Spatial variance in the 12-lead ECG and mechanical dyssynchrony.

INTRODUCTION: Electrical transmission disorders have a deleterious effect on cardiac depolarization, resulting in a disorganized ventricular contraction that reduces global mechanical efficiency; this mechanical dyssynchrony can be corrected by cardiac resynchronization therapy. However, despite adjustments in the electrical criteria selection of QRS for the recognition of mechanical dyssynchrony, a significant proportion of patients do not currently respond to this therapy. PURPOSE: To find if a new predictor of dyssynchrony, the electrocardiogram spatial variance, is a better marker of mechanical dyssynchrony than QRS duration. METHODS: Forty-seven electrocardiograms and 47 strain (2D speckle tracking) echocardiograms were prospectively collected simultaneously in consecutive, non-selected patients; the left ventricular mechanical dispersion was measured in all the cases. The electrocardiographic analysis of variance was made with a digital superposition of the electrocardiographic leads and generates different indexes of variance of both QRS complex and repolarization phase. RESULTS: ROC analysis probed that the best area under the curve (AUC) value correlated with left ventricular mechanical dispersion and was obtained combining several spatial variance markers (considering depolarization and repolarization spatial variance together; AUC = 0.97); the same analysis using the QRS duration versus mechanical dispersion showed a significantly lower AUC value (AUC = 0.64). CONCLUSION: Spatial variance combining depolarization and repolarization markers is a superior predictor of left ventricular mechanical dispersion than QRS duration.

Novel implant technique for septal pacing. A noninvasive approach to nonselective his bundle pacing.

BACKGROUND: His Bundle pacing (HBP) preserves native ventricular activation through His Purkinje. Unfortunately, most current techniques for HBP implants require sheaths, special leads, and an electrophysiology setup for electrogram recording. METHODS: We developed an implantation technique guided by a non-invasive assessment of left ventricular electrical delay (LVED) as a measure of intraventricular dyssynchrony. The objective was to evaluate the usefulness and safety of this technique for implants of pacemakers and ICDs with right ventricular septal pacing (RVSP) using conventional screw-in leads and compare it with a reduced group of HBP (n = 32) guided by His potential mapping. 208 patients eligible for ventricular stimulation were implanted. Conventional screw-in leads were used in all cases. To ensure mechanical stability, stylets required a slight reshaping at the tip RESULTS: RVSP normalized electrical activity in patients with conduction disease, producing NS-HBP-like patterns. The parameters evaluated during implantation for the RVSP group were better than those of HBP and remained constant at a twelve months follow-up. In proportion, the number of dislodgments and the need for CRT upgrade was lower for RVSP than for HBP. Additionally, fluoroscopy time was significantly reduced in the RVSP group. CONCLUSIONS: This technique successfully guided RVSP implants in a non-invasive way and represents a simple alternative to the implant of a cardiac stimulation device.

The Effect of Breath Pacing on Task Switching and Working Memory.

The cortical and subcortical circuit regulating both cognition and cardiac autonomic interactions are already well established. This circuit has mainly been analyzed from cortex to heart. Thus, the heart rate variability (HRV) is usually considered a reflection of cortical activity. In this paper, we investigate whether HRV changes affect cortical activity. Short-term local autonomic changes were induced by three breathing strategies: spontaneous (Control), normal (NB) and slow paced breathing (SB). We measured the performance in two cognition domains: executive functions and processing speed. Breathing maneuvres produced three clearly differentiated autonomic states, which preconditioned the cognitive tasks. We found that the SB significantly increased the HRV low frequency (LF) power and lowered the power spectral density (PSD) peak to 0.1[Formula: see text]Hz. Meanwhile, executive function was assessed by the working memory test, whose accuracy significantly improved after SB, with no significant changes in the response times. Processing speed was assessed by a multitasking test. Consistently, the proportion of correct answers (success rate) was the only dependent variable affected by short-term and long-term breath pacing. These findings suggest that accuracy, and not timing of these two cognitive domains would benefit from short-term SB in this study population.

Classification of ischemic and non-ischemic cardiac events in Holter recordings based on the continuous wavelet transform.

Holter recordings are widely used to detect cardiac events that occur transiently, such as ischemic events. Much effort has been made to detect early ischemia, thus preventing myocardial infarction. However, after detection, classification of ischemia has still not been fully solved. The main difficulty relies on the false positives produced because of non-ischemic events, such as changes in the heart rate, the intraventricular conduction or the cardiac electrical axis. In this work, the classification of ischemic and non-ischemic events from the long-term ST database has been improved, using novel spectral parameters based on the continuous wavelet transform (CWT) together with temporal parameters (such as ST level and slope, T wave width and peak, R wave peak, QRS complex width). This was achieved by using a nearest neighbour classifier of six neighbours. Results indicated a sensitivity and specificity of 84.1% and 92.9% between ischemic and non-ischemic events, respectively, resulting a 10% increase of the sensitivity found in the literature. Extracted features based on the CWT applied on the ECG in the frequency band 0.5-4 Hz provided a substantial improvement in classifying ischemic and non-ischemic events, when comparing with the same classifier using only temporal parameters. Graphical Abstract In this work it is improved the classification of ischemic and non-ischemic events. The main difficulty of ischemic detectors relies on the false positives produced because of non-ischemic events. After a preprocessing stage, temporal and spectral parameters are extracted from events of the Long Term ST Database. The novel parameters proposed in this work are extracted from the Continuous Wavelet Transform. A nearest Neighbor Classifier is used, obtaining a sensitivity and specificity of 84.1% and 92.9%, respectively.

Electrical approach to improve left ventricular activation during right ventricle stimulation.

Coronary sinus mapping is commonly used to evaluate left atrial activation. Herein, we propose to use it to assess which right ventricular pacing modality produces the shortest left ventricular activation times (R-LVtime) and the narrowest QRS widths. Three study groups were defined: 54 controls without intraventricular conduction disturbances; 15 patients with left bundle branch block, and other 15 with right bundle branch block. Left ventricular activation times and QRS widths were evaluated among groups under sinus rhythm, right ventricular apex, right ventricular outflow tract and high output septal zone (SEPHO). Left ventricular activation time was measured as the time elapsed from the surface QRS onset to the most distal left ventricular deflection recorded at coronary sinus. During the above stimulation modalities, coronary sinus mapping reproduced electrical differences that followed mechanical differences measured by tissue doppler imaging. Surprisingly, 33% of the patients with left bundle branch block displayed an early left ventricular activation time, suggesting that these patients would not benefit from resynchronization therapy. SEPHO improved QRS widths and left ventricular activation times in all groups, especially in patients with left bundle branch block, in whom these variables became similar to controls. Left ventricular activation time could be useful to search the optimum pacing site and would also enable detection of non-responders to cardiac resynchronization therapy. Finally, SEPHO resulted the best pacing modality, because it narrowed QRS-complexes and shortened left ventricular activations of patients with left bundle branch block and preserved the physiological depolarization of controls.

Electrical approach to improve left ventricular activation during right ventricle stimulation

Coronary sinus mapping is commonly used to evaluate left atrial activation. Herein, we propose to use it to assess which right ventricular pacing modality produces the shortest left ventricular activation times (R-LVtime) and the narrowest QRS widths. Three study groups were defined: 54 controls without intraventricular conduction disturbances; 15 patients with left bundle branch block, and other 15 with right bundle branch block. Left ventricular activation times and QRS widths were evaluated among groups under sinus rhythm, right ventricular apex, right ventricular outflow tract and high output septal zone (SEPHO). Left ventricular activation time was measured as the time elapsed from the surface QRS onset to the most distal left ventricular deflection recorded at coronary sinus. During the above stimulation modalities, coronary sinus mapping reproduced electrical differences that followed mechanical differences measured by tissue doppler imaging. Surprisingly, 33% of the patients with left bundle branch block displayed an early left ventricular activation time, suggesting that these patients would not benefit from resynchronization therapy. SEPHO improved QRS widths and left ventricular activation times in all groups, especially in patients with left bundle branch block, in whom these variables became similar to controls. Left ventricular activation time could be useful to search the optimum pacing site and would also enable detection of non-responders to cardiac resynchronization therapy. Finally, SEPHO resulted the best pacing modality, because it narrowed QRS-complexes and shortened left ventricular activations of patients with left bundle branch block and preserved the physiological depolarization of controls.

El mapeo del seno coronario se utiliza comúnmente para evaluar la activación de la aurícula izquierda. Aquí, investigamos su utilidad para evaluar qué modalidad de estimulación ventricular derecha produce los menores tiempos de activación ventricular izquierda (R-LVtime). Se definieron tres grupos: 54 controles; 15 pacientes con bloqueo de rama izquierda y 15 con bloqueo de rama derecha. El ancho de QRS y los tiempos de activación fueron evaluados en cada grupo bajo las siguientes modalidades: ritmo sinusal, ápex del ventrículo derecho, tracto de salida del ventrículo derecho y alta salida en septum (SEPHO). El R-LVtime se midió como el tiempo transcurrido desde el inicio del QRS de superficie y la deflexión ventricular izquierda más distal del seno coronario. Durante las distintas modalidades de estimulación, el mapeo del seno coronario reprodujo diferencias eléctricas acompañadas por diferencias mecánicas que fueron evaluadas mediante Tissue Doppler Imaging. El 33% de los pacientes con bloqueo de rama izquierda mostró R-LVtime tempranos, lo que sugiere que estos pacientes no se beneficiarían con terapia de resincronización. SEPHO mejoró el ancho de QRS y el R-LVtime de todos los grupos, especialmente en los pacientes con bloqueo de rama izquierda. En conclusión, el R-LVtime serviría para identificar el sitio óptimo de estimulación y permitiría detectar ciertos no respondedores a la terapia de resincronización. Además, el SEPHO resultó la mejor modalidad de estimulación porque estrechó el QRS y acortó el R-LVtime de los pacientes con bloqueo de rama izquierda pero no alteró la despolarización fisiológica de los controles.