bluuebunny/crossref_metadata_2025 huggingface dataset:
Role of Pulmonary Veins Isolation in Persistent Atrial Fibrillation Ablation:
Authors: STABILE GIUSEPPE , BERTAGLIA EMANUELE , TURCO PIETRO , ZOPPO FRANCO , IULIANO ASSUNTA , ZERBO FRANCESCA , LA ROCCA VINCENZO , DE SIMONE ANTONIO
Published: February 2009

Background: The role of pulmonary veins (PV) isolation in patients with persistent atrial fibrillation (AF) is still debated. The aim of this study was to evaluate the adjunctive role of PV isolation in patients with persistent AF who underwent circumferential PV ablation (anatomical approach).

Methods: We treated 97 consecutive patients presenting with drug‐refractory persistent AF by an anatomical approach (group A, n = 36, mean age = 60 ± 8 years, 29 males) or an integrated approach (group B, n = 61, mean age 59 ± 10 years, 48 males). In all patients, radiofrequency (RF) ablation was performed by means of a nonfluoroscopic navigation system, in order to anatomically create circumferential lines around the PV. In group B, the persistence of PV potentials was ascertained with a multipolar circular catheter. If PV potentials persisted, RF energy targeting the electrophysiological breakthroughs was delivered to disconnect the PV. Past a 2‐month period of observation, success was defined as absence of any atrial tachyarrhythmia recurrence lasting >30 seconds.

Results: Total procedure duration (220 ± 62 minutes vs 140 ± 43 minutes, P < 0.001), fluoroscopy time (35 ± 15 minutes vs 17 ± 9 minutes, P < 0.001), and RF delivery time (48 ± 22 minutes vs 27 ± 9 minutes, P < 0.001) were significantly longer in group B than in group A. One cardiac perforation occurred in group A. After 15 ± 9.1 months, 21 patients in group A (58%) and 34 patients in group B (56%) were free of atrial tachyarrhythmia recurrence (P = 0.9).

Conclusions: In patients with persistent AF, who underwent an anatomical approach, electrophysiological confirmation of PV disconnection significantly increased the fluoroscopy and procedural times, without effect on the long‐term outcomes.
A Prospective Randomized Evaluation of VV Delay Optimization in CRT‐D Recipients: Echocardiographic Observations from the RHYTHM II ICD Study
Authors: BORIANI GIUSEPPE , BIFFI MAURO , MÜLLER CORD PAUL , SEIDL KARL‐HEINZ , GROVE RAINER , VOGT JÜRGEN , DANSCHEL WILFRIED , SCHUCHERT ANDREAS , DEHARO JEAN‐CLAUDE , BECKER THORSTEN , BOULOGNE ERIC , TRAPPE HANS JOACHIM ,   for the Resynchronization for the HemodYnamic Treatment for Heart Failure Management II (RHYTHM II) Investigators
Published: February 2009

Background: All current cardiac resynchronization therapy (CRT) devices allow the programming of the atrioventricular (AV/PV) delays and the sequential stimulation of the ventricles via the inter ventricular (VV) delay.

Aim: This post hoc analysis of the RHYTHM II study was conducted to compare the reverse remodeling associated with VV delay optimization in patients randomly assigned to simultaneous (SIM) biventricular stimulation versus patients assigned to optimized VV delay programming (OPT) (1:3 randomization scheme).

Methods: The analysis included 14 patients assigned to the SIM group and 34 patients to the OPT group who completed the 6‐month follow‐up period with paired echocardiographic recordings.

Results: In both study groups, changes consistent with left ventricular (LV) remodeling were observed between baseline and 6 months, with significant improvements in LV function and decrease in LV dimensions. In the OPT group, there was also a decrease in left atrial diameter and mitral valve closure to opening time. At 6 months, the overall proportion of echocardiographic responders (≥10% decrease in LV end‐systolic volume or ≥5% absolute increase in LV ejection fraction) was similar in both groups. The optimal AV/VV delays, evaluated by maximization of LV outflow tract velocity time integral, changed over time.

Conclusions: Ventriculo‐ventricular delay optimization was associated with better immediate hemodynamic function than simultaneous biventricular stimulation, though did not promote additional reverse remodeling at 6 months and did not increase the proportion of echocardiographic responders to CRT. Optimization of both the AV and VV intervals was patient‐specific and optimal values changed over time.
Implantable Cardioverter Defibrillator Therapy for Primary Prevention of Sudden Cardiac Death after Myocardial Infarction:
Authors: FOLEY PAUL W.X. , ADDISON CLARA E. , WHINNEY STEPHANIE B. , PATEL KIRAN , CUNNINGHAM DAVID , FRENNEAUX MICHAEL P. , LEYVA FRANCISCO
Published: February 2009

Study Objective: To estimate the proportion of patients eligible for implantable cardioverter defibrillator (ICD) therapy for the primary prevention of sudden cardiac death after a myocardial infarction (MI), according to the current guidelines.

Methods: Eligibility was assessed retrospectively at 6 weeks in 513 post‐MI survivors (age 66 ± 13 years, left ventricular ejection fraction 48.2 ± 17%) on the basis of an electrocardiogram and an echocardiogram.

Results: LVEF was ≤ 40% in 37% and ≤ 35% in 30%, and QRS duration was <120 ms in 89% and ≥120 ms in 11% of patients. The proportion of post‐MI patients meeting the criteria set by guidelines were 37% for 2006 American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) 26.5% for 2008 ACC/AHA/Canadian Heart Rhythm Society 16.3% for 2005 US Centers for Medicare and Medicaid Services (CMS), and 5.8% for the 2006 United Kingdom (UK) National Institute of Clinical Excellence (NICE). According to 2005 CMS and 2006 UK‐NICE guidelines, Holter monitoring was required in 7% and 18%, respectively. For the United States (700,000 MI in 2006), the 2006 ACC/AHA/ESC guidelines equate to 216,783 ICD implantations/year. For UK (60,499 MI in 2006), the 2006 NICE guidelines equate to 2,941 ICD implantations, 10,488 Holter studies, and 1,065 VT induction tests/year.

Conclusions: Current ICD therapy guidelines for primary prevention of SCD post‐MI demand a substantial increase in service provision worldwide.
Tricuspid Incompetence Following Permanent Pacemaker Implantation
Authors: KLUTSTEIN MARC , BALKIN JONATHAN , BUTNARU ADI , ILAN MICHAEL , LAHAD AMNON , ROSENMANN DAVID
Published: February 2009

Aim: Severe tricuspid insufficiency (TI) after permanent pacemaker implantation (PPI) has been described in small series of patients, though its incidence is not known.

Methods: We retrospectively analyzed the data of 545 patients who underwent PPI and had Doppler echocardiograms performed before and after the procedure. We excluded 135 patients who had ≥moderate TI on the 1st Doppler echocardiogram.

Results: Group 1 included 75 patients (18.3%) who had a >2 grades worsening of TI, and group 2 included 335 patients (82%) with <2 grade increase in TI after PPI. Patients in group 1 were 77 ± 7 years of age, versus 72 ± 10 years in group 2 (P < 0.001). There was no difference in left ventricular size and function. The TI gradient before PPI was higher in group 2 (25 ± 13 mmHg versus 19 ± 12 mmHg [P < 0.001]), though within the normal range in both groups. The mitral E/A ratio was 0.98 in group 1 versus 1.42 in group 2 (P < 0.001). The systolic TI gradient after implantation was 42 ± 12 mmHg in group 1, versus 33 ± 8 mmHg in group 2 (P < 0.001).

Conclusion: Worsening of TI after PPI was not rare and was observed more often in older patients, with abnormal LV relaxation and who developed pulmonary hypertension after the procedure.
Long‐Term Outcomes of CRT‐PM Versus CRT‐D Recipients
Authors: STABILE GIUSEPPE , SOLIMENE FRANCESCO , BERTAGLIA EMANUELE , ROCCA VINCENZO LA , ACCOGLI MICHELE , SCACCIA ALBERTO , MARRAZZO NATALE , ZOPPO FRANCO , TURCO PIETRO , IULIANO ASSUNTA , SHOPOVA GERGANA , CIARDIELLO CARMINE , DE SIMONE ANTONIO
Published: February 2009

Objective: To compare the rates of all‐cause mortality in recipients of cardiac resynchronization therapy devices without (CRT‐PM) versus with defibrillator (CRT‐D).

Methods: Between February 1999 and July 2004, 233 patients (mean age = 69 ± 8 years, 180 men) underwent implantation of CRT‐PM or CRT‐D devices. New York Heart Association (NYHA) heart failure functional class II was present in 11%, class III in 69%, and class IV in 20% of patients; mean left ventricle ejection fraction (LVEF) was 26.5 ± 6.5 %, 48% presented with idiopathic dilated cardiomyopathy and 49% with ischemic heart disease. Cox multiple variable regression analysis was performed in search of predictors of death.

Results: The clinical characteristics of the 117 CRT‐PM and 116 CRT‐D recipients were similar, except for LVEF (28.2 ± 6.2% vs 25.0 ± 6.5%, respectively; P < 0.001), and ischemic versus nonischemic etiology of heart failure (41% vs 56%, respectively P = 0.02). Over a mean follow‐up of 58 ± 15 months, no significance difference in overall mortality rate was observed between the two study groups. Male sex, NYHA functional class IV, and atrial fibrillation at implant were significant predictors of death.

Conclusions: There was no difference in long‐term survival rate among patients with CRT‐D versus CRT‐PM, although CRT‐D more effectively lowered the sudden death rate. Male sex, NYHA functional class IV, and atrial fibrillation predicted the worst prognosis.
Long‐Term Changes in High‐Voltage Impedance of Defibrillating Leads
Authors: VAL‐MEJIAS JESUS E. , JANET DAMIEN R. , RAMADAS SUMATI
Published: February 2009

Background: The maturation of the high‐voltage impedance (HVLI) of defibrillating leads has not been explored thoroughly. Since impedance influences the charge, current, and energy delivered to the heart in both fixed pulse‐width and fixed tilt implantable cardioverter‐defibrillator (ICD) waveforms, changes in HVLI might have an effect on the defibrillation threshold. This analysis examined the maturation of defibrillation lead HVLI.

Methods: The data were collected in 515 recipients of ICDs capable of storing high‐voltage shock diagnostics, including HVLI. Data with constant superior vena cava (SVC) coil configuration (coil ON or OFF) were collected for up to 24 months. HVLI values were recorded, plotted, and normalized by the value at implant; the percentage of patients in whom HVLI increased or decreased by ≥6 Ω was calculated, and the maturation of leads with SVC ON versus OFF was compared.

Results: A ≥6 Ω increase or decrease in HVLI was observed in 41% of patients more than 3 months after ICD implant, with the magnitudes as follows: 6–7.5 Ω change = 16%, 8–9.5 Ω= 11%, 10–11.5 Ω= 6%, and ≥12 Ω= 8%. In this subgroup, 67% of patients showed an increase in impedance, and the remaining 33% of patients showed a decrease. For ICD‐programmed SVC OFF, the right ventricular (RV) Coil‐to‐Can HVLI increased by 8 Ω after 6 weeks and did not significantly change thereafter.

Conclusions: HVLI changed significantly in 41% of leads after 3 months. The HVLI trend of the RV Coil‐to‐Can configuration appeared to be similar to the SVC Coil/Can‐to‐RV and Coil‐to‐Can configurations. Changes in HVLI of 6–12 Ω will alter the characteristics of the shock waveform and could require retuning of the waveforms to maintain adequate DFT safety margin. If re‐tuning the shock waveforms is not performed, these HVLI changes have the potential to result in elevated DFT. These HVLI changes may partially account for the 15% increase in DFT over time reported in the literature.
T‐Wave Variability as a Risk Stratifier in Patients with Dilated Cardiomyopathy
Authors: TASIČ JERNEJA , ZUPAN IGOR
Published: February 2009

Background: T‐wave alternans is an important identifier of patients at risk of sudden cardiac death (SCD), but the procedure usually requires stress testing. In this study, the variability of T‐wave amplitude (TVAR) was evaluated at rest, as a risk stratifier for SCD.

Methods: This study included 57 patients in sinus rhythm and with a left ventricular ejection fraction ≤40%, of whom 34 (60%) received an implantable cardioverter‐defibrillator (ICD) after surviving SCD, and 23 (40%) presented with ischemic or nonischemic cardiomyopathy and no history of SCD. A 20‐minute high‐resolution electrocardiographic recording for TVAR assessment was performed during supine rest. The vector magnitude was used as a primary lead for TVAR analysis.

Results: The mean, median, and maximum (max) values of TVAR were measured. The patients with ICD had a lower max TVAR than the patients without ICD (67 vs 95 μV; P = 0.045), though the mean and median TVAR values were similar. By multivariate logistic analysis, max TVAR remained a predictor of SCD, after adjustments for potentially confounding factors (P = 0.044).

Conclusion: Max TVAR was a predictor of arrhythmic events in patients with dilated cardiomyopathy at rest.
Evaluation of Sinus and Atrioventricular Nodes Function in Patients with Vasovagal Syncope
Authors: PIETRUCHA ARTUR Z. , WNUK MATEUSZ , WOJEWÓDKA‐ŻAK EWA , WĘGRZYNOWSKA MARTA , MROCZEK‐CZERNECKA DANUTA , BZUKAŁA IRENA , KONDURACKA EWA , PIWOWARSKA WIESŁAWA
Published: February 2009

Aim: Evaluation of sinus and atrioventricular nodes function as a potential factor responsible for prolonged bradycardia, asystole, or both in patients with cardioinhibitory and non‐cardioinhibitory vasovagal syncope (VVS). The study included 258 patients (mean age = 47.7 ± 17.2 years; range 18–62; 147 females) with a history of VVS. They were divided among four groups, according to results of head‐up tilt test (HUTT).

Methods: All patients underwent standard HUTT, carotid sinus massage (CSM), and rapid transesophageal atrial pacing for evaluation of total sinus node recovery time (SNRT), and corrected sinus node recovery time (CNRT), resting and intrinsic heart rate (IHR), and Wenckebach point (WP). Values of SNRT > 1,500 ms, CNRT > 525 ms, WP < 130 bpm, and CSM‐induced pause >3 seconds were considered abnormal.

Results: SNRT, CNRT, and WP before and after pharmacological blockade, resting heart rate, and IHR did not differ significantly among the study groups. The prevalence of mild sinus node dysfunction (SND), decreased value of WP, and cardioinhibitory carotid sinus hypersensitivity was similar among all study groups.

Conclusions: The prevalence of mild SND, abnormal atrioventricular conduction, and carotid sinus hypersensitivity (CSH) was similar among patients with VVS regardless of the type of vasovagal reaction. SND and CSH do not seem to play an important role in the pathogenesis of cardioinhibitory vasovagal reaction.
Early Experience with Robotic Navigation for Catheter Ablation of Paroxysmal Atrial Fibrillation
Authors: KAUTZNER JOSEF , PEICHL PETR , ČIHÁK ROBERT , WICHTERLE DAN , MLČOCHOVÁ HANKA
Published: February 2009

Introduction: Pulmonary venous antra isolation (PVAI) is the cornerstone of catheter ablation procedure for drug refractory paroxysmal atrial fibrillation (AF). However, the procedure is technically challenging. Robotic navigation has a potential to expedite and facilitate the procedure.

Methods: A robotic catheter control system was used for remote navigation‐supported PVAI in 22 patients (mean age = 55 ± 9 years, 16 males, study group). An irrigated‐tip catheter with estimate of catheter force on the tissue was used. This was compared in nonrandomized fashion with conventional hand‐controlled catheter ablation in 16 patients (mean age = 55 ± 9 years, 13 males, control group). The procedures were performed under guidance of Ensite NavX navigation system (St. Jude Medical, St. Paul, MN, USA) and intracardiac echocardiography.

Results: Robotic navigation was associated with significantly shorter overall duration of radiofrequency delivery (1,641 ± 609 vs 2,188 ± 865 seconds, P < 0.01), shorter total procedural time (207 ± 29 vs 250 ± 62 minutes, P = 0.007), fluoroscopy exposure (15 ± 5 vs 27 ± 9 minutes, P < 0.001), and lower radiation dose (1,119 ± 596 vs 3,048 ± 2,029 mGy/m2, P < 0.001). No complication was observed in either the study or the control group. During the 5 ± 1 months follow‐up in the study group and 9 ± 3 months in the control group, 91% and 81% of patients, respectively, were AF free.

Conclusions: In our early clinical experience, PVAI using a remote robotic catheter navigation was effective, safe, and associated with shorter procedural and fluoroscopic times than conventional PVAI.
Effect of Right Ventricular Apical Pacing in Survivors of Myocardial Infarction
Authors: MUTO CARMINE , ASCIONE LUIGI , CANCIELLO MICHELANGELO , CARRERAS GIOVANNI , IENGO RAFFAELE , OTTAVIANO LUCA , CALVANESE RAIMONDO , ACCADIA MARIA , CELENTANO EDUARDO , CIARDIELLO CARMINE , TUCCILLO BERNARDINO
Published: February 2009

Background: Much information is available regarding the possible negative effects of long‐term right ventricular (RV) apical pacing, which may cause worsening of heart failure. However, very limited data are available regarding the effects of RV pacing in patients with a previous myocardial infarction (MI).

Methods and Results: We screened 115 consecutive post‐MI patients and matched a group of 29 pacemaker (PM) recipients with a group of 49 unpaced patients, for age, left ventricular (LV) ejection fraction, and site of MI. During a median follow‐up of 54 months, echocardiograms showed a decrease in LV ejection fraction in the paced group, from 51 ± 10 to 39 ± 11 (P < 0.01), and a minimal change in the unpaced group, from 57 ± 8 to 56 ± 7 (P = 0.98). Similar change was observed in systolic and diastolic diameters and volumes.

Conclusions: The study showed that, in post‐MI patients, RV apical pacing was associated with a worsening of LV function, suggesting that, among MI survivors, the need for a PM is a marker of worse outcome.
Low Referral Rate for Prophylactic Implantation of Cardioverter‐Defibrillators in a Tertiary Care Medical Center
Authors: BRADFIELD JASON , WARNER ALBERTA , BERSOHN MALCOLM M.
Published: February 2009

Background: Implantable cardioverter‐defibrillators (ICDs) for primary prevention became standard of care after the publication of the second Multicenter Automatic Defibrillator Implantation Trial (MADIT‐II) and Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT).

Objective: To determine the percentage of patients in a Veterans Affairs medical center appropriately referred for primary prophylaxis ICD and to further categorize the reasons patients are not being referred.

Methods

: Echocardiograms obtained since the release of MADIT‐II in 2002 were searched for a left ventricular ejection fraction (LVEF) ≤ 35% and ≤30%. We randomly selected 120 patients per year from 2002 to 2006, for a total of 600 patients in each group. Data were reviewed to determine the number of ICD recipients and the reasons patients were not referred.

Results: In the LVEF ≤ 35% group an ICD was implanted in 28% of 392 eligible patients. Nonreferral (58%) was the most common reason that eligible patients did not receive an ICD. Patients were not referred for ICD because of appropriate contraindications in 26% of cases. Overall mortality was 29% (15% with and 31% without ICD). In the LVEF ≤30% group an ICD was implanted in 33% of 388 eligible patients. Nonreferral (51%) was the most common reason that eligible patients did not receive an ICD. Patients were not referred for ICD because of appropriate contraindications in 24% of cases. Overall mortality was 28% (18% with and 32% without ICD).

Conclusions: After the publication of MADIT‐II and SCD‐HeFT, only 42% of eligible patients with LVEF ≤ 35% and 49% of patients with LVEF ≤30% were offered a potentially life‐saving ICD between 2002 and 2006 in our medical center, sometimes with considerable delay.
Spatial Relationships between the Pulmonary Veins and Sites of Complex Fractionated Atrial Electrograms During Atrial Fibrillation
Authors: CHEN JIAN , OFF MORTEN KRISTIAN , SOLHEIM EIVIND , HOFF PER IVAR , SCHUSTER PETER , OHM OLE‐JØRGEN
Published: February 2009

Background: Pulmonary vein (PV) isolation is used for the treatment of atrial fibrillation (AF). Complex fractionated atrial electrogram (CFAE) mapping has been introduced to guide AF ablation. However, the spatial relationship between PV and CFAE is not well defined.

Methods and Results: The study included 21 patients (mean age 57 ± 11 years, 17 men, 14 paroxysmal, two persistent, and five long‐standing persistent AF) referred for PV isolation. Electrograms were sampled for 8 seconds at each site during stable AF (13 induced). High‐frequency was defined as <80 ms of CFAE value. The distance between CFAE and the nearest PV ostium was measured. The PV ostia and antra were demarcated by fluoroscopy guidance and endocardial reconstruction. Among 82 PV mapped (left common four, superior 17, inferior 17; right superior 21, inferior 21, middle 2), 52.4% and 25.6% of high‐frequency CFAE were located on the anterior and posterior walls, respectively, inside the PV or at the ostium. No high‐frequency CFAE was observed in two out of 60 and one out of 20 PV anteriorly, versus seven out of 60 and 11 out of 20 PV (P < 0.001) posteriorly, in paroxysmal and persistent AF, respectively. In the PV with high‐frequency CFAE, the mean shortest distances to the PV ostia in paroxysmal versus persistent AF were 2.7 ± 5.1 versus 7.4 ± 5.4 mm anteriorly (P < 0.01), and 6.5 ± 6.4 versus 9.4 ± 8.4 mm posteriorly (ns).

Conclusions: During PV isolation, extending the ablation lesions by up to 10 mm from the PV ostia might cover most high‐frequency CFAE around the PV antra. High‐frequency CFAE were more often located in the PV ostia in paroxysmal than in persistent AF.
Initial Experience with Catheter Ablation Using Remote Magnetic Navigation in Adults with Complex Congenital Heart Disease and in Small Children
Authors: SCHWAGTEN BRUNO , JORDAENS LUC , WITSENBURG MARTIN , DUPLESSIS FREDERIK , THORNTON ANDREW , VAN BELLE YVES , SZILI‐TOROK TAMAS
Published: February 2009

Background: The improved outcomes and increased availability of surgery for congenital heart disease (CHD) over the last three decades have created a small but steadily increasing subset of patients with unique needs: children and adults with complex arrhythmias in the setting of structural cardiac abnormalities. Radiofrequency catheter ablation (RFCA) in these patients, and in small children with normal cardiac anatomy, is effective but challenging. An understanding of specific anatomical and electrophysiological characteristics of these patients and the technical challenges in addressing them are critical to the success of this therapy. Tools specifically designed for intracardiac diagnosis and therapy in anatomically complex and/or small hearts remain scarce.

Aims: We report single‐center results from an ongoing registry of all patients with congenital heart disease and all children with complex arrhythmias in which the Magnetic Navigation System (MNS) was used.

Results: Included in this report are 12 patients with CHD in whom 17 tachyarrhythmias were treated, and 11 pediatric patients with normal cardiac anatomy who each had a single arrhythmia. The procedures' duration and the duration of fluoroscopy time as well as arrhythmia recurrence rates were comparable to those found in previous reports of procedures performed in adults with structurally normal hearts, and the incidence of complications was quite low.

Discussion: In patients with complex congenital malformations, retrograde mapping of the pulmonary venous atrium was feasible, eliminating the need for puncture of the atrial septum, or surgically placed baffle in many cases. Moreover, the design of the catheter eliminated the need for multiple mapping and ablation catheters.

Conclusion: Our findings suggest that RFCA using the MNS for arrhythmias after surgery for congenital heart disease and in pediatric patients is safe and effective.
Atrio‐Pulmonary Vein Conduction Delay during Pulmonary Vein Isolation for Atrial Fibrillation Is Related to Vein Anatomy, Age, and Focal Activity
Authors: OFF MORTEN K. , SOLHEIM EIVIND , HOFF PER I. , SCHUSTER PETER , OHM OLE‐JØRGEN , CHEN JIAN
Published: February 2009

Background: During pulmonary vein isolation for treatment of atrial fibrillation (AF), a significant delay in atrio‐pulmonary vein (PV) conduction is often observed. We sought to investigate this conduction delay in various PV in individual patients.

Methods: We studied 385 AF patients (mean age: 54 ± 11 years, 74 women) who underwent segmental PV isolation (PVI). A circular decapolar catheter was used to record electrograms at the PV ostia. The time delay from local atrial potential to PV potential was measured in each vein. Conduction delay (CD) was defined as the longest time interval >20 ms observed during PVI.

Results: For patients treated for the first time, CD was more frequently observed in the left common and the right and left superior PVs (84.2%, 67.9%, and 66.2%, respectively) and less frequently in the left and right inferior and right middle PVs (54.3%, 40.0%, and 30.8%, respectively). Veins with CD required more ablation applications (12.4 vs 9.9) and a higher ablated segmental fraction (72.3% vs 63.7%). CD was observed in 75.2% (109/145) of the PVs in which focal activity was detected. Older patients had a higher incidence of PVs with CD than younger patients. There were no gender differences.

Conclusions: The incidence of CD was highest in the left common and superior PVs, in older patients and in PVs with focal activity. PVs with CD required more ablation applications and a larger area of ablation around the ostia. These observations were not found during repeat procedures.
Hemodynamic Benefit of Multiple Programmable Pacing Configurations in Patients with Biventricular Pacemakers
Authors: BALASUNDARAM RAMPRAKASH , RAO HYGRIV B. , SRIDEVI C. , SOMARAJU B. , SINGH BALBIR , CALAMBUR NARASIMHAN
Published: February 2009

Introduction: Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure. However, one‐third of the patients fail to improve with this therapy. Stimulation with different left ventricular stimulation (LVS) configurations has been used to prevent diaphragmatic capture and to decrease the capture thresholds. We evaluated the hemodynamic effects of different LVS configurations using echocardiography.

Methods: Recipients of CRT systems capable of multiple LVS configurations were studied. Biventricular capture was confirmed for each polarity and echocardiographic measurements were made. The atrioventricular and interventricular delays were optimized and kept constant during the study. The cardiac output (CO), myocardial performance index (MPI), and severity of mitral regurgitation (MR) were recorded for all LVS configurations and compared for the best and the worst configurations, determined by CO.

Results: We studied 10 men and four women, 55 ± 13 years of age on average. The CO and MPI changed significantly by changing the LVS configurations. The difference in CO ranged from 0.3 to 1.5 L, and seven patients (50%) showed ≥20% difference in CO between best and worst LVS configurations. Severity of MR decreased by ≥1 grade in nine patients, while in two patients MR worsened despite improvement in CO.

Conclusions: Changing the LVS configuration changes hemodynamic function in some CRT system recipients.
Predictors of Mortality and Hospitalization for Cardiac Causes in Patients with Heart Failure and Nonischemic Heart Disease: A Subanalysis of the ALPHA Study
Authors: ANSELMINO MATTEO , DE FERRARI GAETANO M. , MASSA RICCARDO , MANCA LORENZO , TRITTO MASSIMO , MOLON GIULIO , CURNIS ANTONIO , DEVECCHI PAOLO , BRAGA SIMONA SARZI , BARTESAGHI GIORGIO , KLERSY CATHERINE , ACCARDI FRANCESCO , SALERNO‐URIARTE JORGE A. ,   for the ALPHA Study Group Investigators
Published: February 2009

Background: Several studies have searched for predictors of clinical outcome in patients with heart failure (HF). However, since they were collected in clinical trials, most data were subject to selection biases and do not specifically apply to patients with nonischemic heart disease. This study examined the impact of several variables on combined all‐cause mortality and hospitalization for cardiac causes, in consecutive ambulatory patients with HF included in the ALPHA registry.

Methods and Results: This analysis included 446 patients with HF and nonischemic heart disease, in New York Heart Association functional class II or III, and a left ventricular (LV) ejection fraction below 40%. In 126 patients (73%) the disease was idiopathic dilated cardiomyopathy, in 72 (16%) hypertensive, in nine (2%) valvular, and in 39 (9%) of other etiologies. The median age was 61 years (range 51–69 years) and 349 (78%) patients were men. Over a median follow‐up of 31 months (range 23–40), 82 patients (18%) died or were hospitalized for cardiac causes. In a proportional hazard (Cox) regression model, maximal oxygen consumption (HR 0.9, P = 0.001), LV end‐diastolic diameter (HR 1.07, P < 0.001), resting systolic blood pressure (HR 0.97, P < 0.005), and hemoglobin (HR 0.86, P < 0.05) were independent predictors of the combined study endpoint.

Conclusions: In an unselected population of patients with HF and nonischemic heart disease, a reduced exercise capacity, large LV end‐diastolic diameter, low systolic blood pressure, and hemoglobin were correlated with long‐term all‐cause mortality or hospitalization for cardiac causes. These observations may help stratifying and tailoring the treatment of patients with HF and nonischemic heart disease.
Coronary Blood Flow Produced by Muscle Contractions Induced by Intracardiac Electrical CPR during Ventricular Fibrillation
Authors: WANG HAO , TANG WANCHUN , TSAI MIN‐SHAN , SUN SHIJIE , LI YONGQIN , GILMAN BYRON , KROLL MARK W. , GUAN JUN , BREWER JAMES E. , WEIL MAX H.
Published: February 2009

It has been reported that transthoracic electrical cardiopulmonary resuscitation (ECPR) generates coronary perfusion pressures (CPP) similar to manual chest compressions (MCC). We hypothesized that intracardiac ECPR produces similar CPP.

Methods: ECPR pulse train protocols were applied for 20 seconds in a porcine model following 10 seconds of ventricular fibrillation (VF), using a defibrillator housing electrode and a right ventricular coil (IC‐ECPR). Each protocol consisted of 200‐ms electrical pulse trains applied at a rate of 100 pulse trains/min. The protocols were grouped in skeletal‐based versus cardiac‐based stimulation measurements. CPP was recorded and compared to historical MCC values generated by a similar experimental design. CPP > 15 mm Hg at 30 seconds of VF following the application of an IC‐ECPR protocol was defined as successful.

Results: Mean CPP for all intracardiac ECPR pulse train protocols at 30 seconds of VF was 14.8 ± 3.8 mm Hg (n = 39). Mean CPP in seven successful skeletal‐based IC‐ECPR protocols was 19.4 ± 3.2 mm Hg, and mean CPP in 10 successful cardiac‐based IC‐ECPR protocols was 17.4 ± 2.1 mm Hg. Reported CPP for 15 MCC experiments at 30 seconds of VF was 22.9 ± 9.4 mm Hg (P = 0.35 compared to skeletal‐based IC‐ECPR, P = 0.08 compared to cardiac‐based IC‐ECPR).

Conclusions: Intracardiac applied electrical CPR produced observable skeletal muscle contractions, measurable pressure pulses, and coronary perfusion pressures similar to MCC during a brief episode of untreated VF.
Exact Location of the Branching Bundle in the Living Heart
Authors: ADACHI MASAMITSU , IGAWA OSAMU , YANO AKIO , MIAKE JUNICHIRO , INOUE YOSHIAKI , OGURA KAZUYOSHI , KATO MASARU , IITSUKA KAZUHIKO , HISATOME ICHIRO
Published: February 2009

Aims: The His bundle electrogram is believed to reflect the exact location of the His bundle. However, the distinction between distal His bundle potential and proximal right bundle branch potential is challenging. The aim of this study was to pinpoint the location of the branching point of the His bundle, and to compare that site with the site of recording of the largest His bundle electrogram (LH) during sinus rhythm.

Methods: We hypothesized that the site of earliest His activation (EH) during retrograde conduction via the left bundle branch is the branching point. We studied 15 nonconsecutive patients (mean age = 40 ± 22 years; eight men). We performed a programmed stimulation from right ventricular apex until retrograde right bundle branch block appeared. At that point we measured (1) the distance between antegrade LH site and retrograde EH site and (2) the atrial‐to‐ventricular amplitude ratio (A/V ratio) at both sites.

Results: EH was recorded at the proximal electrode of the His bundle catheter in all patients. Mean distance between EH and LH was 9.8 ± 2.5 mm. The mean A/V ratios at the EH site and the LH site were 1.01 ± 0.42 and 0.08 ± 0.06, respectively.

Discussion: This study showed that the EH site is located approximately 10‐mm proximal to the LH site. The mean A/V ratio at the EH site during sinus rhythm is approximately 1.0. These observations suggest that the majority of His potentials reflect proximal right bundle activation. Before delivering radiofrequency energy in the para‐Hisian area, attention should be paid to the presence of a His potential and to the A/V ratio, rather to the amplitude of the His electrogram.
Esophageal Acid Levels after Pulmonary Vein Isolation for Atrial Fibrillation
Authors: NÖLKER GEORG , RITSCHER GUIDO , GUTLEBEN KLAUS‐JÜRGEN , MARSCHANG HARALD , SCHMIDT MARTIN , RITTGER HARALD , MAYER DIRK , MARROUCHE NASSIR , BRACHMANN JOHANNES , SINHA ANIL‐MARTIN
Published: February 2009

Background: Pulmonary vein antrum isolation (PVAI) is a potentially curative, nonpharmacologic treatment of atrial fibrillation (AF). Several procedural complications have been described, including esophageal wall lesions ranging from erythema and esophagitis, necrosis and ulcer, to atrio‐esophageal fistula. We prospectively studied changes in esophageal acid levels before and after PVAI.

Methods: We performed 24‐hour pH‐metry before and 1.3 ± 1.6 days after PVAI, in 25 patients (mean age = 62 ± 12 years, 17 men) with symptomatic AF. A 2‐mm transnasal probe was inserted into the inferior part of the esophagus and into the stomach to measure pH levels at fixed intervals. DeMeester scores, indicating acidic gastro‐esophageal reflux, were calculated.

Results: The mean number of reflux episodes increased from 89 ± 80 before to 107 ± 94 after PVAI. The mean percentage of time with esophageal pH < 4 was shorter after (108 ± 193 minutes) than before PVAI (159 ± 245 minutes). The mean DeMeester score decreased from 49 ± 68 before to 31 ± 41 after PVAI (P < 0.05). We observed erythema or esophagitis in five patients, necrosis or ulcer in seven, and atrio‐esophageal fistula in no patient.

Conclusions: Our hypothesis of increased acid levels caused by stimulation of the right vagal nerve during isolation of the right upper pulmonary vein was not verified.
Optimization of AV and VV Delays in the Real‐World CRT Patient Population: An International Survey on Current Clinical Practice
Authors: GRAS DANIEL , GUPTA MANISH S. , BOULOGNE ERIC , GUZZO LISA , ABRAHAM WILLIAM T.
Published: February 2009

Background: Cardiac resynchronization therapy (CRT) is an effective treatment for patients suffering from advanced heart failure and electrical dyssynchrony. Limited data suggest that patients may benefit from routine optimization of the atrioventricular (AV) and interventricular (VV) delays; however, there is scarce information available on how and when optimization should be performed.

Objective: The objective of this survey was to characterize the current international standard of care for optimization of the AV and VV delays in CRT devices recipients.

Methods: Centers participating in the Frequent Optimization Survey Using the QuickOpt Method (FREEDOM) study completed surveys probing into their optimization of AV and VV delays procedures. Probes focused on the methods used to optimizing the delays, visits at which optimization of the delays was performed, percentage of patients that underwent optimization, and factors that limited centers from optimizing the CRT systems.

Results: Few of the 118 investigators from 16 countries who responded to the survey routinely optimized the delays in all patients. At follow‐up visits and during hospitalizations, a trend was observed to optimize the delays more often in nonresponders than in responders to CRT. Standard echocardiography was the most common method of optimization. Time availability and lack of qualified staff were the main factors limiting the optimization of CRT systems.

Conclusions: In real‐world practice, AV and VV optimization was not performed in a high proportion of patients. A less time‐consuming and easier optimization method might enable a more systematic optimization of the AV and VV delays at routine follow‐up visits in all recipients of CRT systems.
Recording of Peak Endocardial Acceleration in the Atrium
Authors: GRAS DANIEL , KUBLER LUC , RITTER PHILIPPE , ANSELME FRÉDÉRIC , DELNOY PIERRE PAUL , BORDACHAR PIERRE , RENESTO FABRIZIO , MABO PHILIPPE
Published: February 2009

Background: The important role played by peak endocardial acceleration (PEA or sonR) in hemodynamic monitoring of cardiac resynchronization therapy (CRT) was recently highlighted in several studies with the sensor embedded in a right ventricular (RV) lead tip. This study examined the short‐ and long‐term reliability of a right atrial (RA) sonR sensor.

Methods: RA and RV sonR signals were measured from RA and RV leads respectively, at implant and up to 12 months of follow‐up, in 19 recipients of either single chamber pacemakers or CRT systems. At 1 month of follow up, RA sonR signals and heart rate were simultaneously recorded during exercise.

Results: A reliable RA sonR signal amplitude was measured at implant, proportional to the RV amplitude. We observed in both the right atrium and right ventricle (1) a similar signal noise ratio at implant, (2) a similar evolution of the sonR signal amplitude up to 12 months of follow‐up, and (3) a high correlation between heart rate and RA sonR signal amplitude during exercise.

Conclusions: The RA sonR signal was reliable and proportional to the RV signal on the short and long term, and reflected changes in activity. These observations suggest that the sonR sensor could be placed in the atrium for the hemodynamic monitoring of CRT system recipients.
Relationship between Amplitude and Timing of Heart Sounds and Endocardial Acceleration
Authors: TASSIN AUDE , KOBEISSI ADONIS , VITALI LUCA , ROULEAU FRÉDÉRIC , RITTER PHILIPPE , GAGGINI GUIDO , DUPUIS JEAN‐MARC
Published: February 2009

Objective: To study the correlation between heart sounds and peak endocardial acceleration (PEA) amplitudes and timings, by modulation of paced atrioventricular (AV) delay in recipients of dual chamber pacemakers.

Methods: Ten recipients of dual chamber pacemakers implanted for high‐degree AV block were studied. Endocardial acceleration (EA) and phonocardiographic and electrocardiographic signals were recorded during performance of an AV delay scan in VDD and DDD modes.

Results: First PEA (PEA I) and first heart sound (S1) changed similarly with the AV delay. A close intrapatient correlation was observed between S1 and PEA I amplitudes in all patients (P < 0.0001). The interpatient normalized PEA I to S1 amplitudes correlation was r = 0.89 (P < 0.0001) in DDD mode, and r = 0.81 (P < 0.0001) in VDD mode. The mean cycle‐by‐cycle PEA I to S1 delay was −4.3 ± 22 ms and second PEA (PEA II) to second heart sound (S2) delay was −7.7 ± 15 ms.

Conclusions: A close correlation was observed between PEA I and S1 amplitudes and timings, and between PEA II and S2 timings. These observations support the hypothesis that PEA and heart sounds are manifestations of the same phenomena. EA might be a useful tool to monitor cardiac function.
Agents of Change: The Role of Public Managers in Public Policy
Authors: Hicklin Alisa , Godwin Erik
Published: February 2009

Our article outlines a number of ways that theories of public management can contribute to the work of public policy scholars. We first outline some of the ways in which public managers have been incorporated into previous work on public policy, and the limitations faced by previous treatments. We then discuss the role that public management plays in the policy process, with a specific focus on managerial quality, networking, and performance evaluation.
Trans‐Subsystem Dynamics: Policy Topography, Mass Opinion, and Policy Change
Authors: Jones Michael D. , Jenkins‐Smith Hank C.
Published: February 2009

We argue that the treatment of trans‐subsystem change, and particularly the role of public opinion in fostering such change, within the Advocacy Coalition Framework (ACF) has been underspecified. We propose a model of “policy topography” that combines the concepts of public opinion, clusters of linked subsystems, and policy issue venues. While the ACF has characterized subsystems as relatively self‐contained, we argue that they are more usefully understood as operating in a relatively permeable fashion among evolving clusters of subsystems linked together by networked relations, strategically overlapping policy considerations, and public opinion disruptions. The “policy topography” model offers opportunities to assess the relationships across policy subsystems, and to better specify the critical relationship between public policy and mass opinions. We offer examples, and suggest hypotheses along with avenues for appropriate empirical analysis.
Toward a Theory of Collaborative Policy Networks: Identifying Structural Tendencies
Authors: DeLeon Peter , Varda Danielle M.
Published: February 2009

Support for the “democratization of the policy sciences” has led to the development of a number of frameworks and theories to enhance the normative, multidisciplinary approach to policy analysis. However, this approach has been challenged for failing to produce the objective empirical and normative standards implied by its scientific aspirations. One consideration that has been advanced under a variety of rubrics is “participatory policy analysis.” This is a methodological proposal that expands the range of actors/stakeholders involved in the making and execution of public policy in a discursive or deliberative mode. While much of the research on policy networks is focused on the management and coordination of such networks (i.e., collaborative management), there is little attention on analysis of networks as a participatory policy analytical approach. We propose a theory of “collaborative policy networks” that examines not only the stakeholder composition of a group or the partnerships between any two stakeholders but also the way these stakeholders are embedded in various degrees of institutionalized structure and the discursive tendencies of exchange among them that leads to policy initiative, implementation, evaluation, and possibly termination. Collaborative policy networks are characterized by discursive properties, specifically reciprocity, representation, equality, participatory decision making, and collaborative leadership. We suggest that the results of such research can identify structural signatures of collaborative policy networks that serve as “stamps” of the common nature of such networks that, if fostered, can inform and improve the attempt of networks of partners to achieve policy goals.
Information Processing and Policy Dynamics
Authors: Workman Samuel , Jones Bryan D. , Jochim Ashley E.
Published: February 2009

In this article, we trace the evolution of punctuated equilibrium theories of the policy process to the development of a full theory of government information processing. Noting that punctuated equilibrium is one realization of a larger theory of government information processing, we outline a research agenda for the study of agenda setting, policy dynamics, and information flows in the policy process. In doing so, we relate the study of government information processing to such important features of American government as inter‐institutional dynamics and delegation in the policy process.
Themes and Variations: Taking Stock of the Advocacy Coalition Framework
Authors: Weible Christopher M. , Sabatier Paul A. , McQueen Kelly
Published: February 2009

A policy process framework that has been developed to simplify the complexity of public policy is the advocacy coalition framework (ACF). This essay reports on an analysis of 80 applications of the ACF spanning nearly 20 years. The review shows that the ACF is applicable to various substantive topics, across various geographical areas, and with other policy process theories and frameworks, including the stages heuristic. The most commonly tested hypotheses involve policy change, learning, and coalition stability. Although the hypotheses tend to be confirmed, questions remain about the membership, stability, and defection of coalition members; about the causal mechanisms linking external events and policy change; and about the conditions that facilitate cross‐coalition learning. Emerging areas of research include policy subsystem interdependencies and coordination within, and between, coalitions.
Policy Knowledge, Policy Formulation, and Change: Revisiting a Foundational Question
Authors: James Thomas E. , Jorgensen Paul D.
Published: February 2009

Understanding the influence of policy knowledge (analysis, evaluation) on policy change represents a long‐standing quest in the policy sciences. Despite attempts of Advocacy Coalition Framework (ACF) scholars, the first to embark systematically on this quest, utilization and policy process literatures still run parallel. Through a critique of ACF and utilization studies, we argue that the inability of policy theory to include how and which information decision makers use is the foundational issue hindering efforts to link process and substance in policy theory. Situating utilization studies in the policy design approach offers an improvement in conceptualizing relationships between policy knowledge, process, and change.
Hand eczema in geriatric nurses in Germany – prevalence and risk factors
Authors: Skudlik Christoph , Dulon Madeleine , Wendeler Dana , John Swen M. , Nienhaus Albert
Published: February 2009

Background and objectives:  The aim of this cross‐sectional study was to collect data on the prevalence of hand eczema and relevant risk factors in geriatric nurses in Germany.

Methods:  1375 geriatric nurses from 86 nursing homes were investigated by 41 occupational physicians.

Results:  Hand eczema was diagnosed in 243 nurses, corresponding to a point prevalence of 18% [95% confidence interval (CI) 16–20%]. In most cases (71%), the skin changes were only mild. Two thirds of the geriatric nurses who reported skin changes stated that they had developed hand eczema after starting this profession. In most cases (85%), the clinical course was described as chronic. Risk factors associated with hand eczema were a lifelong tendency for dry skin [odds ratios (OR) 2.76; 95% CI 2.02–3.76] and a history of allergic rhinoconjunctivitis (OR 1.50; 95% CI 1.03–2.18). There was no association between the amount of wet work and hand eczema (OR 1.18; 95% CI 0.76–1.86).

Conclusions:  Our study indicates that it is necessary to provide geriatric nurses with specific skin care advice as part of their training. This might help to identify trainees at increased risk of developing eczema, encouraging the initiation of appropriate skin protection measures, thus preventing chronic disease.