Remote Synchronous Laceration Repair Instruction With Summary Feedback.

Background and Objectives: Social distancing and quarantine requirements imposed during the COVID-19 pandemic necessitated remote training in many learning situations that formerly focused on traditional in-person training. In this context, we developed an adaptive approach to teaching laceration repair remotely while allowing for synchronous instruction and feedback. Methods: In April 2020, 35 family medicine residents from 4 programs in the Midwest United States participated in a real-time, remotely-delivered, 2-hour virtual procedure workshop of instruction in suture techniques for laceration repair. Paired-sample t tests compared scores of learner self-confidence obtained during pre- and posttests. We interpreted short-answer responses with a mixed-methods analysis. Residents submitted photos and videos of suture techniques and received formative feedback based on a predefined rubric. Results: All residents completed the pre- and posttests. The posttest scores for self-confidence across the participants showed significant improvement for all suture techniques. Of the 67 short-answer responses, 38 responses (56.7%) were positive; 9 (13.4%) negative; 8 (11.9%) neutral; and 12 (17.9%) a combination of positive and negative. The workshop was rated by 34 residents (97.1%) as either "about the same as prior training experiences," "better than prior training experiences," or "much better than prior training experiences." Conclusion: Learners reported that a remotely-delivered, real-time, synchronous suture technique workshop was a valuable experience. Further research is needed to establish the efficacy of this platform to promote procedural competence.

A Novel High-Resolution Surface Electrocardiographic Method to Identify and Characterize Myocardial Scar: A Proof-of-Concept Study.

BACKGROUND: The placement of the left ventricular (LV) lead in an area free of myocardial scar is an important determinant of cardiac resynchronization therapy response. We sought to develop and validate a simple, practical, and novel electrocardiographic (ECG)-based approach to intraoperatively identify the presence of LV scar. We hypothesized that there would be a reduction in the measured amplitude of the LV pacing stimulus on the skin surface using a high-resolution (HR) ECG when pacing from LV regions with scar compared with regions without scar. We term this the ECG Amplitude Signal Evaluation (EASE) method. METHODS: Consecutive patients with ischemic LV systolic dysfunction and standard criteria for de novo cardiac resynchronization therapy implantation were prospectively enrolled. All underwent a preimplant contrast-enhanced cardiac magnetic resonance study to assess for scar. The average amplitude of the LV pacing impulse was sampled on HR surface ECG intraprocedurally and then compared with the cardiac magnetic resonance results. RESULTS: A total of 38 LV pacing sites were assessed among 13 recipients. The median voltage measured on the surface HR ECG in regions with scar was reduced by 41% (interquartile range, 17% to 63%), whereas there was no measurable change in voltage (interquartile range, 0 to 0%) in regions without scar compared with the maximal amplitude (Wilcoxon P < 0.0001). CONCLUSION: The EASE method appears to be of potential value as a novel intraoperative tool to guide LV lead placement to regions free of scar. Future work is required to validate the utility of this method in a larger patient cohort.

CONTEXTE: La mise en place de la sonde ventriculaire gauche dans une zone exempte de cicatrice myocardique est un facteur déterminant de la réponse au traitement de resynchronisation cardiaque. Nous avons cherché à développer et à valider une approche électrocardiographique (ECG) simple, concrète et novatrice afin de repérer de manière peropératoire la présence de tissu cicatriciel au ventricule gauche (VG). Nous avons émis l'hypothèse qu'il y aurait une diminution de l'amplitude du rythme de stimulation du ventricule gauche mesurée à la surface de la peau à l'ECG haute résolution (HR) lors de la stimulation de régions du VG présentant du tissu cicatriciel comparativement aux régions exemptes de cicatrices. Il s'agit de ce que nous appelons la méthode EASE ( E CG A mplitude S ignal E valuation). MÉTHODOLOGIE: Des patients vus de manière consécutive qui présentaient une dysfonction systolique ischémique du VG et répondaient aux critères standard pour l'implantation de novo d'un dispositif de resynchronisation cardiaque ont été recrutés de manière prospective. Tous ont fait l'objet d'une résonance magnétique cardiaque améliorée par injection d'un produit de contraste avant l'implantation pour évaluer la présence de tissu cicatriciel. L'amplitude moyenne de l'impulsion de stimulation du VG a été échantillonnée sur l'ECG de surface HR réalisé pendant l'intervention, puis comparée aux résultats de la résonance magnétique cardiaque. RÉSULTATS: En tout, 38 points de stimulation du VG ont été évalués chez 13 receveurs. Le voltage médian mesuré sur l'ECG de surface HR dans les régions présentant du tissu cicatriciel était réduit de 41 % (intervalle interquartile : 17 % à 63 %), tandis qu'il n'y avait pas de changement mesurable du voltage (intervalle interquartile : 0 à 0 %) dans les régions exemptes de cicatrices par rapport à l'amplitude maximale (test de Wilcoxon, p < 0,0001). CONCLUSION: La méthode EASE semble avoir une utilité potentielle en tant que nouvel outil peropératoire pour guider la mise en place de la sonde ventriculaire gauche dans les régions exemptes de cicatrices. Il faudra réaliser d'autres travaux pour valider l'utilité de cette méthode dans une cohorte de patients plus importante.

Application of pharmacogenomics and bioinformatics to exemplify the utility of human ex vivo organoculture models in the field of precision medicine.

Here we describe a collaboration between industry, the National Health Service (NHS) and academia that sought to demonstrate how early understanding of both pharmacology and genomics can improve strategies for the development of precision medicines. Diseased tissue ethically acquired from patients suffering from chronic obstructive pulmonary disease (COPD), was used to investigate inter-patient variability in drug efficacy using ex vivo organocultures of fresh lung tissue as the test system. The reduction in inflammatory cytokines in the presence of various test drugs was used as the measure of drug efficacy and the individual patient responses were then matched against genotype and microRNA profiles in an attempt to identify unique predictors of drug responsiveness. Our findings suggest that genetic variation in CYP2E1 and SMAD3 genes may partly explain the observed variation in drug response.

Left Atrial Function Using Cardiovascular Magnetic Resonance Imaging Independently Predicts Life-Threatening Arrhythmias in Patients Referred to Receive a Primary Prevention Implantable Cardioverter Defibrillator.

BACKGROUND: In this study we aimed to investigate left atrial (LA) function, measured from routine cine cardiovascular magnetic resonance imaging, to determine its value for the prediction of sudden cardiac death (SCD) or appropriate implantable cardioverter defibrillator (ICD) shock in patients who received primary prevention ICD implantation. METHODS: We studied 203 patients with ischemic or idiopathic nonischemic dilated cardiomyopathy who underwent cardiovascular magnetic resonance imaging before primary prevention ICD implantation. LA volumes were measured at end-diastole and end-systole from 4- and 2-chamber cine images, and LA emptying function (LAEF) calculated. Patients were followed for the primary composite end point of SCD or appropriate ICD shock. RESULTS: Mean age was 61 ± 12 years with a mean left ventricular ejection fraction of 24 ± 7%. The mean LAEF was 27 ± 15% (range, 0.9%-73%). At a median follow-up of 1639 days, 35 patients (17%) experienced the primary composite outcome. LAEF was strongly associated with the primary outcome (P = 0.001); patients with an LAEF ≤ 30% experienced a cumulative event rate of 26.1% vs 5.7% (hazard ratio, 5.5; P < 0.001) in patients above this cutoff. This finding was maintained in multivariable analysis (hazard ratio, 4.7; P = 0.002) and was consistently shown in the ischemic and nonischemic dilated cardiomyopathy subgroups. CONCLUSIONS: LAEF is a simple, powerful, and independent predictor of SCD in patients being referred for primary prevention ICD implantation.

A Population-Based Study of Device Eligibility, Use, and Reasons for Nonimplantation in Patients at Heart Function Clinics.

BACKGROUND: Implantable cardioverter defibrillator (ICD) therapy is lifesaving; however, real-world data regarding the proportion of patients eligible for a primary prevention ICD and subsequent use remain sparse. This study evaluated rates of primary prevention ICD eligibility and use among patients in heart function clinics (HFCs) and to identify reasons for nonimplantation. METHODS: A retrospective study was performed of patients seen at HFCs in Alberta, Canada, from 2013 to 2015. Demographics, comorbidities, clinical indications, and reasons for nonimplantation were abstracted. Eligibility was defined according to the 2008 American College of Cardiology/American Heart Association/Heart Rhythm Society ICD, 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society Focused Update, and 2013 Canadian Cardiovascular Society Cardiac Resynchronization Therapy guidelines. Logistic regression was used to calculate an odds ratio (OR) and 95% confidence interval (CI) for predictors of nonimplantation. RESULTS: Among 1239 patients in HFCs, the median age was 70 years (interquartile range, 59-80), 67% were male, and the median left ventricular ejection fraction was 0.40 (interquartile range, 0.28-0.53). Overall, 45% of patients (n = 553) met guideline criteria for an ICD, and of those, 36% (n = 198) received a device. Among device nonrecipients, 52% (n = 185) had no documented reason for nonimplantation. The most common reason for nonimplantation among nonrecipients was patient preference (48%). Predictors associated with nonimplantation were age more than 75 years (OR, 1.92; 95% CI, 1.31-2.82) and history of cancer (OR, 2.26; 95% CI, 1.07-4.78). At 3 years follow-up, 27% of nonrecipients were deceased. CONCLUSIONS: We found that one-third of patients who met guideline criteria received an ICD and that documentation for nonimplantation was poor.

CONTEXTE: Le défibrillateur cardioverteur implantable (DCI) sauve des vies. Or, les données recueillies dans la pratique réelle concernant le pourcentage de patients admissibles à l'implantation d'un tel dispositif en prévention primaire et l'utilisation subséquente de ce dispositif sont très limitées. Cette étude a évalué le taux de patients admissibles à la pose d'un DCI en prévention primaire et le taux d'utilisation de ce dispositif chez des patients traités en clinique de cardiologie. Elle a également recensé les motifs de non-implantation. MÉTHODOLOGIE: Une étude rétrospective a été réalisée chez des patients traités de 2013 à 2015 dans plusieurs cliniques de cardiologie de l'Alberta, au Canada. Les données relatives aux caractéristiques démographiques, aux comorbidités, aux indications cliniques et aux motifs de la non-implantation ont été extraites. L'admissibilité était définie en fonction des lignes directrices de 2008 de l'American College of Cardiology, de l'American Heart Association et de la Heart Rhythm Society sur le DCI, de leur mise à jour ciblée en 2012 et des lignes directrices de 2013 de la Société canadienne de cardiologie sur la thérapie de resynchronisation cardiaque. Une régression logistique a été utilisée pour calculer le risque relatif approché (RRA) et l'intervalle de confiance (IC) à 95 % associés aux facteurs de prédiction de la non-implantation. RÉSULTATS: L'âge médian des 1 239 patients traités en clinique de cardiologie était de 70 ans (plage interquartile : 59 ­ 80 ans); 67 % d'entre eux étaient des hommes, et la fraction d'éjection ventriculaire gauche médiane était de 0,40 (plage interquartile : 0,28 ­ 0,53). D'une manière générale, 45 % des patients (n = 553) répondaient aux critères énoncés dans les lignes directrices pour la pose d'un DCI, et 36 % d'entre eux (n = 198) ont reçu un dispositif. Parmi les patients qui n'ont pas reçu de dispositif, aucun motif justifiant la non-implantation n'a été documenté chez 52 % des patients (n = 185); chez les 48 % des patients restants, le motif le plus courant pour justifier la non-implantation a été la préférence du patient. Les facteurs de prédiction associés à la non-implantation ont été l'âge (plus de 75 ans; RRA : 1,92; IC à 95 % : 1,31 ­ 2,82) et les antécédents de cancer (RRA : 2,26; IC à 95 % : 1,07 ­ 4,78). Après 3 ans de suivi, 27 % des patients qui n'avaient pas reçu de dispositif étaient décédés. CONCLUSIONS: Nous avons constaté que le tiers des patients qui répondaient aux critères énoncés dans les lignes directrices ont reçu un DCI et que les motifs justifiant la non-implantation étaient mal documentés.

Baseline delayed left ventricular activation predicts long-term clinical outcome in cardiac resynchronization therapy recipients.

AIMS: We undertook this analysis to assess the relationship between delayed left ventricular activation time (LVAT), assessed prior to cardiac resynchronization therapy (CRT), with the long-term clinical outcomes in CRT recipients. We also sought to determine if baseline LVAT had similar predictive value in patients who were versus were not chronically paced prior to CRT. METHODS AND RESULTS: Baseline pre-implant electrocardiograms (ECGs) of 219 consecutive patients undergoing CRT were analysed. Of these, 68 (31%) were chronically right ventricular (RV)-paced pre-CRT. Maximum LVAT was measured as QRS-duration minus time from QRS onset to the first notch in the QRS. Cox models were used to assess the association between LVAT and clinical outcome (death or cardiac transplant). Over a median follow-up of 56 months, 92 patients (42%) died and 10 (5%) underwent cardiac transplant. In the non-RV-paced group an independent linear relationship between LVAT and outcome [hazard ratio (HR) 0.67 per 50 ms increase in LVAT; 95% confidence interval (CI) 0.46-0.99] was observed. An LVAT ≥ 125 ms was associated with a markedly lower risk of outcome (adjusted HR 0.51; 95% CI 0.30-0.86) in these patients. Despite a similar incidence of death or cardiac transplantation in the RV-paced group vs. the non-paced one, no significant association between LVAT and outcome was observed in the RV-paced group. CONCLUSION: Baseline LVAT, a simple ECG measure, independently predicts long-term outcome with CRT in non-RV paced patients. However, prolonged LVAT is not associated with an altered prognosis in patients chronically RV paced prior to CRT.

Association of rate-controlled persistent atrial fibrillation with clinical outcome and ventricular remodelling in recipients of cardiac resynchronization therapy.

BACKGROUND: Whether patients with persistent atrial fibrillation (AF) obtain the same degree of benefit with cardiac resynchronization therapy (CRT) as those in sinus rhythm remains unclear. METHODS: We enrolled 93 patients undergoing CRT implantation, 20 (22%) of whom had rate-controlled persistent AF. The primary endpoint was CRT response defined as 1 class improvement in Specific Activity Scale and 15% reduction in left ventricular end-systolic volume (LVESV) during 12 months. Other endpoints included changes in 6-minute walk distance, quality of life, B-type natriuretic peptide, and survival. RESULTS: Baseline characteristics were similar in those with and without AF. Response to CRT was observed in 42% vs 54% of those with and without AF, respectively (P=0.3). Both groups had significant improvements in 6-minute walk distance, quality of life, and LVESV, but the improvement in LVESV was smaller in those with AF (13.7%±14.9% vs 27.7%±23.7%; P=0.02). During 2.8±1.4 years of follow-up, AF was associated with a 2.2-fold increased risk of death or transplantation (95% confidence interval, 1.2-3.9; P=0.01). CONCLUSIONS: Compared with patients without rate-controlled persistent AF, those with rate-controlled persistent AF had similar rates of clinical improvement but less left ventricular reverse remodelling in the first year after CRT. AF was associated with a markedly higher risk of death or transplantation in long-term follow-up. Given these findings, randomized studies assessing CRT efficacy in those with AF are warranted.

Relationship between left ventricular lead position using a simple radiographic classification scheme and long-term outcome with resynchronization therapy.

BACKGROUND: Benefit from cardiac resynchronization therapy (CRT) is likely influenced by the location of the left ventricular (LV) lead. PURPOSE: To evaluate the association of LV lead position with outcome after CRT. METHODS: Two-hundred and fifty patients with LV dysfunction, New York Heart Association (NYHA) class III (68%) or IV (32%) symptoms, and QRS durations > or =120 ms were followed for a median of 30 months post-CRT. LV lead position was categorized as anterior (n = 20, 8%), lateral (n = 128, 51%), or posterior (n = 102; 41%) using postero-anterior and lateral postoperative chest radiographs. RESULTS: Median age was 69 years and most (68%) had ischemic LV dysfunction. Clinical response, defined by a > or =1 NYHA class reduction, was lower in patients with an anterior (30%) versus lateral (76%) or posterior (73%) lead position (p = 0.001). An anterior versus nonanterior position was independently associated with a two to three-fold higher risk for nonresponse to CRT, cardiovascular death, death from worsening heart failure or cardiac transplantation, and death from any cause. Repositioning of the LV lead from an anterior to a nonanterior position in seven patients who had not clinically responded to CRT after > or =6 months resulted in clinical improvement in all cases. CONCLUSIONS: An anterior versus nonanterior LV lead position is independently associated with an increased likelihood of nonresponse to CRT and a higher risk of serious outcomes. Repositioning of an anteriorly placed LV lead to a nonanterior position should be considered in CRT nonresponders.