Standardized programming to reduce the burden of inappropriate therapies in implantable cardioverter defibrillators - Single centre follow up results.

BACKGROUND: Current algorithms and device morphology templates have been proposed in current Implantable Cardioverter-Defibrillators (ICDs) to minimize inappropriate therapies (ITS), but this has not been completely successful. AIM: Assess the impact of a deliberate strategy of using an atrial lead implant with standardized parameters; based on all current ICD discriminators and technologies, on the burden of ITS. METHOD: A retrospective single-centre analysis of 250 patients with either dual chamber (DR) ICDs or biventricular ICDs (CRTDs) over a (41.9 ± 27.3) month period was performed. The incidence of ITS on all ICD and CRTD patients was chronicled after the implementation of standardized programming. RESULTS: 39 events of anti-tachycardial pacing (ATP) and/or shocks were identified in 20 patients (8% incidence rate among patients). The total number of individual therapies was 120, of which 34% were inappropriate ATP, and 36% were inappropriate shocks. 11 patients of the 250 patients received ITS (4.4%). Of the 20 patients, four had ICDs for primary prevention and 16 for a secondary prevention. All the episodes in the primary indication group were inappropriate, while seven patients (43%) of the secondary indication group experienced inappropriate therapies. CONCLUSIONS: The burden of ITS in the population of patients receiving ICDs was 4.4% in the presence of atrial leads. The proposed rationalized programming criteria seems an effective strategy to minimize the burden of inappropriate therapies and will require further validation.

Intracardiac electrogram envelope detection during atrial fibrillation using fast orthogonal search.

The performance of any intracardiac electrogram processing method is limited by the accuracy of its activation detection approach. The most common activation detection approaches in the literature aim to find the highest peak in the activation envelope disregarding the start and end points. However, the duration of the activation can be used to extract useful information such as wave collisions. In this work, we propose a novel orthogonal based approach for fast and accurate estimation of the start and end of the activations (activation envelope) in intracardiac recordings during atrial fibrillation. Wavelet decomposition of the signals was used to create a pool of basis functions for the proposed modeling method. The database included 24 recordings of approximate length of 6s obtained from atrial endocardium of 5 patients who underwent catheter ablation therapy. The start and end of activations in each electrogram was manually annotated by an expert electrophysiologist and the annotations were used as a gold standard to calculate the performance of our envelope detection method. The results show promising performance and excellent robustness to training data for our proposed method with respect to envelope estimation error.

Computationally efficient method for localizing the spiral rotor source using synthetic intracardiac electrograms during atrial fibrillation.

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is an extremely costly public health problem. Catheter-based ablation is a common minimally invasive procedure to treat AF. Contemporary mapping methods are highly dependent on the accuracy of anatomic localization of rotor sources within the atria. In this paper, using simulated atrial intracardiac electrograms (IEGMs) during AF, we propose a computationally efficient method for localizing the tip of the electrical rotor with an Archimedean/arithmetic spiral wavefront. The proposed method deploys the locations of electrodes of a catheter and their IEGMs activation times to estimate the unknown parameters of the spiral wavefront including its tip location. The proposed method is able to localize the spiral as soon as the wave hits three electrodes of the catheter. Our simulation results show that the method can efficiently localize the spiral wavefront that rotates either clockwise or counterclockwise.

OVA-induced airway hyperresponsiveness alters murine heart rate variability and body temperature.

Altered autonomic (ANS) tone in chronic respiratory disease is implicated as a factor in cardiovascular co-morbidities, yet no studies address its impact on cardiovascular function in the presence of murine allergic airway (AW) hyperresponsiveness (AHR). Since antigen (Ag)-induced AHR is used to model allergic asthma (in which ANS alterations have been reported), we performed a pilot study to assess measurement feasibility of, as well as the impact of allergic sensitization to ovalbumin (OVA) on, heart rate variability (HRV) in a murine model. Heart rate (HR), body temperature (T(B)), and time- and frequency-domain HRV analyses, a reflection of ANS control, were obtained in chronically instrumented mice (telemetry) before, during and for 22 h after OVA or saline aerosolization in sensitized (OVA) or Alum adjuvant control exposed animals. OVA mice diverged significantly from Alum mice with respect to change in HR during aerosol challenge (P < 0.001, Two-Way ANOVA; HR max change Ctrl = +80 ± 10 bpm vs. OVA = +1 ± 23 bpm, mean ± SEM), and displayed elevated HR during the subsequent dark cycle (P = 0.006). Sensitization decreased the T(B) during aerosol challenge (P < 0.001). Sensitized mice had decreased HRV prior to challenge (SDNN: P = 0.038; Low frequency (LF) power: P = 0.021; Low/high Frequency (HF) power: P = 0.042), and increased HRV during Ag challenge (RMSSD: P = 0.047; pNN6: P = 0.039). Sensitized mice displayed decreased HRV subsequent to OVA challenge, primarily in the dark cycle (RMSSD: P = 0.018; pNN6: P ≤ 0.001; LF: P ≤ 0.001; HF: P = 0.040; LF/HF: P ≤ 0.001). We conclude that implanted telemetry technology is an effective method to assess the ANS impact of allergic sensitization. Preliminary results show mild sensitization is associated with reduced HRV and a suppression of the acute T(B)-response to OVA challenge. This approach to assess altered ANS control in the acute OVA model may also be beneficial in chronic AHR models.

Advances in the treatment of atrial fibrillation.

Management of atrial fibrillation (AF) has changed greatly in the past 10 years. The advent of a greater understanding of the pathophysiology of AF has resulted in major therapeutic breakthroughs, both in invasive and non-invasive strategies. New antiarrhythmic agents with fewer side effects, new anticoagulants and technical advances in ablation have changed the treatment of this condition. Molecular modification of the highly effective amiodarone, to improve safety and tolerability, has produced promising analogues such as Dronedarone. Although this drug seems less effective than amiodarone in preventing AF recurrence, the drug presented an interesting data on reduction of stroke and cardiovascular death, a novel effect that needs further investigation. New antiarrhythmics with atria selectiveness such Vernakalant, might be useful for cardioversion in AF without ventricular proarrhythmia. Dabigatran, a prodrug that directly inhibits thrombin, represents an alternative to warfarin for anticoagulant treatment in selected patients. In AF ablation, technological advances are sure to result in the necessary improvements in the safety and procedures efficacy. These technologies include ablation catheters designed to electrically isolate the pulmonary veins with improved safety, efficacy, speed, and precision and improved imaging and electrical mapping systems. Although pulmonary vein isolation remains essential for most ablation procedures, the role of substrate modification has taken on increasing importance. In this article, we review the advances in the treatment of AF, focus on the new medications and advances in invasive procedures.

Supraventricular tachycardia promotes release of troponin I in patients with normal coronary arteries.

BACKGROUND: Troponin I and T are sensitive markers of myocardial injury. The presence of elevated troponin often prompts further investigation with coronary angiography. METHODS: We present a series of patients presenting to our unit with raised troponin I and supraventricular tachycardia (SVT) that prompted coronary angiography. RESULTS: All patients had normal epicardial vessels at angiogram, no evidence of muscle bridging or pulmonary embolism. CONCLUSION: The presence of tachycardia sufficient to warrant hospital admission can raise troponin, and this should be viewed in context when a decision on angiography is to be taken.

Use of medications in Wolff-Parkinson-White syndrome.

The diagnosis of Wolff-Parkinson-White syndrome is generally straightforward; however, the management may not be, and requires an understanding of the competing risks of various treatment options and that of the clinical setting in which the diagnosis is made. The symptomatic patient with Wolff-Parkinson-White has an increased risk of atrial fibrillation and a small but significant risk of sudden cardiac death. Therapy is based on reduction in symptom burden and attenuation of the risk of pre-excited atrial fibrillation. Catheter ablation is the most effective means of achieving this goal with abolition of symptoms and risk of pre-excited atrial fibrillation. Medication is often employed in the acute setting to terminate paroxysms of arrhythmia associated with the accessory pathway and reduce the subsequent burden of symptoms until ablation can be performed. An overview of the agents commonly used is provided together with recommendations.

Left ventricular dysfunction resulting from frequent unifocal ventricular ectopics with resolution following radiofrequency ablation.

A case is presented, in which asymptomatic but persistent right ventricular outflow tract (RVOT) ectopics resulted in left ventricular (LV) dilatation and systolic dysfunction. The patient underwent extensive investigation with no other cause for the cardiomyopathy being found. Successful ablation of the RVOT ectopic focus resulted in normalization of LV size and function. This case suggests that frequent ventricular ectopy should be considered as a potentially remediable cause of LV dysfunction.

Effect of protein source and soluble carbohydrate addition on rumen fermentation and lactation performance of Holstein cows.

Rumen in vitro and in vivo experiments were conducted to evaluate the effect of rumen undegradable protein and soluble carbohydrates on rumen ammonia N release and lactation performance of Holstein cows. In the in vitro experiment, freeze-dried annual ryegrass (Lolium multiflorum, LAM) pasture was supplemented 1:1 with ground corn-based grain supplements containing expeller or solvent soybean meal with sucrose or lactose supplements at 0, 2.5, or 5% of dry matter (DM). The ammonia release rate was slower with expeller compared with solvent soybean meal-supplemented diets. Sucrose supplementation at the 5% level lowered rumen ammonia concentrations, but lactose-fortification of grain supplements was without effect. In the in vivo study, 32 multiparous Holstein cows were blocked according to milk yield and randomly assigned to corn-based grain supplements containing 1) solvent soybean meal, 2) solvent soybean meal + 5% sucrose supplement, 3) expeller soybean meal, or 4) expeller soybean meal + 5% sucrose supplement. Grain supplements and fresh annual ryegrass were component fed at approximately a 1:1 grain to forage ratio (DM basis). Forage DM intake was higher for cows receiving solvent soybean meal supplemented grain supplements than those receiving expeller soybean meal (12.2 +/- 2.1 vs. 11.4 +/- 2.2 kg/d), but total DM intake was similar for all diets (22.8 +/- 2.9 kg/d). Fat-corrected milk yield was similar for all diets averaging 37.5, 38.2, 39.1, and 37.6 kg/d for diets 1 to 4, respectively. Rumen fermentation, milk urea nitrogen, and body condition were unaffected by supplements; however, cows fed grain supplement 1 utilized dietary energy more efficiently than cows offered the other dietary treatments. High dietary crude protein concentrations may have limited lactation response to rumen undegradable protein and sugar.

Supplemental dietary protein for grazing dairy cows: effect on pasture intake and lactation performance.

One hundred twenty-four cows (92 multiparous and 32 primiparous) were used to evaluate the effect of grain supplements containing high crude protein [(22.8% CP, 5.3% rumen undegradable protein (RUP), dry matter basis], moderate CP (16.6% CP, 6.1% RUP), and moderate CP with supplemental RUP (16.2% CP, 10.8% RUP) on lactation performance of Holstein cows rotationally grazing annual ryegrass-oat pastures. Supplemental protein was provided by solvent extracted soybean meal in the high CP and moderate CP supplements and as a corn gluten meal-blood meal mixture (2.8:1) in the moderate CP, high RUP supplement. Cows were blocked according to previous mature milk equivalent production and calving date (partum group; 0 d in milk or postpartum group; 21 to 65 d in milk) and randomly assigned to dietary treatments. Grain was individually fed, at approximately a 1:3 grain to milk ratio, before a.m. and p.m milkings. The study was replicated during two grazing seasons that averaged 199 d. Cows had ad libitum access to bermudagrass hay while on pasture (dry matter intake = 1.3 kg/d). Protein supplementation had no effect on study long pasture dry matter (12.7 +/- 1.0 kg/d) or total dry matter (23.9 +/- 1.2 kg/d) consumption. Protein concentration did not affect actual milk yield of either calving group (high CP vs. moderate CP); however, postpartum group cows receiving high CP grain supplements maintained greater milk fat concentrations (3.34 vs. 3.11%), which led to higher fat-corrected milk (FCM) yields than control cows receiving moderate CP grain diets (30.3 vs. 28.9 kg/d). Crude protein concentration in milk of high CP-supplemented, postpartum group cows was also higher than moderate CP cows (3.42 vs. 3.27%). Additional RUP did not increase FCM yield above that generated by moderate CP grain diets for partum (34.3 vs. 32.9 kg/d) or postpartum-group cows (28.9 vs. 28.2 kg/d). Increasing CP concentration of grain supplement did not affect milk yield of Holstein cows grazing immature winter annual pastures. Supplementing additional RUP was without benefit, indicating that in this study energy deprivation may have been the major nutritional constraint for high-producing dairy cows grazing lush pastures.

Chemical composition, ensiling characteristics, and apparent digestibility of summer annual forages in a subtropical double-cropping system with annual ryegrass.

A 2-yr study was conducted to determine the chemical composition and digestibility of silages made from forage sorghum, pearl millet, and tropical corn managed to optimize forage quality. Silages were ensiled in upright concrete silos lined with plastic and fed to heifers to determine in vivo apparent digestibility. Samples were collected before and after ensiling to determine ensiling characteristics and forage quality. After ensiling, tropical corn had the greatest dry matter (DM), the lowest crude protein, and the greatest water-soluble concentrations. Tropical corn silage had a pH of 3.96. The pH of forage sorghum silage was 4.09, and pearl millet had a pH of 4.50. Pearl millet had the lowest concentration of preensiled water-soluble carbohydrate, which likely caused the high pH in the silage. There were no differences among the forages in DM loss during ensiling in yr 2. Heifers fed pearl millet silage consumed more DM, but digestible DM intake was not different among the three groups of heifers. The results of this experiment indicate that pearl millet would be less desirable as a crop intended solely for silage production. Both forage sorghum and tropical corn could be grown specifically for ensiling based on DM digestibility. The decision on which crop to use should be based on factors such as production costs, forage yields, and local growing conditions rather than silage quality.

Relationships between in situ protein degradability and grass developmental morphology.

The objective of this research was to determine the relationships between the morphological development and in situ ruminally degradable protein (RDP), ruminally undegradable protein (RUP), and microbial protein of two cool season grasses (intermediate wheatgrass and smooth bromegrass) and two warm season grasses (switchgrass and big bluestem). The initial growth of grass tillers grown near Mead, Nebraska was clipped at ground level six times during the 1992 growing season and morphologically classified. Mean stage was calculated. Forage was ground to pass a 2-mm screen and was incubated in ruminally fistulated steers for 16 h. The RUP was adjusted for microbial protein and acid detergent insoluble N. The mean stage of cool season grasses was higher than that of warm season grasses throughout the growing season. The RDP decreased as plant maturity increased for all species. The RUP expressed as a percentage of crude protein for the cool season grasses was lower than that for warm season grasses. The RUP for intermediate wheatgrass, smooth bromegrass, and switchgrass remained constant across maturities, but RUP for big bluestem decreased as maturity increased. Microbial augmentation of RUP decreased as crude protein decreased in all species. The RUP corrected for acid detergent insoluble N and microbial protein was relatively constant across plant maturities. The quantification of RUP across a range of plant maturities provided information for incorporating RUP content of forage grasses into the diets of animals.

Plant limitations to fiber digestion and utilization.

Energy availability from forages is limited by fiber concentration because fiber is slowly and incompletely digested, whereas cell solubles are almost completely digested. Thus, the proportion of fiber to cell solubles is a major determinant of energy availability in forages. Grasses normally have more fiber than legumes, especially in leaves. Grass fiber is more digestible than that of legumes, but that of legumes digests at a faster rate. Ruminants digest 40-50% of legume fiber and 60-70% of grass fiber. Some fiber cannot be digested no matter how long it remains in the rumen. Lignin is thought to interfere with microbial degradation of fiber polysaccharides by acting as a physical barrier and by being cross-linked to polysaccharides by ferulate bridges. In addition to the effects of lignin, physical and structural barriers may limit fiber digestibility. Because the middle lamella and primary wall of thick-walled cells are so highly lignified, many cells can be digested only from the interior of the cell. For many cells, access to cell interiors is limited because of large particle sizes. Forage digestibility could be improved by reducing the amount of lignified cells or by developing improved cultivars so that lignified cells are more digestible.

Ruminal degradation of switchgrass, big bluestem, and smooth bromegrass leaf proteins.

Two in situ protein disappearance experiments were conducted to determine disappearance rates of leaf protein fractions and characterize individual leaf protein fractions that escaped ruminal degradation. Fresh leaf blades of two warm-season grasses, switchgrass (Panicum virgatum L.) and big bluestem (Andropogon gerardii Vitman), and one cool-season grass, smooth bromegrass (Bromus inermis Leyss.), were included in Exp. 1. Only warm-season grasses were used in Exp. 2. Leaves were harvested from greenhouse-grown plants, placed in polyester bags, and incubated up to 48 h in situ in three ruminally fistulated steers fed diets of warm-season grass hay. The rate of protein disappearance for switchgrass (.037 h-1) was slower (P < .10) than that for big bluestem (.110 h-1). Big bluestem and smooth bromegrass (.169 h-1) disappeared at similar rates, whereas switchgrass disappeared more slowly (P < .05) than smooth bromegrass in Exp. 1. Rates of protein disappearance in Exp. 2 were similar for switchgrass (.112 h-1) and big bluestem (.116 h-1). Major protein fractions that resisted ruminal degradation in both experiments, detected using SDS-PAGE, were at approximate molecular weights of 56, 26, and 24 kDa. For switchgrass and big bluestem, total protein and individual protein fractions were generally at higher concentrations and present for longer periods of time than for smooth bromegrass. This suggests that a mechanism may exist in C4 species that allows certain protein fractions to remain undegraded for longer periods compared with smooth bromegrass.