Antidromic AVRT with changing His activation. What is the mechanism?

We present a case of antidromic AVRT involving an atriofascicular pathway in a patient with an atretic coronary sinus os. This patient had left ventricular dysfunction with rate-related left bundle branch block aberrancy in sinus rhythm. In the electrophysiology lab, there was VA dissociation for a few beats during antidromic tachycardia. The possible mechanisms that could explain this intracardiac finding are discussed.

Reconstruction of osseous defect with symphysis block graft for implant placement.

Introduction: Symphysis being an autogenous bone graft serves as one of the best graft for augmenting osseous defects of alveolar process with excellent results. It has been favoured mainly due to its local availability, accessibility and lesser resorption compared to other bones in the region. Case report: A 21/M reported to the department of Implantology with the complaint of missing tooth in the upper front tooth region since 1 year. History revealed extraction of upper left central incisor an year ago following trauma. Diagnosis was made as Siebert's Class I with horizontal bone loss irt 21 region with a bone defect of 10.54 x 5.08 x 4.85 mm. So a complete prosthetic rehabilitation protocol was made with an implant placement and grafting was planned with symphysis being most favourable. Conclusion: The mandibular symphysis is a reliable intraoral graft site that can be used in the office setting with low morbidity. Because of the intraoral approach and lack of cutaneous scarring, patient acceptance is high.

PCR-based Evaluation of Human Papillomavirus Genotypes in Oral Lichen Planus.

Objective: The objective of the study was to use polymerase chain reaction (PCR) to examine and compare the genotype distribution of human papillomavirus (HPV) in oral lichen planus (OLP). Materials and Methods: Deoxyribonucleic acid (DNA) was extracted from 20 OLP biopsy specimens. Conventional PCR assay employing consensus HPV primers was used to identify HPV DNA. Positive PCR samples were then subjected to PCR assay with HPV type-specific primers. Results: Out of the total 20 OLP specimens evaluated, eight samples (40%) were positive for HPV. Females had a 41.7% higher HPV-positive rate than males. The most common type in the HPV type-specific PCR assay was HPV-18 (75%), which is a high-risk type of HPV linked to malignant diseases. The erosive kind of OLP had the greatest percentage of HPV positives (50%). Conclusion: The present study confirms the detection of HPV in OLP lesions, as determined by PCR-coupled HPV gene sequencing, as well as its likely mechanism of malignant transformation.

Impact of transesophageal electrophysiological study on midterm management of pediatric tachyarrhythmias.

Background: Transesophageal electrophysiological study (TEEPS) is a minimally invasive procedure that helps in evaluating the risk of recurrence of supraventricular tachycardia based on the inducibility of the tachycardia. The purpose of this study was to evaluate the diagnostic capability, negative predictive value of noninducibility of tachycardia and safety of TEEPS among the Indian pediatric population. Methods: It is a retrospective single-center observational study of all patients who underwent TEEPS from January 01, 2014, to December 31, 2020. Results: Twenty-two TEEPS procedures were done in eighteen children with three children undergoing more than one procedure. The median duration of follow-up was 42.97 months (8.52-82.12 months). Out of the 22 procedures, four were conducted for acute tachycardia termination, two for tachycardia suppression assessment, and sixteen to assess tachycardia inducibility off medications. Tachycardia was noninducible in nine children and inducible in six children. Two children had clinical recurrence of tachycardia on follow-up. Out of these two children, one had noninducibility of tachycardia on TEEPS. The negative predictive value of TEEPS was 88.89% in this study. None of the children had any postprocedure complication. Conclusions: TEEPS is a safe procedure. It is used to assess the efficacy of medication in the suppression of arrhythmia. The noninducibility of tachycardia has a high negative predictive value and is a good indicator of nonrecurrence of clinical tachycardia on midterm follow-up.

Do the predictors of right ventricular pacing-induced cardiomyopathy add up?

OBJECTIVE: Knowledge of factors causing pacing-induced cardiomyopathy (PICM) is incomplete. We sought to estimate the incidence and predisposing factors for PICM and evaluate if the risk they portend adds up. METHODS: Single centre retrospective study where consecutive patients with preserved LVEF undergoing pacemaker (PM) implantation between 2012 and 2018 were analysed. RESULTS: A total of 749 patients (68.4 % male; mean age 59.2 ± 14.08 years) were included in the analysis. PICM developed in 74 (9.9%) patients over a median follow up of 2.2 years (IQR 1.1-3.2). Pre-implant LVEF, paced QRS duration and RV pacing burden were independent predictors of PICM. Using 90 % specificity cut-off values for LVEF and paced QRS, and the value separating lowest tertile of RV pacing from the higher tertiles, three risk factors were identified: (i) baseline LVEF < 55 %, (ii) paced QRS duration > 160 msec, and (iii) RV pacing burden > 33 %. Patients with two or more risk factors were at the highest risk (OR 11.62, 95 % CI 4.62-29.21, p-value < 0.001) for developing PICM while those with one risk factor had an intermediate risk (OR 3.89, 95 % CI 1.62-9.34, p-value 0.002) when compared to those without any risk factors. CONCLUSION: Low-normal baseline LVEF, wider paced QRS and higher RV pacing burden independently predicted the development of PICM. The presence of ≥2 factors increased the odds of PICM, twelve-fold. A narrower paced QRS, the only modifiable risk factor may help mitigate development of PICM.

Association Between Iatrogenic Delivery for Suspected Fetal Growth Restriction and Childhood School Outcomes.

Importance: Timely delivery of infants suspected of having fetal growth restriction (FGR) is a balance between preventing stillbirth and minimizing prematurity, particularly because many infants with suspected FGR have normal growth. Objective: To explore the association between iatrogenic delivery for suspected FGR and childhood school outcomes. Design, Setting, and Participants: A retrospective whole-population cohort study linking perinatal data from births 32 weeks' or more gestation between January 1, 2003, to December 31, 2013, to developmental and educational test scores at preparatory school, and at school grades 3, 5, and 7 in Victoria, Australia. Follow-up was concluded in 2019. Exposures: Suspicion or nonsuspicion of FGR, presence or absence of iatrogenic delivery (defined as early induction of labor or cesarean delivery prior to labor) for suspected FGR, and presence or absence of small for gestational age (SGA). Main Outcomes and Measures: The coprimary outcomes were being in the bottom 10th percentile on 2 or more of 5 developmental domains at school entry and being below the national minimum standard on 2 or more of 5 educational domains in grades 3, 5, or 7. Results: In the birth population of 705 937 infants, the mean gestation at birth was 39.1 (SD, 1.5) weeks and the mean birth weight was 3426 (SD, 517) grams. The birth population linked to 181 902 children with developmental results and 425 717 children with educational results. Compared with infants with severe SGA (birth weight <3rd percentile) not suspected of having FGR, infants with severe SGA delivered for suspected FGR were born earlier (mean gestation, 37.9 weeks vs 39.4 weeks). They also had a significantly increased risk of poor developmental outcome at school entry (16.2% vs 12.7%; absolute difference, 3.5% [95% CI, 0.5%-6.5%]); adjusted odds ratio [aOR], 1.36 [95% CI, 1.07-1.74]) and poor educational outcomes in grades 3, 5, and 7 (for example, in grade 7: 13.4% vs 10.5%; absolute difference, 2.9% [95% CI, 0.4%-5.5%]); aOR, 1.33 [95% CI, 1.04-1.70]). There was no significant difference between infants with normal growth (birth weight ≥10th percentile) delivered for suspected FGR and those not suspected of having FGR in developmental outcome (8.6% vs 8.1%; absolute difference, 0.5% [95% CI, -1.1% to 2.0%]); aOR, 1.17 [95% CI, 0.95-1.45]) or educational outcome in grade 3, 5 or 7, despite being born earlier (mean gestation, 38.0 weeks vs 39.1 weeks). Conclusions and Relevance: In this exploratory study conducted in Victoria, Australia, iatrogenic delivery of infants with severe SGA due to suspected FGR was associated with poorer school outcomes compared with infants with severe SGA not suspected of having FGR. Iatrogenic delivery of infants with normal growth due to suspected FGR was not associated with poorer school outcomes compared with infants with normal growth not suspected of having FGR.

Postpacing interval is shorter than tachycardia cycle length-What's the mechanism?

A 33-year-old male who underwent surgery for Tetralogy of Fallot presented with atrial flutter. Electrophysiology study revealed concealed entrainment along the mid lateral right atrium with postpacing interval shorter than the tachycardia cycle length. Ablation at this site terminated the tachycardia. The presence of shorter PPI than TCL was due to a large virtual electrode leading to downstream capture of far field tissue. This case demonstrates that sites showing PPI shorter than TCL are in a slow conducting narrow critical isthmus and hence constitute good ablation targets.

Ventricular noncompaction and long QT syndrome - A deadly double hit for the foetus.

Congenital long QT syndrome [LQTS] is a channelopathy characterized by QT prolongation and polymorphic VT. LQTS however need not be a purely electrical disease. Defects in ion channels may cause myocardial architectural disruption leading to ventricular non compaction [VNC]. It is defined as the presence of prominent ventricular trabeculations and deep intertrabecular recesses within the endomyocardium. We describe the in-utero management of a foetus who was later found to have LQTS with VNC. The detection of ventricular tachycardia and complete heart block in utero should arouse the suspicion of LQTS. It would be wise to avoid QT prolonging antiarrhythmics in this subset of patients.

The pitfalls of using birthweight centile charts to audit care.

OBJECTIVES: Timely delivery of fetal growth restriction (FGR) is important in reducing stillbirth. However, targeted earlier delivery of FGR preferentially removes smaller babies from later gestations, thereby right-shifting the distribution of birthweights at term. This artificially increases the birthweight cutoffs defining the lower centiles and redefines normally grown babies as small by population-based birthweight centiles. Our objective was to compare updated Australian national population-based birthweight centile charts over time with the prescriptive INTERGROWTH-21st standard. METHODS: A retrospective descriptive study of all singleton births ≥34 weeks' gestation in Victoria, Australia in five two-year epochs: 1983-84, 1993-94, 2003-04, 2013-14, and 2016-17. The birthweight cutoffs defining the 3rd and 10th centile from three Australian national population-based birthweight centile charts, for births in 1991-1994, in 1998-2007, and 2004-2013 respectively, were applied to each epoch to calculate the proportion of babies with birthweight <3rd and <10th centile. The same analysis was done using the INTERGROWTH-21st birthweight standard. To assess change over gestation, proportions were also calculated at preterm, early term and late term gestations. RESULTS: From 1983-84 to 2016-17, the proportion of babies with birthweight <3rd fell across all birthweight centile charts, from 3.1% to 1.7% using the oldest Australian chart, from 3.9% to 1.9% using the second oldest Australian chart, from 4.3% to 2.2% using the most recent Australian chart, and from 2.0% to 0.9% using the INTERGROWTH-21st standard. A similar effect was evident for the <10th centile. The effect was most obvious at term gestations. Updating the Australian population birthweight chart progressively right-shifted the birthweight distribution, changing the definition of small over time. The birthweight distribution of INTERGROWTH-21st was left-shifted compared to the Australian charts. CONCLUSIONS: Locally-derived population-based birthweight centiles are better for clinical audit of care but should not be updated. Prescriptive birthweight standards are less useful in defining 'small' due to their significant left-shift.

Prognostic significance of accelerated ventricular response during radiofrequency ablation of premature ventricular complexes.

BACKGROUND: Accelerated ventricular response is frequently observed during radiofrequency ablation (RFA) of premature ventricular complexes (PVCs). We hypothesized that acceleration indicates an appropriate site and adequate injury to the arrhythmogenic tissue, and sought to investigate its value in predicting the outcome. METHODS: We retrospectively analyzed RFA procedures performed for PVCs in our institution from 2011 to 2019. RESULTS: Fifty-eight patients (29 male; age 42.7 ± 15.6 years) underwent 62 RFA procedures. The most common site was the right ventricular outflow tract (67.7%). Acute success was seen in 88.7%. Accelerated ventricular response was observed in 60.0% of the successful procedures. After a median follow-up of 14.0 months (IQR: 6.0-26.6 months), 16 patients had a recurrence. Recurrence was significantly lower in the group with acceleration than in the group without acceleration (12.5% vs. 57.1%; log-rank P < 0.001). The 1-year recurrence rate was 6.5% in the acceleration group and 41.6% in the group without acceleration. On multivariable analysis the adjusted hazard ratio was 0.17 (95% CI, 0.04-0.64; Cox regression P = 0.009). The sensitivity, specificity, positive predictive, and negative predictive values of accelerated response to predict long-term success were 75.7%, 75.0%, 87.5%, and 57.2%, respectively. CONCLUSIONS: The recurrence after PVC ablation is significantly lower when an accelerated response was observed at the successful location during RFA. This can be an additional useful marker of long-term success.

Risk factor assessment for fetal growth restriction, are we providing best care?

Serial third trimester ultrasound examinations for fetal biometry are recommended for women with risk factors of fetal growth restriction (FGR). We conducted a retrospective cohort study on all singleton births in Victoria from 2009 to 2017 to assess how many women with major risk factors for FGR had serial third trimester biometry. Only 19.5% of women with at least one major risk factor for FGR had evidence of serial third trimester ultrasound assessments. The development and implementation of a state-wide or nationwide guideline for early pregnancy risk factor assessment in FGR may be beneficial.

Cardiovascular implantable electronic device lead removal in a resource-constrained setting: A single-center experience from India.

BACKGROUND: Data from large-volume centers in developed countries, using dedicated tools, show a high success rate with a good safety record for the percutaneous lead removal procedure. However, there are constraints to replicate the results in a resource-poor setting and there is limited data from India. METHODS: We retrospectively analyzed lead removal procedures performed in our institution from 2008 to 2019. RESULTS: Seventy-five patients underwent percutaneous removal of 138 leads. Of these, 44 procedures and 80 leads qualified as extraction with a median dwell time of 52.1 (IQR 28.2-117.2) months. Overall, 33/44 (75.0%) procedures were successful and 65/80 (81.2%) leads were successfully extracted. Manual traction was successful in the extraction of 44/57 (77.2%) leads. All leads implanted less than 2.7 years could be removed with manual traction alone. Specialized tools were used in 23 leads and 21 (91.3%) of those could be successfully extracted. Inability to use dedicated tools was an independent predictor of procedural failure (adjusted OR 14.0; 95% CI 1.8-110.2; p-value 0.012). Right-sided implant (adjusted OR 12.6; 95% CI 1.3-119.5; p-value 0.027) was also independently associated with failure. There was 1 death (1.3%) and minor complications occurred in 6 (8.0%) patients. CONCLUSIONS: In a resource-limited setting, percutaneous lead extraction of predominantly pacemaker leads by manual traction methods achieved success in extracting about three-fourths of the leads. Inability to use specialized tools was the main factor limiting success. The complication rate was low.