardio-defibrillator or resynchronization pacemakers were studied. ECG were registered with Synchromax® in all patients, with native rhythm and under artificial stimulation. Results : Thirteen out of eighteen patients deteriorated their synchrony (72.2%) due to artificial stimulation, the other five remained with unchanged dyssynchrony index. Seven out of those thirteen cases reached a severe degree of dyssynchrony (53.8%). The ANOVA test confirmed a statistically significant difference between the pre- and post-stimulation (p <0.01); it was also confirmed that the apical implant causes more dyssynchrony than the septal implant (p=0.036). Conclusion: Synchromax® allows detection of electrical dyssynchrony induced by right ventricular stimulation. It is suggested that the implants could be guided with this easy to use, reproducible and operator independent technology.

Three-dimensional echocardiographic evaluation of mechanical dyssynchrony in systolic heart failure with narrow QRS complex

Objectives To investigate the role of three-dimensional echocardiography (3DE) in evaluation of left ventricular mechanical dyssynchrony (LVMD) in heart failure (HF) patients with narrow QRS. Methods 143 subjects (70 with HF and narrow QRS, 23 with HF and LBBB and 50 controls) were subjected to 3DE, evaluating global and regional dyssynchrony using systolic dyssynchrony index, maximum segmental dyssynchrony and opposite segment dyssynchrony. Spatial distribution of LVMD was studied in each patient using 3DE derived regional time volume curves. Extent of LVMD in HF patients with narrow QRS was compared to those with left bundle branch block (LBBB). Results Frequency of LVMD was similar in HF patients with narrow QRS or LBBB (55.7% vs. 47.8%, p = NS). There was no difference in the severity of LVMD between these two groups (10.7 ± 6.7% vs. 12.1 ± 7.4%, p = NS). Both HF groups had significantly more dyssynchrony than controls. A scattered pattern of distribution of asynchronous segments was seen in narrow QRS patients; 33.96% of them had their earliest contracting segment, instead of delayed segment, located in areas conventionally targeted for LV pacing i.e. anterolateral, inferolateral or inferior segments. Conclusions 3DE confirmed significant dyssynchrony in > 50% HF patients with narrow QRS as demonstrated by other imaging methods. 3D distribution patterns of asynchronous segments indicate possibility of left ventricular mechanics related reasons responsible for lack of CRT responsiveness, an observation that generates hypothesis on possible reasons of CRT non-responsiveness.

Efectos de la estimulación endocárdica prolongada sobre la sincronía mecánica ventricular izquierda. Ensayo piloto aplicando análisis de fase por tomografía computada por emisión de fotón único gatillada. Estimulación prolongada y disincronía mecánica / Effects of prolonged endocardial stimulation on left ventricular mechanical synchrony. A pilot study applying gated-SPECT phase analysis. Endocardial stimulation and dyssynchrony

Resumen: Objetivo: Evaluar la disincronía mecánica ventricular izquierda (DMVI) asociada a la estimulación endocárdica prolongada del ventrículo derecho mediante el ensayo piloto de una nueva técnica de imagen en Uruguay. Métodos: Se estudiaron 12 pacientes con marcapasos implantados al menos hace un año utilizando SPECT gatillada con 99mTc-MIBI y análisis de fase en reposo. Se registraron variables clínicas, duración del QRS, tasa, modo y sitio de estimulación ventricular, presencia y extensión de infarto e isquemia, volúmenes cavitarios y FEVI en reposo. Utilizando V-Sync de Emory Cardiac Toolbox se obtuvieron desviación estándar y ancho de banda de fase en reposo (grados), comparando los individuos con FEVI ≥ y < 50% con una población control. Resultados: Los pacientes de la serie con estimulación endocárdica prolongada en el ventrículo derecho exhibieron marcada DMVI. Los pacientes con FEVI moderada/severamente disminuida (con diámetros cavitarios mayores, estimulación septal, infarto extenso o isquemia significativa) exhibieron mayor disincronía que aquellos con FEVI conservada/levemente disminuida (ancho de banda = 144.33o vs. 77.41o, p < 0.05; desviación estándar = 46.67o vs. 26.81o, p < 0.05). Conclusiones: En la cardiopatía isquémica la elevada tasa de estimulación endocárdica crónica se asocia con marcada DMVI, aun cuando la función sistólica esté conservada. El análisis de fase podría ser una herramienta válida para evaluar la disincronía asociada al infarto en pacientes con marcapasos, y aportar a la indicación oportuna del pasaje (upgrading) al modo de estimulación biventricular.

Abstract: Objetive: To evaluate left ventricular mechanical dyssynchrony (LVMD) associated with prolonged right ventricular pacing through an innovative imaging technique as a pilot study in Uruguay. Methods: A 99mTc-MIBI gated-SPECT and phase analysis was performed in 12 patients with pace-makers implanted at least one year before scintigraphy, due to advanced atrioventricular block. Clinical data, QRS duration, rate, mode and site of pacing in right ventricle, chamber diameters, presence and extension of myocardial scar and ischaemia, as well as LVEF at rest, were recorded. Using V-Sync of Emory Cardiac Toolbox, a standard deviation (PSD) and band-width (PBW) from rest phase histogram was obtained and these indexes were compared with controls in the subgroups of patients with LVEF ≥ 50% and < 50%. Results: Patients with prolonged RV endocardial pacing exhibited marked LVMD. More severe dyssynchrony was found in patients with impaired LVEF than in patients with preserved LVEF (PSD: 46.67o vs. 26.81o, P < .05; PBW: 144.33o vs. 77.41o, P < .05). Higher left ventricle diameters, extensive infarct, or significant ischaemia were found in patients with impaired LVEF. Conclusions: Chronic right ventricular pacing was invariably associated with LVMD, even when systolic function was preserved. Phase analysis could be a potentially useful technique to evaluate LMVD associated with myocardial scar in patients with pacemakers, and to decide promptly the upgrading to biventricular pacing.

Accessory pathway induced dilated cardiomyopathy / 中华实用儿科临床杂志

Accessory pathway-induced dilated cardiomyopathy is a new diagnosis proposed recently.Pre-excitation of part of the myocardium may mediate electrical and mechanical dyssynchrony,which will result in decreased left ventricular systolic function and increased diameter of left ventricle in patients with right-sided overt accessory pathways (type B ventricular preexcitation).Its features are listed as follows:(1) Incessant and prolonged tachyarrhythmia never happened.Tachycardiomyopathy and other causes of dilated cardiomyopathy are excluded.(2) Right-sided overt accessory pathways are shown by electrocardiogram.(3)Echocardiography indicates dyssynchronous left ventricle contraction,decreased left ventricular systolic function and increased diameter of left ventricle.Normal interventricular septal motion,recovered left ventricular and reversed left ventricular remodeling can be realized by radiofrequency ablation with a good prognosis.To infant patients,taking anti arrhythmia drugs to inhibit the conduction of the accessory pathway was recommended.

Assessment of left ventricular dyssynchrony and its relationship with cardiac function in dilated cardiomyopathy by two-dimensional strain parameters / 中国医学影像技术

Objective To explore value of two-dimensional speckle tracking imaging (2D-STI) strain parameters in assessment of left ventricular (LV) dyssynchrony and its relationship with cardiac function in patients with dilated cardiomyopathy (DCM).Methods Totally 25 patients with DCM and 25 age-matched normal controls were enrolled.The LV time to peak longitudinal strain (Tls) and time to peak circumferential strain (Tcs) were measured by 2D-STI,from which the standard deviations and maximal differences of the Tls in all 18 segments,6 segments at apical 4-chamber,3-chamber and 2 chamber views (Tls-SD,Tls-SD-4,Tls-SD-3,Tls SD-2,Tls dif,Tls-dif-4,Tls-dif-3,Tls-dif-2) were calculated,as same as the standard deviations and maximal differences of Tcs in all 18 segments,6 segments at mitral valve,papillary muscle,apical short-axis views (Tcs-SD,Tcs-SD-M,Tcs-SD-P,Tcs-SD-A,Tcs-dif,Tcs-dif-M,Tcs-dif-P,Tcs-dif-A) were calculated.Results Compared with the control group,the global and segmental strain parameters of the DCM group increased significantly (all P＜0.05).Except for Tcs-dif-P and Tcs dif,the residual strain parameters were negatively correlated with LV ejection fraction (all P＜0.05).Except for Tcs-dif-M,Tcs dif-P and Tcs-dif,there was a positive correlation between strain parameters and E/e in DCM group (all P ＜0.05).Conclusion In patients with DCM,LV dyssynchrony exists both in global and regional,which may aggravates the LV function damage.2D-STI strain parameters can objectively evaluate LV dyssynchrony and its relationship with cardiac function in patients with DCM.

Patient-Ventilator Dyssynchrony / 대한구급학회지

In mechanically ventilated patients, assisted mechanical ventilation (MV) is employed early, following the acute phase of critical illness, in order to eliminate the detrimental effects of controlled MV, most notably the development of ventilator-induced diaphragmatic dysfunction. Nevertheless, the benefits of assisted MV are often counteracted by the development of patient-ventilator dyssynchrony. Patient-ventilator dyssynchrony occurs when either the initiation and/or termination of mechanical breath is not in time agreement with the initiation and termination of neural inspiration, respectively, or if the magnitude of mechanical assist does not respond to the patient's respiratory demand. As patient-ventilator dyssynchrony has been associated with several adverse effects and can adversely influence patient outcome, every effort should be made to recognize and correct this occurrence at bedside. To detect patient-ventilator dyssynchronies, the physician should assess patient comfort and carefully inspect the pressure- and flowtime waveforms, available on the ventilator screen of all modern ventilators. Modern ventilators offer several modifiable settings to improve patient-ventilator interaction. New proportional modes of ventilation are also very helpful in improving patient-ventilator interaction.

Patient-Ventilator Dyssynchrony / 대한중환자의학회지

In mechanically ventilated patients, assisted mechanical ventilation (MV) is employed early, following the acute phase of critical illness, in order to eliminate the detrimental effects of controlled MV, most notably the development of ventilator-induced diaphragmatic dysfunction. Nevertheless, the benefits of assisted MV are often counteracted by the development of patient-ventilator dyssynchrony. Patient-ventilator dyssynchrony occurs when either the initiation and/or termination of mechanical breath is not in time agreement with the initiation and termination of neural inspiration, respectively, or if the magnitude of mechanical assist does not respond to the patient's respiratory demand. As patient-ventilator dyssynchrony has been associated with several adverse effects and can adversely influence patient outcome, every effort should be made to recognize and correct this occurrence at bedside. To detect patient-ventilator dyssynchronies, the physician should assess patient comfort and carefully inspect the pressure- and flowtime waveforms, available on the ventilator screen of all modern ventilators. Modern ventilators offer several modifiable settings to improve patient-ventilator interaction. New proportional modes of ventilation are also very helpful in improving patient-ventilator interaction.

Disincronía ventricular izquierda en la estimulación septal prolongada / Left ventricular dyssynchrony in prolonged septal stimulation

La estimulación por marcapasos se asocia con eventos adversos graves. En la siguiente serie de casos se evaluó la disincronía mecánica intraventricular izquierda (DMVI) en la estimulación endocárdica prolongada del ventrículo derecho a nivel septal. Se estudiaron 6 personas con marcapasos implantados no antes de un año utilizando SPECT gatillado con 99mTc-MIBI y análisis de fase en reposo. Se registraron variables clínicas, duración del QRS, tasa y modo de estimulación ventricular, presencia y extensión de isquemia y/o infarto, volúmenes cavitarios y FEVI en reposo. Utilizando V-Sync de Emory Cardiac Toolbox se obtuvieron el ancho de banda (AB) y el desvío estándar de fase (DEF) en reposo (grados), comparándolos con una población control. La estimulación endocárdica prolongada en el septum ventricular derecho se asoció con marcada DMVI, aun cuando la función sistólica estaba conservada. Aquellos con FEVI moderada/gravemente disminuida (caracterizados por diámetros cavitarios mayores, infarto o isquemia grave) exhibieron mayor disincronía que aquellos con FEVI conservada/levemente disminuida (AB: 177.3o vs. 88.3o; DEF: 53.1o vs. 33.8o). En los casos con cardiopatía isquémica portadores de marcapasos, el AF es una herramienta válida de potencial utilidad para evaluar la disincronía asociada al infarto y, eventualmente, aportar a la decisión oportuna del pasaje al modo de estimulación biventricular.

Pacemaker stimulation is associated with unpredictable severe cardiac events. We evaluated left ventricular mechanical dyssynchrony (LVMD) during prolonged septal right ventricular pacing. We performed 99mTc-MIBI gated-SPECT and phase analysis in 6 patients with pacemakers implanted at least one year before scintigraphy due to advanced atrioventricular block. Using V-Sync of Emory Cardiac Toolbox we obtained phase bandwidth (PBW) and standard deviation (PSD) from rest phase histogram. Clinical variables, QRS duration, rate and mode of pacing in septal right ventricle wall, chamber diameters, presence and extension of myocardial scar and ischemia and rest LVEF were recorded. Prolonged septal endocardial pacing is associated with marked LVMD, even when systolic function was preserved. More severe dyssynchrony was found in patients with impaired LVEF, higher left ventricle diameters, extensive infarct or severe ischemia than in patients with preserved LVEF (PBW: 177.3o vs. 88.3o; PSD: 53.1o vs. 33.8o). In the patients with ischemic heart disease and pacemaker, gated-SPECT phase analysis is a valid and potentially useful technique to evaluate LMVD associated with myocardial scar and to decide the upgrading to biventricular pacing mode.

Evaluation on the ventricular dyssynchrony in patients with pulmonary hypertension using velocity vector imaging / 中华超声影像学杂志

Objective To determine whether strain and strain rate derived from velocity vector imaging ( VVI) allowed assessment of regional and global right ventricular ( RV) dysfunction and intra‐and inter‐ventricular dyssynchrony in patients with pulmonary hypertension ( PHTN) . Methods Ninety‐nine patients were enrolled , including 35 controls and 64 PHTN patients . All participants underwent echocardiography examinations and off line strain/strain rate analysis . Bi‐ventricular regional peak systolic strain ,strain rate ,and the time‐to‐peak systolic variables were measured at the RV free wall ,inter‐ventricular septum ,and LV lateral wall in apical four chamber views . Standard deviations of the time‐to‐peak systolic strain (SD‐Ts) and strain rate (SD‐Tsr) at six RV and three left ventricular (LV) segments were calculated to define intra‐and inter‐ventricular dyssynchrony . Results Compared with the controls , segmental and global peak systolic strain and strain rate decreased in the PHTN patients . And intra‐right ventricular dyssynchrony was present in the PHTN patients [SD‐Ts:(28 ± 20)ms in controls vs (61 ± 62) ms in patients , P = 0 .003 ] . The difference between the time‐to‐peak systolic strain rate at the basal segment of RV free wall and LV lateral wall indicated earlier RV free wall contraction in PHTN patients , relativetoLVlateralwall,particularlyinthoseseverePHTNpatients[(13±13)msincontrolsvs( -49± 14) ms in patients , P < 0 .01] . Conclusions PHTN impairs RV myocardial contraction and induces to ventricular mechanical dyssynchrony .VVI could monitor RV function during the treatment of PHTN .