Brugada syndrome (BrS) is a primary electrical disease associated with life-threatening arrhythmi... more Brugada syndrome (BrS) is a primary electrical disease associated with life-threatening arrhythmias. It is estimated to cause at least 20% of sudden cardiac deaths (SCDs) in patients with normal cardiac anatomy. In this review paper, we discuss recent advances in complex BrS pathogenesis, diagnostics, and current standard approaches to major arrhythmic events (MAEs) risk stratification. Additionally, we describe a protocol for umbrella reviews to systematically investigate clinical, electrocardiographic, electrophysiological study, programmed ventricular stimulation, and genetic factors associated with BrS, and the risk of MAEs. Our evaluation will include MAEs such as sustained ventricular tachycardia, ventricular fibrillation, appropriate implantable cardioverter–defibrillator therapy, sudden cardiac arrest, and SCDs from previous meta-analytical studies. The protocol was written following the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) g...
Background: Adequate contact between the catheter tip and tissue is important for optimal lesion ... more Background: Adequate contact between the catheter tip and tissue is important for optimal lesion formation and, in some procedures, it has been associated with improved effectiveness and safety. We evaluated the potential benefits of contact force-sensing (CFS) catheters during non-fluoroscopic radiofrequency catheter ablation (NF-RFCA) of idiopathic ventricular arrhythmias (VAs) originating from outflow tracts (OTs). Methods: A group of 102 patients who underwent NF-RFCA (CARTO, Biosense Webster Inc., Irvine, CA, USA) of VAs from OTs between 2014 to 2018 was retrospectively analyzed. Results: We included 52 (50.9%) patients in whom NF-RFCA was performed using CFS catheters and 50 (49.1%) who were ablated using standard catheters. Arrhythmias were localized in the right and left OT in 70 (68.6%) and 32 (31.4%) patients, respectively. The RFCA acute success rate was 96.1% (n = 98) and long-term success during a minimum 12-month follow-up (mean 51.3 ± 21.6 months) was 85.3% (n = 87), ...
BACKGROUND Discrepancies between increased left ventricular mass (LVM) and electrocardiographic (... more BACKGROUND Discrepancies between increased left ventricular mass (LVM) and electrocardiographic (ECG) criteria for the diagnosis of left ventricular hypertrophy (LVH) are described in the literature. AIMS This study aimed to evaluate the usefulness of ECG criteria in the diagnosis of LVH, as determined by cardiac magnetic resonance (CMR) imaging, using various LVM indexing methods. METHODS We included 53 patients who underwent CMR imaging and had electrocardiograms of appropriate quality available in their medical records. The majority of the study patients had cardiovascular diseases. We defined CMR‑LVH as increased LVM, also assessed after LVM indexing to body surface area (LVM/BSA), height1.7, height2.7, or as the percentage of predicted LVM (%pLVM). To determine ECG‑LVH, 10 different ECG-LVH criteria were used. RESULTS The prevalence of CMR‑LVH ranged from 11% (for %pLVM) to 72% (for LVM/BSA). At the same time, for a single criterion, the prevalence of ECG‑LVH ranged between 1.9...
Polski merkuriusz lekarski : organ Polskiego Towarzystwa Lekarskiego, 2019
Cardiovascular implantable electronic devices (CIED) encompass permanent cardiac pacemakers (PM) ... more Cardiovascular implantable electronic devices (CIED) encompass permanent cardiac pacemakers (PM) and implantable cardioverterdefibrillators (ICD). CIED play an important role in treatment of cardiac arrhythmias, including significant bradyarrhythmias and tachyarrhythmias. The conventional right ventricular endocardial leads as well as right ventricular pacing may increase valvular defects (especially dysfunction of tricuspid and mitral valve), cause adverse cardiac remodelling and lead to a decrease in left ventricular ejection fraction. These changes may be due to mechanical damage to the leaflets or other structures of the tricuspid apparatus, such as the annulus, papillary muscles or chordae tendineae. In addition, the endocardial lead passing through the tricuspid valve may adhere to it and exacerbate the inflammatory processes and fibrosis of its leaflets. On the other hand, right ventricular pacing leads to electromechanical dyssynchrony of the cardiac muscle. New forms of CIE...
It is unclear whether chronic kidney disease (CKD) increases thromboembolism in atrial fibrillati... more It is unclear whether chronic kidney disease (CKD) increases thromboembolism in atrial fibrillation (AF). We conducted a retrospective cross-sectional analysis of 502 non-anticoagulated AF patients (median age, 66 (60–73) years, median CHA2DS2-VASc score, 3.0 (2.0–4.0)) with an estimated glomerular filtration rate (eGFR) ≥ 15 mL/min/1.73 m2. Endogenous thrombin potential (ETP), clot permeability (Ks), and clot lysis time (CLT), among others, were determined. Patients with stage 4 CKD (n = 87; 17.3%) had higher ETP and prolonged CLT compared with those with stage 3 CKD. In patients with stages 3 to 4 CKD (n = 180; 35.9%) N-terminal pro-B-type natriuretic peptide predicted low Ks (the lowest quartile, odds ratio [OR] per 100 pg/mL: 1.03, 95% confidence interval [CI]: 1.01–1.06) and prolonged CLT (the top quartile, OR per 100 pg/mL: 1.05, 95% CI: 1.02–1.08), but not high ETP. In the whole cohort, after adjustment for CHA2DS2-VASc score, stage 4 CKD, but not stage 3 CKD, predicted high ...
Reduction of heart rate variability (HRV) parameters may be a risk factor and precede the occurre... more Reduction of heart rate variability (HRV) parameters may be a risk factor and precede the occurrence of arrhythmias or the development of heart failure and complications in people with postinfarct left ventricular dysfunction and after coronary artery bypass grafting. Data on this issue in adults after a Fontan operation (FO) are scarce. This study assessed the association between HRV, exercise capacity, and multiorgan complications in adults after FO. Data were obtained from 30 FO patients (mean age 24 ± 5.4 years) and 30 healthy controls matched for age and sex. HRV was investigated in all patients by clinical examination, laboratory tests, echocardiography, a cardiopulmonary exercise test, and 24-h electrocardiogram. The HRV parameters were reduced in the FO group. Reduced HRV parameters were associated with patients’ age at the time of FO, time since surgery, impaired exercise capacity, chronotropic incompetence parameters, and multiorgan complications. Univariate analysis showe...
In selected patients, cardiac resynchronization therapy (CRT) improves heart failure (HF) symptom... more In selected patients, cardiac resynchronization therapy (CRT) improves heart failure (HF) symptoms and reduces morbidity and mortality. [1][2][3][4] The response rate to CRT depends on whether functional measures, event-based and composite clinical endpoints, or remodelling as an endpoint are used. 5 However, it is estimated that about 30% of patients do not respond to CRT. 5 Therefore, alternative pacing modalities including synchronized left ventricular pacing (LVP) have been proposed to further improve clinical outcomes. Early studies investigated the acute haemodynamic effects associated with LVP and compared them with right ventricular (RV) and/ or biventricular pacing (BVP) (Table ). Kass et al. 6 suggested that single-site LVP, at the site of greatest delay, in HF patients with intraventricular conduction delay may provide at least similar benefits to BVP. Further studies have found that LVP is associated with greater haemodynamic benefit when compared with BVP, when ventricular fusion caused by intrinsic activation is present. 7 Moreover, synchronized LVP results in better RV haemodynamics than BVP (Table ). 8 Recently, patients with an indication for CRT pacemaker, left bundle branch block (LBBB) QRS morphology, PR interval <250 ms, and without significant coronary artery disease were implanted with right atrial and left ventricular (LV) leads only and devices were carefully programmed to achieve fusion during LVP. This approach resulted in significant LV reverse remodelling, increased left ventricular ejection fraction (LVEF), and in 69% of patients was associated with decreased mitral regurgitation. 9 Left ventricular-only pacing, compared with BVP, generally reduces device energy consumption, while lack of RV lead may additionally be associated with lower rates of periprocedural and long-term complications.
We present a case of a 31-year-old woman with complete congenital AVB at 16 weeks of gestation (g... more We present a case of a 31-year-old woman with complete congenital AVB at 16 weeks of gestation (gravida 2, para 1). Previous pregnancy was delivered via elective caesarean section with temporary backup pacing. The patient underwent dual chamber (DDD) pacemaker implantation 3 years prior to the current hospitalization (after her first pregnancy) to avoid complications during planned future pregnancies. Shortly after implantation, she presented with pacemaker pocket infection with Staphylococcus aureus and the entire pacing system was removed . The patient never reported light-headedness, dizziness, or syncope. The patient did not consent to contralateral pacemaker reimplantation. The patient was referred to our centre to develop an indi-
'X-ray investigations have been in the forefront of the diagnosis of leading causes of death, Tub... more 'X-ray investigations have been in the forefront of the diagnosis of leading causes of death, Tuberculosis in 19th century, and cardiovascular disorders and cancer in the 21st century. Every day, many patients undergo X-ray based radiological examinations, including chest radiographs, coronary angiography, and computed tomography that provide invaluable information for the diagnosis and management of cardiovascular disorders'. Dr Mirsadraee reflected on how following Röntgen's Nobel Prize in 1901, Sir Godfrey Newbold Hounsfield was awarded the Nobel Prize in Medicine in 1979 for developing the diagnostic technique of X-ray computed tomography. 'In his Prize Lecture, Sir Godfrey shows images of the heart with detectors synchronized to the heartbeat. Forty years later in 2019, cardiac CT plays a very important role in assessment of heart disorders', he added. Another important discovery of Röntgen, continued Dr Mirsadraee, was that the X-rays can be stopped by lead. With the detrimental hazards of exposure to ionizing radiation becoming evident early in clinical practice the discovery had been fundamental to radiation protection.
Background: Atrial septal communications (ASCs) include atrial septal defects (ASDs) and patent f... more Background: Atrial septal communications (ASCs) include atrial septal defects (ASDs) and patent foramen ovale (PFO). The purpose of this study was to assess P-wave dispersion (PWD) and the prevalence of arrhythmia in patients before and after ASC closure. We analysed the clinical history and performed 12-lead electrocardiograms, echocardiograms, and 24-h Holter electrocardiograms in patients with ASC, before and six months after ASC closure. We included patients with ASD (n = 56) and PFO (n = 73). PWD before percutaneous ASC closure was predicted by right ventricular outflow tract (RVOT) proximal diameter, left atrial area, ASD, smoking, and paroxysmal dyspnoea, R 2 = 0.67; p < 0.001. RVOT proximal diameter was an independent predictor of PWD, both in patients with ASD and PFO. Six months after successful closure of ASC, a reduction in PWD was observed in the whole group of patients as well as in patients with ASD and PFO considered separately. A decrease in PWD was associated with reduction of maximum P-wave duration. At the same time, in the whole group, we noticed a reduction in the number of supraventricular and ventricular extrasystolic beats and fewer atrial fibrillation (AF) episodes, p < 0.04 for all variables. Postprocedural AF episodes in patients with ASD were predicted by PWD of 80 ms. Conclusions: Percutaneous closure of ASC is associated with a reduction of PWD and fewer arrhythmia episodes six months after the procedure. PWD predicts AF episodes after ASD closure.
However, enacting change may become easier, as the 'millennial' generation is now entering the wo... more However, enacting change may become easier, as the 'millennial' generation is now entering the workforce (including healthcare), and medical school curricula are increasingly shunning the traditional didactic methods of teaching for more interactive methods. Millennials often view hierarchies as relics of an older era and are more amenable to breaking down traditional roles and embracing open communication. There are several ways we can improve the current situation. First, we need to recognize the value of each member of the medical team. Junior residents and medical students have the most time available to be at the bedside and bond with their patients, gleaning useful information in the process to aid in diagnosis and management. More senior residents and Fellows, with some years of experience under their belts, are able to teach and mentor those below them. In charge of the team, senior doctors, with years of experience and knowledge, can help guide decision-making and management. By encouraging junior colleagues to freely express their concerns and uncertainties about management, and actively eliciting their feedback and ideas, senior team members can promote a friendlier environment for learning. 6 Some have also proposed encouraging staff to refer to each other by their first name to create a more collegial and relaxed learning environment. 7 It is critical to note that we do not mean to call for a complete tear down of the medical hierarchy. Senior members of the team have invaluable experience and knowledge and should be given due respect by those junior to them. Instead, we call for efforts to work towards a more inclusive environment that espouses friendliness and a willingness to accept mistakes as part of the learning process. If the aviation industry has done the same to drastically improve safety, so can medicine.
Sports-associated sudden cardiac arrest (SCA) constitutes an important problem. Causes of SCA dur... more Sports-associated sudden cardiac arrest (SCA) constitutes an important problem. Causes of SCA during sport activities include Brugada syndrome (BrS) among others. We describe a 29-year-old male, without a history of cardiovascular disease, who suffered from SCA during football training and despite intensive treatment, after almost 4 weeks of hospitalization, unfortunately died. Detailed medical documentation review showed grade I atrioventricular block, intraventricular conduction abnormalities and BrS type 2 morphology of ST-segment elevation on resting 12-lead electrocardiogram (ECG). The patient had a history of syncope during physical activity. Further echocardiographic study did not reveal significant structural heart disease. Submaximal exercise testing was performed and showed ventricular extrasystoles during physical activity and type 1 BrS morphology of ST-segment elevation during recovery phase. We compared observed ECG changes to those present in a healthy football player and described noticeable similarities. Exercise ECG testing, especially in patients after syncope of probable arrhythmic etiology, may unmask BrS ECG pattern and lead to BrS diagnosis.
Brugada syndrome (BrS) is a cardiac channelopathy associated with ventricular arrhythmias and sud... more Brugada syndrome (BrS) is a cardiac channelopathy associated with ventricular arrhythmias and sudden cardiac death. Diagnosis of BrS is based on type 1 BrS electrocardiogram (ECG) pattern (coved pattern) presence, observed spontaneously or after provocation test. The worldwide prevalence of BrS ECG patterns is estimated to reach 0.4% and strongly depends on the population studied. BrS results from various genetic mutations of sodium, calcium and potassium channels and/or associated proteins affecting ion currents. SCN5A mutations are the most prevalent in BrS. Pathogenesis of BrS is explained by the depolarization theory, the repolarization theory and the neural crest theory, which seem to be complimentary, at least partially. This review summarizes current diagnostic criteria of BrS and epidemiology of BrS ECG patterns. We also discuss the recent understanding of BrS pathophysiology and the role of genetic testing in
BACKGROUND Dense fibrin clot formation and hypofibrinolysis have been reported in atrial fibrilla... more BACKGROUND Dense fibrin clot formation and hypofibrinolysis have been reported in atrial fibrillation (AF). It is unclear which factors affect fibrin clot properties in AF. METHODS AND RESULTS We investigated plasma fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP) as well as other coagulation and fibrinolysis parameters along with N-terminal pro-B-type natriuretic peptide (NT-proBNP) in 160 AF patients (median age, 70.5years). Previous stroke (n=15; 9.4%) was associated with decreased Ks (P=0.04) and longer CLT (P=0.005), together with higher antiplasmin (P=0.03) and lower tissue-type plasminogen activator (P=0.01). Lower Ks (P=0.04) and tendency towards longer CLT (P=0.10) were observed in patients with a left atrium diameter>40mm. Patients with a CHA2DS2-VASc score of 3 or more (82.5%) were characterized by higher thrombin-activatable fibrinolysis inhibitor antigen (P=0.009). Ks was inversely correlated with log NT-proBNP (r=-0.34, P<0.0001), plasminogen activator inhibitor-1 (PAI-1) antigen (r=-0.24, P=0.002) and C-reactive protein (r=-0.18, P=0.02), while CLT was positively correlated with log NT-proBNP (R=0.61, P<0.0001) and ETP (r=0.37, P<0.0001), which were interrelated (r=0.59, P<0.0001). After adjustment for potential confounders, PAI-1 (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.02-1.26) was the only independent predictor of low Ks (the lowest quartile,≤6×10-9cm2), while NT-proBNP (OR: 1.21; 95% CI: 1.12-1.31) and PAI-1 (OR: 1.30; 95% CI: 1.12-1.51) both predicted prolonged CLT (the top quartile,≥109min). CONCLUSION In AF patients prothrombotic fibrin clot properties assessed ex vivo are determined by PAI-1 and NT-proBNP and this phenotype is associated with prior ischemic stroke.
Brugada syndrome (BrS) is a primary electrical disease associated with life-threatening arrhythmi... more Brugada syndrome (BrS) is a primary electrical disease associated with life-threatening arrhythmias. It is estimated to cause at least 20% of sudden cardiac deaths (SCDs) in patients with normal cardiac anatomy. In this review paper, we discuss recent advances in complex BrS pathogenesis, diagnostics, and current standard approaches to major arrhythmic events (MAEs) risk stratification. Additionally, we describe a protocol for umbrella reviews to systematically investigate clinical, electrocardiographic, electrophysiological study, programmed ventricular stimulation, and genetic factors associated with BrS, and the risk of MAEs. Our evaluation will include MAEs such as sustained ventricular tachycardia, ventricular fibrillation, appropriate implantable cardioverter–defibrillator therapy, sudden cardiac arrest, and SCDs from previous meta-analytical studies. The protocol was written following the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) g...
Background: Adequate contact between the catheter tip and tissue is important for optimal lesion ... more Background: Adequate contact between the catheter tip and tissue is important for optimal lesion formation and, in some procedures, it has been associated with improved effectiveness and safety. We evaluated the potential benefits of contact force-sensing (CFS) catheters during non-fluoroscopic radiofrequency catheter ablation (NF-RFCA) of idiopathic ventricular arrhythmias (VAs) originating from outflow tracts (OTs). Methods: A group of 102 patients who underwent NF-RFCA (CARTO, Biosense Webster Inc., Irvine, CA, USA) of VAs from OTs between 2014 to 2018 was retrospectively analyzed. Results: We included 52 (50.9%) patients in whom NF-RFCA was performed using CFS catheters and 50 (49.1%) who were ablated using standard catheters. Arrhythmias were localized in the right and left OT in 70 (68.6%) and 32 (31.4%) patients, respectively. The RFCA acute success rate was 96.1% (n = 98) and long-term success during a minimum 12-month follow-up (mean 51.3 ± 21.6 months) was 85.3% (n = 87), ...
BACKGROUND Discrepancies between increased left ventricular mass (LVM) and electrocardiographic (... more BACKGROUND Discrepancies between increased left ventricular mass (LVM) and electrocardiographic (ECG) criteria for the diagnosis of left ventricular hypertrophy (LVH) are described in the literature. AIMS This study aimed to evaluate the usefulness of ECG criteria in the diagnosis of LVH, as determined by cardiac magnetic resonance (CMR) imaging, using various LVM indexing methods. METHODS We included 53 patients who underwent CMR imaging and had electrocardiograms of appropriate quality available in their medical records. The majority of the study patients had cardiovascular diseases. We defined CMR‑LVH as increased LVM, also assessed after LVM indexing to body surface area (LVM/BSA), height1.7, height2.7, or as the percentage of predicted LVM (%pLVM). To determine ECG‑LVH, 10 different ECG-LVH criteria were used. RESULTS The prevalence of CMR‑LVH ranged from 11% (for %pLVM) to 72% (for LVM/BSA). At the same time, for a single criterion, the prevalence of ECG‑LVH ranged between 1.9...
Polski merkuriusz lekarski : organ Polskiego Towarzystwa Lekarskiego, 2019
Cardiovascular implantable electronic devices (CIED) encompass permanent cardiac pacemakers (PM) ... more Cardiovascular implantable electronic devices (CIED) encompass permanent cardiac pacemakers (PM) and implantable cardioverterdefibrillators (ICD). CIED play an important role in treatment of cardiac arrhythmias, including significant bradyarrhythmias and tachyarrhythmias. The conventional right ventricular endocardial leads as well as right ventricular pacing may increase valvular defects (especially dysfunction of tricuspid and mitral valve), cause adverse cardiac remodelling and lead to a decrease in left ventricular ejection fraction. These changes may be due to mechanical damage to the leaflets or other structures of the tricuspid apparatus, such as the annulus, papillary muscles or chordae tendineae. In addition, the endocardial lead passing through the tricuspid valve may adhere to it and exacerbate the inflammatory processes and fibrosis of its leaflets. On the other hand, right ventricular pacing leads to electromechanical dyssynchrony of the cardiac muscle. New forms of CIE...
It is unclear whether chronic kidney disease (CKD) increases thromboembolism in atrial fibrillati... more It is unclear whether chronic kidney disease (CKD) increases thromboembolism in atrial fibrillation (AF). We conducted a retrospective cross-sectional analysis of 502 non-anticoagulated AF patients (median age, 66 (60–73) years, median CHA2DS2-VASc score, 3.0 (2.0–4.0)) with an estimated glomerular filtration rate (eGFR) ≥ 15 mL/min/1.73 m2. Endogenous thrombin potential (ETP), clot permeability (Ks), and clot lysis time (CLT), among others, were determined. Patients with stage 4 CKD (n = 87; 17.3%) had higher ETP and prolonged CLT compared with those with stage 3 CKD. In patients with stages 3 to 4 CKD (n = 180; 35.9%) N-terminal pro-B-type natriuretic peptide predicted low Ks (the lowest quartile, odds ratio [OR] per 100 pg/mL: 1.03, 95% confidence interval [CI]: 1.01–1.06) and prolonged CLT (the top quartile, OR per 100 pg/mL: 1.05, 95% CI: 1.02–1.08), but not high ETP. In the whole cohort, after adjustment for CHA2DS2-VASc score, stage 4 CKD, but not stage 3 CKD, predicted high ...
Reduction of heart rate variability (HRV) parameters may be a risk factor and precede the occurre... more Reduction of heart rate variability (HRV) parameters may be a risk factor and precede the occurrence of arrhythmias or the development of heart failure and complications in people with postinfarct left ventricular dysfunction and after coronary artery bypass grafting. Data on this issue in adults after a Fontan operation (FO) are scarce. This study assessed the association between HRV, exercise capacity, and multiorgan complications in adults after FO. Data were obtained from 30 FO patients (mean age 24 ± 5.4 years) and 30 healthy controls matched for age and sex. HRV was investigated in all patients by clinical examination, laboratory tests, echocardiography, a cardiopulmonary exercise test, and 24-h electrocardiogram. The HRV parameters were reduced in the FO group. Reduced HRV parameters were associated with patients’ age at the time of FO, time since surgery, impaired exercise capacity, chronotropic incompetence parameters, and multiorgan complications. Univariate analysis showe...
In selected patients, cardiac resynchronization therapy (CRT) improves heart failure (HF) symptom... more In selected patients, cardiac resynchronization therapy (CRT) improves heart failure (HF) symptoms and reduces morbidity and mortality. [1][2][3][4] The response rate to CRT depends on whether functional measures, event-based and composite clinical endpoints, or remodelling as an endpoint are used. 5 However, it is estimated that about 30% of patients do not respond to CRT. 5 Therefore, alternative pacing modalities including synchronized left ventricular pacing (LVP) have been proposed to further improve clinical outcomes. Early studies investigated the acute haemodynamic effects associated with LVP and compared them with right ventricular (RV) and/ or biventricular pacing (BVP) (Table ). Kass et al. 6 suggested that single-site LVP, at the site of greatest delay, in HF patients with intraventricular conduction delay may provide at least similar benefits to BVP. Further studies have found that LVP is associated with greater haemodynamic benefit when compared with BVP, when ventricular fusion caused by intrinsic activation is present. 7 Moreover, synchronized LVP results in better RV haemodynamics than BVP (Table ). 8 Recently, patients with an indication for CRT pacemaker, left bundle branch block (LBBB) QRS morphology, PR interval <250 ms, and without significant coronary artery disease were implanted with right atrial and left ventricular (LV) leads only and devices were carefully programmed to achieve fusion during LVP. This approach resulted in significant LV reverse remodelling, increased left ventricular ejection fraction (LVEF), and in 69% of patients was associated with decreased mitral regurgitation. 9 Left ventricular-only pacing, compared with BVP, generally reduces device energy consumption, while lack of RV lead may additionally be associated with lower rates of periprocedural and long-term complications.
We present a case of a 31-year-old woman with complete congenital AVB at 16 weeks of gestation (g... more We present a case of a 31-year-old woman with complete congenital AVB at 16 weeks of gestation (gravida 2, para 1). Previous pregnancy was delivered via elective caesarean section with temporary backup pacing. The patient underwent dual chamber (DDD) pacemaker implantation 3 years prior to the current hospitalization (after her first pregnancy) to avoid complications during planned future pregnancies. Shortly after implantation, she presented with pacemaker pocket infection with Staphylococcus aureus and the entire pacing system was removed . The patient never reported light-headedness, dizziness, or syncope. The patient did not consent to contralateral pacemaker reimplantation. The patient was referred to our centre to develop an indi-
'X-ray investigations have been in the forefront of the diagnosis of leading causes of death, Tub... more 'X-ray investigations have been in the forefront of the diagnosis of leading causes of death, Tuberculosis in 19th century, and cardiovascular disorders and cancer in the 21st century. Every day, many patients undergo X-ray based radiological examinations, including chest radiographs, coronary angiography, and computed tomography that provide invaluable information for the diagnosis and management of cardiovascular disorders'. Dr Mirsadraee reflected on how following Röntgen's Nobel Prize in 1901, Sir Godfrey Newbold Hounsfield was awarded the Nobel Prize in Medicine in 1979 for developing the diagnostic technique of X-ray computed tomography. 'In his Prize Lecture, Sir Godfrey shows images of the heart with detectors synchronized to the heartbeat. Forty years later in 2019, cardiac CT plays a very important role in assessment of heart disorders', he added. Another important discovery of Röntgen, continued Dr Mirsadraee, was that the X-rays can be stopped by lead. With the detrimental hazards of exposure to ionizing radiation becoming evident early in clinical practice the discovery had been fundamental to radiation protection.
Background: Atrial septal communications (ASCs) include atrial septal defects (ASDs) and patent f... more Background: Atrial septal communications (ASCs) include atrial septal defects (ASDs) and patent foramen ovale (PFO). The purpose of this study was to assess P-wave dispersion (PWD) and the prevalence of arrhythmia in patients before and after ASC closure. We analysed the clinical history and performed 12-lead electrocardiograms, echocardiograms, and 24-h Holter electrocardiograms in patients with ASC, before and six months after ASC closure. We included patients with ASD (n = 56) and PFO (n = 73). PWD before percutaneous ASC closure was predicted by right ventricular outflow tract (RVOT) proximal diameter, left atrial area, ASD, smoking, and paroxysmal dyspnoea, R 2 = 0.67; p < 0.001. RVOT proximal diameter was an independent predictor of PWD, both in patients with ASD and PFO. Six months after successful closure of ASC, a reduction in PWD was observed in the whole group of patients as well as in patients with ASD and PFO considered separately. A decrease in PWD was associated with reduction of maximum P-wave duration. At the same time, in the whole group, we noticed a reduction in the number of supraventricular and ventricular extrasystolic beats and fewer atrial fibrillation (AF) episodes, p < 0.04 for all variables. Postprocedural AF episodes in patients with ASD were predicted by PWD of 80 ms. Conclusions: Percutaneous closure of ASC is associated with a reduction of PWD and fewer arrhythmia episodes six months after the procedure. PWD predicts AF episodes after ASD closure.
However, enacting change may become easier, as the 'millennial' generation is now entering the wo... more However, enacting change may become easier, as the 'millennial' generation is now entering the workforce (including healthcare), and medical school curricula are increasingly shunning the traditional didactic methods of teaching for more interactive methods. Millennials often view hierarchies as relics of an older era and are more amenable to breaking down traditional roles and embracing open communication. There are several ways we can improve the current situation. First, we need to recognize the value of each member of the medical team. Junior residents and medical students have the most time available to be at the bedside and bond with their patients, gleaning useful information in the process to aid in diagnosis and management. More senior residents and Fellows, with some years of experience under their belts, are able to teach and mentor those below them. In charge of the team, senior doctors, with years of experience and knowledge, can help guide decision-making and management. By encouraging junior colleagues to freely express their concerns and uncertainties about management, and actively eliciting their feedback and ideas, senior team members can promote a friendlier environment for learning. 6 Some have also proposed encouraging staff to refer to each other by their first name to create a more collegial and relaxed learning environment. 7 It is critical to note that we do not mean to call for a complete tear down of the medical hierarchy. Senior members of the team have invaluable experience and knowledge and should be given due respect by those junior to them. Instead, we call for efforts to work towards a more inclusive environment that espouses friendliness and a willingness to accept mistakes as part of the learning process. If the aviation industry has done the same to drastically improve safety, so can medicine.
Sports-associated sudden cardiac arrest (SCA) constitutes an important problem. Causes of SCA dur... more Sports-associated sudden cardiac arrest (SCA) constitutes an important problem. Causes of SCA during sport activities include Brugada syndrome (BrS) among others. We describe a 29-year-old male, without a history of cardiovascular disease, who suffered from SCA during football training and despite intensive treatment, after almost 4 weeks of hospitalization, unfortunately died. Detailed medical documentation review showed grade I atrioventricular block, intraventricular conduction abnormalities and BrS type 2 morphology of ST-segment elevation on resting 12-lead electrocardiogram (ECG). The patient had a history of syncope during physical activity. Further echocardiographic study did not reveal significant structural heart disease. Submaximal exercise testing was performed and showed ventricular extrasystoles during physical activity and type 1 BrS morphology of ST-segment elevation during recovery phase. We compared observed ECG changes to those present in a healthy football player and described noticeable similarities. Exercise ECG testing, especially in patients after syncope of probable arrhythmic etiology, may unmask BrS ECG pattern and lead to BrS diagnosis.
Brugada syndrome (BrS) is a cardiac channelopathy associated with ventricular arrhythmias and sud... more Brugada syndrome (BrS) is a cardiac channelopathy associated with ventricular arrhythmias and sudden cardiac death. Diagnosis of BrS is based on type 1 BrS electrocardiogram (ECG) pattern (coved pattern) presence, observed spontaneously or after provocation test. The worldwide prevalence of BrS ECG patterns is estimated to reach 0.4% and strongly depends on the population studied. BrS results from various genetic mutations of sodium, calcium and potassium channels and/or associated proteins affecting ion currents. SCN5A mutations are the most prevalent in BrS. Pathogenesis of BrS is explained by the depolarization theory, the repolarization theory and the neural crest theory, which seem to be complimentary, at least partially. This review summarizes current diagnostic criteria of BrS and epidemiology of BrS ECG patterns. We also discuss the recent understanding of BrS pathophysiology and the role of genetic testing in
BACKGROUND Dense fibrin clot formation and hypofibrinolysis have been reported in atrial fibrilla... more BACKGROUND Dense fibrin clot formation and hypofibrinolysis have been reported in atrial fibrillation (AF). It is unclear which factors affect fibrin clot properties in AF. METHODS AND RESULTS We investigated plasma fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP) as well as other coagulation and fibrinolysis parameters along with N-terminal pro-B-type natriuretic peptide (NT-proBNP) in 160 AF patients (median age, 70.5years). Previous stroke (n=15; 9.4%) was associated with decreased Ks (P=0.04) and longer CLT (P=0.005), together with higher antiplasmin (P=0.03) and lower tissue-type plasminogen activator (P=0.01). Lower Ks (P=0.04) and tendency towards longer CLT (P=0.10) were observed in patients with a left atrium diameter>40mm. Patients with a CHA2DS2-VASc score of 3 or more (82.5%) were characterized by higher thrombin-activatable fibrinolysis inhibitor antigen (P=0.009). Ks was inversely correlated with log NT-proBNP (r=-0.34, P<0.0001), plasminogen activator inhibitor-1 (PAI-1) antigen (r=-0.24, P=0.002) and C-reactive protein (r=-0.18, P=0.02), while CLT was positively correlated with log NT-proBNP (R=0.61, P<0.0001) and ETP (r=0.37, P<0.0001), which were interrelated (r=0.59, P<0.0001). After adjustment for potential confounders, PAI-1 (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.02-1.26) was the only independent predictor of low Ks (the lowest quartile,≤6×10-9cm2), while NT-proBNP (OR: 1.21; 95% CI: 1.12-1.31) and PAI-1 (OR: 1.30; 95% CI: 1.12-1.51) both predicted prolonged CLT (the top quartile,≥109min). CONCLUSION In AF patients prothrombotic fibrin clot properties assessed ex vivo are determined by PAI-1 and NT-proBNP and this phenotype is associated with prior ischemic stroke.
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Papers by Paweł Matusik