Assessment of the role of speckle tracking echocardiography in targeting the left ventricular lead position in patients undergoing cardiac resynchronization therapy

Background: Cardiac Resynchronization Therapy [CRT] is now a well-established treatment for patients with advanced heart failure through biventricular pacing. Optimizing the left ventricular [LV] lead position via echocardiographic speckle tracking guidance could reduce the rate of non-responders to CRT

Objectives: to assess the role of speckle tracking echocardiography in determining the proper position of the left ventricular lead in patients undergoing CRT

Methods: the study population comprised 50 patients who were indicated for CRT according to the ESC 2012 guidelines. Speckle tracking echocardiography was done to all patients before CRT implantation or shortly after implantation while switching off pacing to determine the latest activated myocardial wall of the LV. The patients were classified after CRT implantation into two groups; the first group [group A] included 20 patients and represented those with concordance between the most mechanically delayed myocardial wall derived from speckle tracking echocardiography and the coronary sinus lead position, and the second group [group B] included 30 patients that showed discordance between them. Both groups were recruited for follow-up after a period of 6 months to assess clinical response, echocardiographic response and mortality

Results: Significant correlation was observed between echocardiographic response and the LV lead concordance [p value=0.041], and between combined clinical and echocardiographic response and LV lead concordance. There was a nearly significant difference between clinical response and the LV lead concordance [p value=0.057], and there was a trend towards less mortality in the group with concordant LV lead [10.5% in the concordant group versus 24.1% in the discordant group] with no statistical significance [p value=0.286]

Conclusions: we demonstrated an increased benefit with an echocardiographically optimized LV lead position targeting the most delayed myocardial wall by 2D speckle tracking echocardiography

Compromising bradycardia: management in the Emergency Department of National Heart Institute

The need to treat bradycardias is dictated primarily by the clinical Presentation of the patient [1]. Bradycardia may bean incidental finding in asymptornatic patients [2]. On the other hand, bradycardia may present with haemodynamic instability and loss of consciousness [3]. Out of the bradycardic rhythms to be encountered in these patients, high grade atrioventricular-block represents a significant portion [4]. Compromising bradycardia requires an effective diagnostic and therapeutic approach [1]. The goal of initial management is stabilization by increase of the ventricular rate by both pharmacological and non-pharmacological interventions, sometimes even cardiopulmonary resuscitation is required [5]. A careful clinical workup for potential causes, including ischacmic and non-ischaemic aetiologies, is crucial for successful management [6]. There are only a few reports available on the management and outcome of patients presenting with compromising bradycardia to the emergency department [ED] [1]. This study include 210 consecutive patients, with compromising bradycardia, admitted to the emergency department of National Heart Institute [tertiary Care hospital] within eight month period, 107 patients [51%] females, 103 patients [49%] males, whose age ranged from 25 to 89 years. The aim of this study is to report the incidence, symptoms, presenting rhythm, underlying mechanism, management, and outcome of patients presenting with compromising bradycardia to the emergency department and to assess the incidence of patients in need for temporary and permanent pacing. All patients were subjected to full history taking, general and local cardiac examination, resting 12-leads ECG and routine laboratory investigation