Clinical Features and Sites of Ablation for Patients With Incessant Supraventricular Tachycardia From Concealed Nodofascicular and Nodoventricular Tachycardias.

OBJECTIVES: This study sought to describe the clinical features and sites of successful ablation for incessant nodofascicular (NF) and nodoventricular (NV) tachycardias. BACKGROUND: Incessant supraventricular tachycardias have been associated with tachycardia-induced cardiomyopathies and have been previously attributed to permanent junctional reciprocating tachycardias, atrial tachycardias, and atrioventricular nodal re-entrant tachycardias. Incessant concealed NF and NV tachycardias have not been described previously. METHODS: Three cases of incessant concealed NF and NV re-entrant tachycardias were identified from 2 centers. RESULTS: The authors describe 3 cases with incessant supraventricular tachycardia resulting from NV (2 cases) and NF (1 case) pathways. Atrioventricular nodal re-entrant tachycardia was excluded by His synchronous premature ventricular complexes that either delayed or terminated the tachycardia. Ventricular pacing showed constant and progressive fusion in cases 1 and 3. In 2 cases, there was spontaneous initiation with a 1:2 response (cases 1 and 3); the presence of retrograde longitudinal dissociation or marked decremental pathway conduction in cases 1 and 3 sustains these tachycardias. The NV pathway was successfully ablated in the slow pathway region in case 3 and at the right bundle branch in case 1. The NF pathway was successfully ablated within the proximal coronary sinus in case 2. CONCLUSIONS: This is the first report of incessant supraventricular tachycardia using concealed NF or NV pathways. These tachycardias demonstrated spontaneous initiation from sinus rhythm with a 1:2 response and retrograde longitudinal dissociation or marked decremental pathway conduction. Successful ablation was achieved at either right-sided sites or within the coronary sinus.

Metabolomic Profiling in Relation to New-Onset Atrial Fibrillation (from the Framingham Heart Study).

Previous studies have shown several metabolic biomarkers to be associated with prevalent and incident atrial fibrillation (AF), but the results have not been replicated. We investigated metabolite profiles of 2,458 European ancestry participants from the Framingham Heart Study without AF at the index examination and followed them for 10 years for new-onset AF. Amino acids, organic acids, lipids, and other plasma metabolites were profiled by liquid chromatography-tandem mass spectrometry using fasting plasma samples. We conducted Cox proportional hazard analyses for association between metabolites and new-onset AF. We performed hypothesis-generating analysis to identify novel metabolites and hypothesis-testing analysis to confirm the previously reported associations between metabolites and AF. Mean age was 55.1 ± 9.9 years, and 53% were women. Incident AF developed in 156 participants (6.3%) in 10 years of follow-up. A total of 217 metabolites were examined, consisting of 54 positively charged metabolites, 59 negatively charged metabolites, and 104 lipids. None of the 217 metabolites met our a priori specified Bonferroni corrected level of significance in the multivariate analyses. We were unable to replicate previous results demonstrating associations between metabolites that we had measured and AF. In conclusion, in our metabolomics approach, none of the metabolites we tested were significantly associated with the risk of future AF.

Medication adherence and heart failure.

Heart failure remains among the most prevalent and burdensome medical conditions in the United States. With increasing awareness regarding resource use and costs of care, there has been significant interest in the identification of factors that influence rates of hospitalization and readmission in individuals with heart failure. Medication adherence has been identified as one such modifiable factor. Many barriers to medication adherence have been identified and include factors related to the patient, those related to their medical condition, their medical regimen, the healthcare system and others that are social and socioeconomic in nature. Identification of these barriers has led to novel interventions for improving medication adherence with the goal of improving the care of individuals with heart failure.

Predictors of severe morbidity and death after elective abdominal aortic aneurysmectomy in patients with chronic obstructive pulmonary disease.

OBJECTIVE: This study sought to identify risk factors associated with an unfavorable outcome after elective abdominal aortic aneurysm (AAA) repair in patients with chronic obstructive pulmonary disease (COPD). METHODS: The clinical records of 158 patients who underwent elective open AAA repair with COPD determined from preadmission International Classification of Diseases-ninth revision codes during a 12-year period at the University of Michigan were reviewed. Patients with uncomplicated outcomes (group I) were compared with those with unfavorable postoperative outcomes (group II). The unfavorable outcomes were defined as myocardial infarction, acute renal failure, worsening respiratory insufficiency necessitating tracheostomy, or death within 30 days of surgery. Logistic regression analyses of variables that were identified as being statistically significant in the univariate analysis were used to develop a predictive model of these events. RESULTS: Group I included 133 patients (77 men, 56 women) with a mean age of 70.1 years, and group II included 25 patients (13 men, 12 women) with a mean age of 71.4 years. Preoperative factors statistically related (P =.002) to an unfavorable outcome in group II patients included: suboptimal COPD management (fewer prescribed inhalers), lower hematocrit, preoperative renal insufficiency, and coronary artery disease. Importantly, abnormal preoperative spirometry and arterial blood gases were not predictive of a poor outcome. Univariate analysis also revealed increased hospital (25 versus 13 days; P =.0001) and intensive care unit (14 versus 4 days; P =.001) length of stays and a greater need for prolonged ventilation (8 versus 1 day; P =.039) for group II patients compared with group I patients. The 30-day mortality rate in the entire experience was 3.2% (5/158). No specific variables associated with mortality were identified. CONCLUSION: Fewer prescribed inhalers, lower hematocrit, renal insufficiency, and coronary artery disease are preoperative factors associated with unfavorable outcomes after open elective surgical repair of AAA in patients with COPD. Intensive management of these factors may reduce the hazards of AAA operations in these patients. COPD alone should not be considered a deterrent to the surgical treatment of AAAs.