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Pace
Kinds of Pace Selected AbstractsKEEPING PACE WITH EVOLVING PRISON POPULATIONS FOR EFFECTIVE MANAGEMENTCRIMINOLOGY AND PUBLIC POLICY, Issue 2 2003JOHN WOOLDREDGE [source] Determination of dissociation constants of folic acid, methotrexate, and other photolabile pteridines by pressure-assisted capillary electrophoresisELECTROPHORESIS, Issue 17 2006Zoltán Szakács Abstract Pressure-assisted CE (PACE) was applied to determine the previously inaccessible complete set of pK values for folic acid and eight related multiprotic compounds. PACE allowed the determination of all acidity macroconstants at low (,0.1,mM) concentration without interferences of selfassociation or photodegradation throughout the pH range. The accuracy of the constants was verified by NMR-pH, UV-pH, and potentiometric titrations and the data could be converted into physiological ionic strength. It was shown that even three overlapping pK values can be determined by CE with good precision (<0.06) and accuracy if an appropriately low sample throughput is used. Experimental aspects of PACE for the quantitation of acid,base properties are analyzed. The site-specific basicity data obtained for folic acid and methotrexate (MTX) reveal that apparently slight constitutional differences between folic acid and MTX carry highly different proton-binding propensities at analogous moieties, especially at the pteridine N1,locus, providing straightforward explanation for the distinctive binding to dihydrofolate reductase at the molecular level. [source] Whole-system approaches to health and social care partnerships for the frail elderly: an exploration of North American models and lessonsHEALTH & SOCIAL CARE IN THE COMMUNITY, Issue 5 2006Dennis L. Kodner PhD Abstract Irrespective of cross-national differences in long-term care, countries confront broadly similar challenges, including fragmented services, disjointed care, less-than-optimal quality, system inefficiencies and difficult-to-control costs. Integrated or whole-system strategies are becoming increasingly important to address these shortcomings through the seamless provision of health and social care. North America is an especially fertile proving ground for structurally oriented whole-system models. This article summarises the structure, features and outcomes of the Program of All-Inclusive Care for Elderly People (PACE) programme in the United States, and the Système de soins Intégrés pour Personnes Âgées (SIPA) and the Programme of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) in Canada. The review finds a somewhat positive pattern of results in terms of service access, utilisation, costs, care provision, quality, health status and client/carer satisfaction. It concludes with the identification of common characteristics which are thought to be associated with the successful impact of these partnership initiatives, as well as a call for further research to understand the relationships, if any, between whole-system models, services and outcomes in integrated care for elderly people. [source] Brief measure of expressed emotion: internal consistency and stability over timeINTERNATIONAL JOURNAL OF METHODS IN PSYCHIATRIC RESEARCH, Issue 4 2003Seija Sandberg Consultant, Senior Lecturer Abstract The study examined three methodological aspects of expressed emotion (EE) as assessed in the course of PACE (Psychosocial Assessment of Childhood Experiences) interviews with a parent. In a sample of 87 children, aged 6,13 years, enrolled in a prospective study examining the role of stress on the course of asthma, EE was assessed at three time points, 9 months apart. A high degree of agreement was found among the three concurrent measures of negative and positive EE (kappas from 0.74 to 0.97, and from 0.45 to 0.88, respectively; p , 0.0001 in all instances). The temporal stability of all measures was lower, although statistically significant in all but 2 instances (kappas from 0.19 to 0.59, and from 0.11 to 0.39, respectively). The temporal stability across measures, as well as across interviewers and over time, was broadly similar (kappas from 0.21 to 0.56 for negative EE, and from 0.09 to 0.38 for positive EE, with all but three of the 36 statistically significant). The findings provide support for the underlying assumptions of the PACE-EE and show the utility of measures based on just very brief periods of non-directive interviewing, making them practical in a wide range of studies with EE just one of a larger set of measures. Copyright © 2003 Whurr Publishers Ltd. [source] Rates of Acute Care Admissions for Frail Older People Living with Met Versus Unmet Activity of Daily Living NeedsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2006Laura P. Sands PhD OBJECTIVES: To determine whether older people who do not have help for their activity of daily living (ADL) disabilities are at higher risk for acute care admissions and whether entry into a program that provides for these needs decreases this risk. DESIGN: A longitudinal cohort study. SETTING: Thirteen nationwide sites for the Program of All-inclusive Care for the Elderly (PACE). PACE provides comprehensive medical and long-term care to community-living older adults. PARTICIPANTS: Two thousand nine hundred forty-three PACE enrollees with one or more ADL dependencies. MEASUREMENTS: Unmet needs were defined as the absence of paid or unpaid assistance for ADL disabilities before PACE enrollment. Hospital admissions in the 6 months before PACE enrollment and acute admissions in the first 6 weeks and the 7th through 12th weeks after enrollment were determined. RESULTS: Those who lived with unmet ADL needs before enrollment were more likely to have a hospital admission before PACE enrollment (odds ratio (OR)=1.28, 95% confidence interval (CI)=1.01,1.63) and an acute admission in the first 6 weeks after enrollment (OR=1.45, 95% CI=1.00,2.09) but not after 6 weeks of receiving PACE services (OR=0.86, 95% CI=0.53,1.40). CONCLUSION: Frail older people who live without needed help for their ADL disabilities have higher rates of admissions while they are living with unmet ADL needs but not after their needs are met. With state governments under increasing pressure to develop fiscally feasible solutions for caring for disabled older people, it is important that they be aware of the potential health consequences of older adults living without needed ADL assistance. [source] Risk of Hip Fracture in Disabled Community-Living Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2003Louise C. Walter MD OBJECTIVES: To determine the rate of hip fracture and risk factors associated with hip fractures in disabled older persons who enroll in the Program of All-Inclusive Care for the Elderly (PACE), a program providing comprehensive care to community-living nursing-home-eligible persons. DESIGN: Prospective cohort study between January 1990 and December 1997. SETTING: The twelve PACE demonstration sites: San Francisco, California; Columbia, South Carolina; Detroit, Michigan; Denver, Colorado; East Boston, Massachusetts; El Paso, Texas; Milwaukee, Wisconsin; Oakland, California; Portland, Oregon; Rochester, New York; Sacramento, California; and the Bronx, New York. PARTICIPANTS: Five thousand one hundred eighty-seven individuals in PACE; mean age 79, 71% female, 49% white, 47% with dementia. MEASUREMENTS: Functional status, cognitive status, demographics, and comorbid conditions were recorded on all the participants, who were tracked for occurrence of a hip fracture. The goals were to determine the rate of hip fracture and identify risk factors. RESULTS: Two hundred thirty-eight hip fractures (4.6%) occurred during follow-up. The rate of hip fracture was 2.2% per person-year. Four independent predictors of hip fracture were identified using Cox proportional hazard analysis: age of 75 and older (adjusted hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.4,2.8); white ethnicity (HR = 2.1, 95% CI = 1.6,2.8); ability to transfer independently to and from bed, chair, and toilet (HR = 3.0, 95% CI = 1.2,7.2); and five or more Short Portable Mental Status Questionnaire errors (HR = 1.6, 95% CI = 1.3,2.1). The incidence of hip fracture ranged from 0.5% per person-year in persons with zero to one independent risk factors to 4.7% per person-year in those with all four independent risk factors. CONCLUSIONS: The rate of hip fracture in this cohort of disabled community-living older adults was similar to that reported in nursing home cohorts. Older age, white race, ability to transfer independently, and cognitive impairment were independent predictors of hip fracture. Persons with these risk factors should be targeted for preventive interventions, which should include strategies for making transferring safer. [source] Diffusion-weighted imaging of the liver: Comparison of navigator triggered and breathhold acquisitionsJOURNAL OF MAGNETIC RESONANCE IMAGING, Issue 3 2009Bachir Taouli MD Abstract Purpose To compare a free breathing navigator triggered single shot echoplanar imaging (SS EPI) diffusion-weighted imaging (DWI) sequence with prospective acquisition correction (PACE) with a breathhold (BH) DWI sequence for liver imaging. Materials and Methods Thirty-four patients were evaluated with PACE-DWI and BH DWI of the liver using b-values of 0, 50, and 500 s/mm2. There were 29 focal liver lesions in 18 patients. Qualitative evaluation was performed on a 3-point scale (1,3) by two independent observers (maximum score 9). Quantitative evaluation included estimated SNR (signal to noise ratio), lesion-to-liver contrast ratio, liver and lesion apparent diffusion coefficients (ADCs), and coefficient of variation (CV) of ADC in liver parenchyma and focal liver lesions (estimate of noise contamination in ADC). Results PACE-DWI showed significantly better image quality, higher SNR and lesion-to-liver contrast ratio when compared with BH DWI. ADCs of liver and focal lesions with both sequences were significantly correlated (r = 0.838 for liver parenchyma, and 0.904 for lesions, P < 0.0001), but lower with the BH sequence (P < 0.02). There was higher noise contamination in ADC measurement obtained with BH DWI (with a significantly higher SD and CV of ADC). Conclusion The use of a navigator echo to trigger SS EPI DWI improves image quality and liver to lesion contrast, and enables a more precise ADC quantification compared with BH DWI acquisition. J. Magn. Reson. Imaging 2009;30:561,568. © 2009 Wiley-Liss, Inc. [source] THE PRESIDENT'S COUNCIL ON BIOETHICS,REQUIESCAT IN PACEJOURNAL OF RELIGIOUS ETHICS, Issue 2 2010Ronald M. Green ABSTRACT In mid-June 2009, the Obama administration dissolved the President's Council on Bioethics (PCBE), a group established by President George W. Bush in August 2001 and whose nearly eight-year life was marked from beginning to end by controversy. While some will regret the PCBE's passing, others will regard the Council as a failed experiment in doing public bioethics. [source] Right Ventricular Septal Pacing: A Comparative Study of Outflow Tract and Mid Ventricular SitesPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 10 2010RAPHAEL ROSSO M.D. Background: Prolonged right ventricle (RV) apical pacing is associated with left ventricle (LV) dysfunction due to dysynchronous ventricular activation and contraction. Alternative RV pacing sites with a narrower QRS compared to RV pacing might reflect a more physiological and synchronous LV activation. The purpose of this study was to compare the QRS morphology, duration, and suitability of RV outflow tract (RVOT) septal and mid-RV septal pacing. Methods: Seventeen consecutive patients with indication for dual-chamber pacing were enrolled in the study. Two standard 58-cm active fixation leads were passed to the RV and positioned in the RVOT septum and mid-RV septum using a commercially available septal stylet (model 4140, St. Jude Medical, St. Paul, MN, USA). QRS duration, morphology, and pacing parameters were compared at the two sites. The RV lead with less-satisfactory electrical parameters was withdrawn and deployed in the right atrium. Results: Successful positioning of the pacing leads at the RVOT septum and mid-RV septum was achieved in 15 patients (88.2%). There were no significant differences in the mean stimulation threshold, R-wave sensing, and lead impedance between the two sites. The QRS duration in the RVOT septum was 151 ± 14 ms and in the mid-RV septum 145 ± 13 ms (P = 0.150). Conclusions: This prospective observational study shows that septal pacing can be reliably achieved both in the RVOT and mid-RV with active fixation leads using a specifically shaped stylet. There are no preferences in regard to acute lead performance or paced QRS duration with either position. (PACE 2010; 33:1169,1173) [source] Anterior Mitral Valve Length is Associated with Ventricular Tachycardia in Patients with Classical Mitral Valve ProlapsePACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 10 2010MURAT AKCAY M.D. Background: The aim of this study was to investigate the electrocardiographic and echocardiographic predictors of ventricular tachycardia (VT) in patients with classical mitral valve prolapse (MVP). Methods: Thirty patients (nine men and 21 women; mean age, 41.5 ± 15 years) in sinus rhythm with mitral valve prolapse who had VT in 24-hour Holter analysis and 30 patients with MVP without VT (eight men and 22 women; mean age, 43 ± 16 years) were included in this study. Transthoracic echocardiography, QT analyses from 12-lead electrocardiography, and 24-hour Holter electrocardiogram recordings were performed. Results: Mitral posterior leaflet thickness (0.48 ± 0.03 cm vs 0.43 ± 0,08 cm, P = 0.025), mitral anterior leaflet length (3.2 ± 0.24 cm vs 2.9 ± 0.36, P < 0.001), mitral posterior leaflet length (2.2 ± 0.3 cm vs 1.9 ± 0.35 cm, P = 0.01), left atrium anteroposterior diameter (4.2 ± 0.8 cm vs 3.5 ± 0.5 cm, P = 0.001), and mitral annulus circumference (15.7 ± 1.3 cm vs 14.6 ± 1.6 cm, P = 0.004) were increased significantly in MVP cases with VT. No significant difference was found between the cases with and without VT in terms of frequency- and time-domain analysis. QT dispersion (72 ± 18 ms vs 55 ± 15 ms, P = 0.0002) and corrected QT dispersion (QTcD) (76 ± 18 ms vs 55 ± 15 ms, P = 0.0002) were significantly increased in cases with VT compared with those without VT. Based on logistic regression analysis for MVP cases, in the case of VT, an enhancement in QTcD (P = 0.01) and the mitral anterior leaflet length (P = 0.003) were the independent predictors of VT. Conclusion: Mitral anterior leaflet length and enhanced QTcD are closely related with VT in patients with classical MVP. (PACE 2010; 33:1224,1230) [source] Left Atrial Ablation at the Anatomic Areas of Ganglionated Plexi for Paroxysmal Atrial FibrillationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 10 2010EVGENY POKUSHALOV M.D., Ph.D. Background:,Modification of left atrial ganglionated plexi (GP) is a promising technique for the treatment of paroxysmal atrial fibrillation (AF) but its therapeutic efficacy is not established. This study aimed at evaluating the effectiveness of anatomic GP modification by means of an implantable arrhythmia monitoring device. Methods:,In 56 patients with paroxysmal AF, radiofrequency ablation at anatomic sites, where the main clusters of GP have been identified in the left atrium, was performed. In all patients, an electrocardiogram monitor (Reveal XT, Medtronic Inc., Minneapolis, MN, USA) was implanted before (n = 7) or immediately after (n = 49) AF ablation. Results:,Average duration of the procedure was 142 ± 18 min and average fluoroscopy time 20 ± 7 min. In total, 53,81 applications of RF energy were delivered (mean of 18.2 ± 3.8 at each of the four areas of GP ablation). Heart rate variability was assessed in 31 patients. Standard deviation of RR intervals over the entire analyzed period, the root mean square of differences between successive RR intervals, and high frequencies decreased, while HRmin, HRmean, and LF to HF ratio increased immediately postablation; these values returned to baseline 6 months after the procedure. At end of 12-month follow-up, 40 (71%) patients were free of arrhythmia recurrence. Ten patients had AF recurrence, two patients had left atrial flutter, and four patients had episodes of flutter as well as AF recurrence. Duration of episodes of AF after ablation gradually decreased over the follow-up period. Conclusions:,Regional ablation at the anatomic sites of the left atrial GP can be safely performed and enables maintenance of sinus rhythm in 71% of patients with paroxysmal AF for a 12-month period. (PACE 2010; 33:1231,1238) [source] Catheter Ablation for Paroxysmal Atrial Fibrillation: A Randomized Comparison between Multielectrode Catheter and Point-by-Point AblationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2010ALAN BULAVA M.D., Ph.D. Introduction:,Catheter ablation for paroxysmal atrial fibrillation is widely used for patients with drug-refractory paroxysms of arrhythmia. Recently, novel technologies have been introduced to the market that aim to simplify and shorten the procedure. Aim:,To compare the clinical outcome of pulmonary vein (PV) isolation using a multipolar circular ablation catheter (PVAC group), with point-by-point PV isolation using an irrigated-tip ablation catheter and the CARTO mapping system (CARTO group; CARTO, Biosense Webster, Diamond Bar, CA, USA). Methods:,Patients with documented PAF were randomized to undergo PV isolation using PVAC or CARTO. Atrial fibrillation (AF) recurrences were documented by serial 7-day Holter monitoring. Results:,One hundred and two patients (mean age 58 ± 11 years, 68 men) were included in the study. The patients had comparable baseline clinical characteristics, including left atrial dimensions and left ventricular ejection fraction, in both study arms (PVAC: n = 51 and CARTO: n = 51). Total procedural and fluoroscopic times were significantly shorter in the PVAC group (107 ± 31 minutes vs 208 ± 46 minutes, P < 0.0001 and 16 ± 5 minutes vs 28 ± 8 minutes, P < 0.0001, respectively). The AF recurrence was documented in 23% and 29% of patients in the PVAC and CARTO groups, respectively (P = 0.8), during the mean follow-up of 200 ± 13 days. No serious complications were noted in both study groups. Conclusions:,Clinical success rates of PV isolation are similar when using multipolar circular PV ablation catheter and point-by-point ablation with a three-dimensional (3D) navigation system in patients with PAF, and results in shorter procedural and fluoroscopic times with a comparable safety profile. (PACE 2010; 33:1039,1046) [source] Emotional Stress Triggers Symptoms in Hypertrophic Cardiomyopathy: A Survey of the Hypertrophic Cardiomyopathy AssociationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2010RACHEL LAMPERT M.D. Background:,Symptoms are among the most important factors impacting quality of life (QOL) in hypertrophic cardiomyopathy (HCM) patients, and reflect a poor prognosis. Whether emotional stress can trigger symptoms of chest pain, dyspnea, palpitations, and lightheadedness has not been described. Methods:,Members of the Hypertrophic Cardiomyopathy Association (HCMA) received an electronic link via e-mail to an ongoing online survey, also accessed via links on the HCMA message-board and homepage. Between May 2007 and November 2008, there were 1,297 respondents. The survey queried demographic and self-reported clinical information, and types and triggers of symptoms. Respondents reported physical and emotional QOL on a 1,10 Likert scale. Results:,Symptoms reported included chest pain (49%), dyspnea (70%), palpitations (61%), and syncope/lightheadedness (59%). The most common symptom trigger was exertion, 64% describing symptoms while climbing stairs or hills. Forty-nine percent described experiencing symptoms during emotional stress. Those reporting chest pain were more likely to report emotion triggering (60%) than those reporting palpitations, syncope/lightheadedness, or dyspnea (50,54% each). Both physical and emotional QOL were significantly decreased in those describing emotion-triggered symptoms. Women were more likely than men to report symptoms overall, as well as emotion-triggered symptoms (50% vs 35%, P < 0.001) and exertion-triggered symptoms (79% vs 58%, P < 0.001). After controlling for presence of symptoms, both emotion- and exertion-triggered symptoms remained significantly more common in women. Conclusions:,Triggering of symptoms by emotion is common in individuals with HCM. Further studies will determine pathways linking emotional stressors with chest pain, dyspnea, palpitations, and lightheadedness in these patients. (PACE 2010; 33:1047,1053) [source] Female-Specific Education, Management, and Lifestyle Enhancement for Implantable Cardioverter Defibrillator Patients: The FEMALE-ICD StudyPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2010LAUREN D. VAZQUEZ Ph.D. Background:,Significant rates of psychological distress occur in implantable cardioverter defibrillator (ICD) patients. Research has demonstrated that women are particularly at risk for developing distress and warrant psychosocial attention. The major objectives were to implement and test the effectiveness of a female-specific psychosocial group intervention on disease-specific quality of life outcomes in outpatient female ICD recipients versus a wait-list control group. Method:,Twenty-nine women were recruited for the study. Fourteen women were randomized to the intervention group and participated in a psychosocial intervention focused on female-specific issues; 15 were randomized to the wait-list control group. All women completed individual psychological batteries at baseline and at 1-month follow-up measuring shock anxiety and device acceptance. Results:,Pre-post measures of shock anxiety demonstrated a significant time by group interaction effect with the intervention group having a significantly greater decrease (Pillai's trace = 5.58, P = 0.026). A significant interaction effect (Pillai's trace = 5.05, P = 0.046) was found, such that women under the age of 50 experienced greater reduction in shock anxiety than their middle-aged cohorts. Pre-post measures of device acceptance revealed a significant time by group interaction effect with the intervention group having significantly greater increases (Pillai's trace = 5.80, P = 0.023). Conclusions:,Structured interventions for female ICD patients involving ICD-specific education, cognitive behavioral therapy strategies, and group social support provide improvements in shock anxiety and device acceptance at 1-month re-assessment. Young women appear to be an at-risk subgroup of this population and may experience more benefit from psychosocial treatment targeting device-specific concerns. (PACE 2010; 33:1131,1140) [source] Rationale and Design of the OPTION Study: Optimal Antitachycardia Therapy in ICD Patients without Pacing IndicationsPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2010CHRISTOF KOLB M.D. Background:,Implantable cardioverter-defibrillators (ICDs) represent the treatment of choice for primary and secondary prevention of sudden cardiac death but ICD therapy is also plagued by inappropriate shocks due to supraventricular tachyarrhythmias. Dual-chamber (DC) ICDs are considered to exhibit an enhanced discrimination performance in comparison to single-chamber (SC) ICDs, which results in reduction of inappropriate detections in a short- to mid-term follow-up. Comparative data on long-term follow-up and especially on inappropriate shocks are limited. Methods:,The aim of the OPTION study is to assess whether an optimized treatment with DC ICDs improves patient outcome and decreases the rate of inappropriate shocks in comparison to SC ICDs. DC ICD therapy optimization is achieved by optimal customizing of antitachycardia therapy parameters, activation of discrimination algorithms, antitachycardia pacing in the slow ventricular tachycardia zone, and avoidance of right ventricular pacing with the SafeR algorithm mode. The OPTION study, a prospective, multicenter, randomized, single-blinded, parallel study, will randomize 450 patients on a 1:1 allocation to either an SC arm with backup pacing at VVI 40 beats per minute (bpm) or to the DC arm with SafeR pacing at 60 bpm. Patients will be followed for 27 months. Primary outcome measure is the time to first occurrence of inappropriate shock and a combined endpoint of cardiovascular morbidity and all-cause mortality. Conclusion:,The study will evaluate the relative performance of DC in comparison to SC ICDs in terms of inappropriate shock reduction and patient outcome. (PACE 2010; 33:1141,1148) [source] Heart Rate Turbulence Impairment and Ventricular Arrhythmias in Patients with Systemic SclerosisPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2010PIOTR BIENIAS M.D., Ph.D. Background:,Arrhythmias, conduction disturbances, and cardiac autonomic nervous system dysfunction are the most frequent cardiovascular complications in systemic sclerosis (scleroderma). The aim of the study was to assess heart rate turbulence (HRT) in systemic sclerosis patients and to identify the relationship between HRT and occurrence of arrhythmias. Methods:,Forty-five patients with scleroderma (aged 54.6 ± 14.7 years) and 30 healthy sex- and age-matched subjects were examined. In addition to routine studies, 24-hour Holter monitoring with assessment of HRT was performed. Results:,As compared to controls, HRT was significantly impaired in systemic sclerosis patients. Abnormal HRT defined as turbulence onset (TO) ,0.0% and/or turbulence slope (TS) ,2.5 ms/RR (ms/RR interval) was found in 19 (42%) scleroderma patients and in no members of the control group. Serious ventricular arrhythmias Lown class IV (VA-LownIV), for example, couplets and/or nonsustained ventricular tachycardias, were observed in 16 (36%) scleroderma patients. The median value of TS was significantly lower in systemic sclerosis patients with VA-LownIV than in patients without VA-LownIV (3.68 vs 7.00 ms/RR, P = 0.02). The area under curve of ROC analysis for prediction of VA-LownIV was 0.72 (95% confidence interval [CI] 0.56,0.87) and revealed that TS <9.0 ms/RR was associated with VA-Lown IV occurrence, with sensitivity of 93.7% and specificity of 44.8%. Univariate and multivariate analyses confirmed that lower values of TS were associated with VA-LownIV occurrence (odds ratio 1.52, 95% CI 1.09,2.12, P = 0.01). Conclusions:,Patients with systemic sclerosis are characterized by significant HRT impairment. Assessment of HRT and especially TS is useful in the identification of patients at risk for ventricular arrhythmias. (PACE 2010; 920,928) [source] Acute Effects of Moxonidine on Cardiac Autonomic ModulationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2010DAYIMI KAYA M.D. Background: Moxonidine, an imidazoline I1 receptor agonist, is a centrally acting antihypertensive agent having sympatholytic effect. However, there are only limited data regarding the effects of this drug on autonomic cardiac functions. Methods and results: In this study we investigated the acute effects of moxonidine on cardiac autonomic modulation by heart rate variability (HRV) analysis. The effects of oral 0.4-mg moxonidine were studied on 11 healthy male volunteers in a randomized, double-blind, placebo controlled, and crossover study. After 15 minutes rest, time and frequency domain parameters of HRV were calculated from 5-minute continue electrocardiography recordings in supine position, during controlled respiration (15 breath/min) and during handgrip exercise before and 1 hour after taking placebo or moxonidine. Baseline parameters before taking placebo and moxonidine were similar (P > 0.05). Moxonidine, but not placebo, caused an increase in heart failure (HF) (119 ± 21 vs 156 ± 23, P = 0.029) and HFnu (39 ± 4 vs 47 ± 4, P = 0.033) and decrease in LFnu (61 ± 4 vs 53 ± 4, P = 0.033) and LF/HF ratio (1.96 ± 0.36 vs 1.12 ± 0.35, P = 0.010) in supine position compared with baseline parameters. However, there was no difference in other time or frequency domain parameters during controlled breathing and handgrip exercise either with moxonidine or placebo administration (P > 0.05). Single dose of moxonidine administration increases cardiovagal tone but parasympathetic and sympathetic autonomic maneuvers attenuated its short term effects on HRV in healthy male subjects. (PACE 2010; 929,933) [source] Predictors of Early Mortality in Patients Age 80 and Older Receiving Implantable DefibrillatorsPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2010DREW ERTEL M.D. Background: There are no upper age restrictions for implantable defibrillators (ICDs) but their benefit may be limited in patients , 80 years with strong competing risks of early mortality. Risk factors for early (1-year) mortality in ICD recipients , 80 years of age have not been established. Methods: Two-center retrospective cohort study to assess predictors of one-year mortality in ICD recipients , 80 years of age. Results: Of 2,967 ICDs implanted in the two centers from 1990,2006, 225 (7.6%) patients were ,80 years of age and followed-up at one of the two centers. Mean age was 83.3 ± 3.1 years and follow-up time 3.3 ± 2.6 years. Median survival was 3.6 years (95% confidence interval 2.3,4.9). Multivariate predictors of 1-year mortality included ejection fraction (EF) , 20% and the absence of beta-blocker use. Actuarial 1-year mortality of ICD recipients , 80 with an EF , 20% was 38.2% versus 13.1% in patients 80+ years with an EF > 20% and 10.6% for patients < 80 years with an EF , 20% (P < 0.001 for both). There was no significant difference in the risk of appropriate ICD therapy between those patients 80+ years with EF above and below 20%. Conclusion: In general, patients , 80 years of age who meet current indications for ICD implantation live sufficiently long to warrant device implantation based on anticipated survival alone. However, those with an EF , 20% have a markedly elevated 1-year mortality with no observed increase in appropriate ICD therapy, thus reducing the benefit of device implantation in this population. (PACE 2010; 981,987) [source] Utilization of Defibrillators and Resynchronization Therapy at the Time of Evaluation at a Heart Failure and Cardiac Transplantation CenterPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2010DANIEL B. SIMS M.D. Background: Internal cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) reduce mortality, but are underutilized in routine clinical practice. The use of these devices in patients at the time of an initial evaluation at an advanced heart failure and cardiac transplantation center is unknown. Methods: We retrospectively analyzed consecutive patients who were enrolled in a database examining parameters of cardiopulmonary exercise testing in chronic heart failure (CHF) patients at the time of an initial outpatient evaluation at a tertiary care center. Rates of ICD and CRT use in eligible patients were determined. Results: Two hundred two patients had an average age of 54 ± 13 years and an average peak oxygen consumption (pVO2) of 12.5 ± 4.5 mL/kg/min. Of 97 patients eligible for an ICD only, 57% had an ICD at the time of evaluation. Sixty-four percent of ICD-eligible male patients had an ICD compared to 36% of ICD-eligible female patients (P = 0.015). Of 105 patients meeting criteria for CRT, 54% had a CRT device. There was no difference between CRT use in eligible male and female patients. Conclusions: ICDs and CRT are underutilized in patients with severe CHF at the time of evaluation at a tertiary care center despite young age, objective functional limitation, and active consideration for advanced CHF therapies. Female patients have lower rates of ICD use than male patients. (PACE 2010; 988,993) [source] Focal Atrial Tachycardia Originating from the Donor Superior Vena Cava after Bicaval Orthotopic Heart TransplantationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2010HAW-KWEI HWANG M.D. An 11-year-old boy, who underwent bicaval orthotopic heart transplantation for idiopathic dilated cardiomyopathy, had a focal atrial tachycardia originating from the donor superior vena cava. The pathogenesis of this tachycardia may be related to transplant rejection or transplant vasculopathy. Radiofrequency catheter ablation can eliminate this unique tachycardia and result in hemodynamic improvement. (PACE 2010; e68,e71) [source] Focal Ablation versus Single Vein Isolation for Atrial Tachycardia Originating from a Pulmonary VeinPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2010BRYAN BARANOWSKI M.D. Background: Rapid, disorganized firing from a pulmonary vein (PV) focus may initiate atrial fibrillation. The natural history of PV atrial tachycardia (AT), resulting in a slower, more organized form of firing, is less clear. Furthermore, the optimal therapeutic approach to a PV AT is poorly defined. Objective: This study assessed the characteristics and long-term outcomes of focal ablation versus PV isolation for ATs arising from a single PV. Methods: We reviewed 886 consecutive patients who underwent an AT radiofrequency ablation at our institution from January 1997 through August 2008. Results: Twenty-six patients had focal AT with a mean cycle length of 364 ± 90 ms that arose from within a single PV. Ten patients underwent focal ablation of their AT and 16 patients underwent PV isolation of the culprit vein. All procedures were acutely successful. The average follow-up was 25 months (range 2,90 months). There were three recurrences of AT in patients who underwent a focal ablation. There were no recurrences in patients who underwent targeted PV isolation (P = 0.046). No patients developed atrial fibrillation or AT from another focus during the follow-up period. Conclusion: PV AT can be successfully treated with single vein isolation or focal ablation with a low risk of recurrence or the development of atrial fibrillation. PV isolation may be the preferred approach when the AT focus arises from a site distal to the ostium where targeted ablation could result in phrenic nerve injury or occlusion of a pulmonary venous branch. (PACE 2010; 776,783) [source] Long-Term Effects of Upgrading to Biventricular Pacing: Differences with Cardiac Resynchronization Therapy as Primary IndicationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2010GAETANO PAPARELLA M.D. Background: Few studies have assessed the long-term effects of cardiac resynchronization therapy (CRT) in patients with advanced heart failure (HF) and previously right ventricular apical pacing (RVAP). Aims: To assess the clinical and hemodynamic impact of upgrading to biventricular pacing in patients with severe HF and permanent RVAP in comparison with patients who had CRT implantation as initial therapy. Methods and Results: Thirty-nine patients with RVAP, advanced HF (New York Heart Association [NYHA] III,IV), and severe depression of left ventricular ejection fraction (LVEF) were upgraded to biventricular pacing (group A). Mean duration of RVAP before upgrading was 41.8 ± 13.3 months. Clinical and echocardiographic results were compared to those obtained in a group of 43 patients with left bundle branch block and similar clinical characteristics undergoing "primary" CRT (group B). Mean follow-up was 35 ± 10 months in patients of group A and 38 ± 12 months in group B. NYHA class significantly improved in groups A and B. LVEF increased from 0.23 ± 0.07 to 0.36 ± 0.09 (P < 0.001) and from 0.26 ± 0.02 to 0.34 ± 0.10 (P < 0.001), respectively. Hospitalizations were reduced by 81% and 77% (P < 0.001). Similar improvements in echocardiographic signs of ventricular desynchronization were also observed. Conclusion: Patients upgraded to CRT exhibit long-term clinical and hemodynamic benefits that are similar to those observed in patients treated with CRT as initial strategy. (PACE 2010; 841,849) [source] Response to Cardiac Resynchronization Therapy in Patients with Heart Failure and Renal InsufficiencyPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2010EVAN C. ADELSTEIN M.D. Background: Renal insufficiency (RI) adversely impacts prognosis in heart failure (HF) patients, partly because renal and cardiac dysfunction are intertwined, yet few cardiac resynchronization therapy (CRT) studies have examined patients with moderate-to-severe RI. Methods: We analyzed 787 CRT-defibrillator (CRT-D) recipients with a glomerular filtration rate (GFR) measured prior to implant. Patients were grouped by GFR (in mL/min/1.73 m2): ,60 (n = 376), 30,59 (n = 347), and <30 (n = 64). Overall survival, changes in left ventricular (LV) ejection fraction and LV end-systolic diameter, and GFR change at 3,6 months were compared among CRT-D groups and with a control cohort (n = 88), also stratified by GFR, in whom LV lead implant was unsuccessful and a standard defibrillator (SD) was placed. All patients met clinical criteria for CRT-D. Results: Among CRT-D recipients, overall survival improved incrementally with higher baseline GFR (for each 10 mL/min/1.73 m2 increase, corrected hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.13,1.30, P < 0.0001). Survival among SD and CRT-D patients within GFR < 30 and GFR , 60 groups was similar, whereas CRT-D recipients with GFR 30,59 had significantly better survival compared to SD counterparts (HR 2.23, 95% CI 1.34,3.70; P = 0.002). This survival benefit was associated with improved renal and cardiac function. CRT recipients with GFR , 60 derived significant echocardiographic benefit but experienced a GFR decline, whereas those with GFR < 30 had no echocardiographic benefit but did improve GFR. Conclusions: CRT may provide the largest survival benefit in HF patients with moderate RI, perhaps by improving GFR and LV function. Severe baseline RI predicts poor survival and limited echocardiographic improvement despite a modest GFR increase, such that CRT may not benefit those with GFR < 30 mL/min/1.73 m2. CRT recipients with normal renal function derive echocardiographic benefit but no overall survival advantage. (PACE 2010; 850,859) [source] Significant Left Atrial Appendage Activation Delay Complicating Aggressive Septal Ablation during Catheter Ablation of Persistent Atrial FibrillationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2010CHEN-XI JIANG M.D. Background:,This study aims to describe significant left atrial appendage activation following ablation of persistent atrial fibrillation, and explore its relationship with aggressive septal ablation. Methods and Results:,Significant left atrial appendage activation delay was found in 23 out of 201 patients undergoing persistent atrial fibrillation ablation. Of them, 14 were found in their index procedures, of whom septal line ablation was performed in nine (odds ratio 15.2, 95% confidence interval 4.6,50.8, P < 0.001). Another nine were found during their redo procedures (including two with biatrial activation dissociation), all of whom received extensive left septal complex fractionated electrograms ablation in their prior procedures (P = 0.002). Electrocardiograph showed split P wave with the latter component merged into the QRS wave. Activation mapping demonstrated the earliest breakthrough of the left atrium changed to coronary sinus in 18 (85.7%) patients. After 1 month, the mitral A wave velocity was 18.2 ± 17.0 cm/s, and decreased significantly as compared with preablation (20.2 ± 19.1 vs 58.2 ± 17.9 cm/s, P = 0.037) in patients undergoing redo procedures. Fourteen (60.9%) remained arrhythmia-free during follow-up for 10.6 ± 6.2 months. Conclusion:,Septal line ablation and extensive septal complex fractionated electrograms ablation are correlated with significant left atrial activation delay or even biatrial activation dissociation, and should be performed with prudent consideration. (PACE 2010; 33:652,660) [source] A Survey of the Practice of Lead Extraction in the United StatesPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2010CHARLES A. HENRIKSON M.D. Background:,Endovascular lead extraction is an important component of the management of patients with chronically implanted arrhythmia control devices. Although it is associated with the potential for significant morbidity and mortality, there is little information about its scope and practice. Methods:,We surveyed 1,000 physician members of the Heart Rhythm Society via e-mail solicitation. Results:,Of the 252 respondents (25%), 221 (88%) reported either performing extractions themselves (63%), or having privileges at a hospital where extractions are performed (25%). Electrophysiologists perform extractions at most sites (83%) but cardiac surgeons perform endovascular lead extraction at a significant minority of sites (20%). Most respondents report low annual volumes of extractions at their site: 15% reported <10 procedures/year, 42% 10,25 procedures/year, 23% 26,50 procedure/year, and only 19% reported >50 procedures/year. Thirty-six percent of respondents reported that extractions were done in the operating room (OR) with surgeon present or immediately available, 39% in the electrophysiology (EP) lab with surgeon and OR identified and available, and 25% in EP lab without a surgeon or OR identified. The overall risks of lead extraction were felt to be 1,5% of major complication and 0.5,1% of mortality, roughly in line with published data. Conclusions:,While there is agreement as to the risk of major complication and death from lead extraction, the degree of surgical availability varies considerably. The new guidelines document recommends the ability to promptly initiate an emergent surgical procedure, and this should be an important goal for all extractionists. (PACE 2010; 33:721,726) [source] Underutilization of Implantable Cardioverter Defibrillators Post Coronary Artery Bypass Grafting in Patients with Systolic DysfunctionPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2010JERRY M. JOHN M.D. Background: Evaluation of the need for prophylactic internal cardiac defibrillators among patients with ischemic cardiomyopathies should be deferred until at least 3 months after revascularization procedures to allow adequate time for recovery of ventricular function. Methods: Among patients with left ventricular systolic dysfunction (LVSD) who undergo coronary artery bypass grafting (CABG), the proportion of patients who are risk stratified postoperatively with reassessment of left ventricular ejection fraction (LVEF) is unknown. Results: One hundred and six patients with LVSD (LVEF < 40%) who underwent CABG during 2004,2006 and survived 3 months post CABG were evaluated. Follow-up was assessed by chart review and telephone contact. LVEF was not reassessed in 24% (25/106) of the population, none of whom underwent internal cardioverter defibrillator (ICD) implantation. Of those with LVEF reassessed, persistent LVSD was present in 20/81 (25%), 12 of whom were referred for prophylactic ICD placement. Conclusion: One-fourth of patients with LVSD who undergo CABG do not have LVEF reassessed postoperatively which may lead to underutilization of ICDs. (PACE 2010; 33:727,733) [source] Radiofrequency Transseptal Catheter Electrode FracturePACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2010ASHOK J. SHAH M.D. Transseptal puncture is performed using a long needle advanced from the femoral approach. A radiofrequency catheter has been developed that delivers a short burst of radiofrequency energy and creates a micro puncture in the interatrial septum. We describe a case in which the distal radiofrequency electrode broke and became embedded in the interatrial septum. (PACE 2010; 33:e57,e58) [source] All is Not Lost: Utilizing Continuous Remote ILR Monitoring to Diagnose SyncopePACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2010PAUL S. G. HONG M.D. A 63-year-old man with frequent unexplained syncope was implanted with a second generation remotely monitored implantable loop recorder for continuous electrocardiogram (ECG) monitoring. He had a subsequent syncopal episode and despite accidental destruction of his patient activator, vital ECG data from the event were transmitted wirelessly, enabling a cardiac arrhythmia to be excluded. This case highlights the benefit of remote monitoring in syncope assessment, as well as a transmission system that ensures prompt analysis of the ECG data and therefore rapid optimal patient management. (PACE 2010; 33:763,765) [source] Predictive Capability of Left Atrial Size Measured by CT, TEE, and TTE for Recurrence of Atrial Fibrillation Following Radiofrequency Catheter AblationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 5 2010SACHIN S. PARIKH M.D. Background: Recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA) has been well established and is in part related to left atrial (LA) size. The purpose of this study was to assess the predictive capability of LA diameter (LAD) and LA volume (LAV) by echocardiography and computed tomography (CT) to determine success in patients undergoing RFCA of AF. Methods: Eighty-eight patients with paroxysmal or persistent AF who had undergone RFCA and had a prior transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), and CT were enrolled in the study. TTE LADs and LV ejection fraction as well as TEE LADs and LAVs in three views were recorded. CT LAVs were also recorded. Clinical parameters prior to ablation as well as at 1-year follow-up were assessed. Results: A total of 40 (45%) patients with paroxysmal AF and 48 (55%) patients with persistent AF were analyzed. Paroxysmal AF patients had a RFCA success rate of 88% at 1 year with persistent AF patients having a 52% success rate (P < 0.001). A CT-derived LAV , 117 cc was associated with an odds ratio (OR) for recurrence of 4.8 (95% confidence interval [CI]=[1.4,16.4], P = 0.01) while a LAV ,130 cc was associated with an OR for recurrence of 22.0 (95% CI =[2.5,191.0], P = 0.005) after adjustment for persistent AF. Conclusions: LA dimensions and AF type are highly predictive of AF recurrence following RFCA. LAV by CT has significant predictive benefit over standard LADs in severely enlarged atria even after adjustment for AF type. (PACE 2010; 532,540) [source] Cardiac Resynchronization Therapy in Non-Left Bundle Branch Block MorphologiesPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 5 2010JOHN RICKARD M.D. Introduction: In select patients with systolic heart failure, cardiac resynchronization therapy (CRT) has been shown to improve quality of life, exercise capacity, ejection fraction (EF), and survival. Little is known about the response to CRT in patients with right bundle branch block (RBBB) or non-specific intraventricular conduction delay (IVCD) compared with traditionally studied patients with left bundle branch block (LBBB). Methods: We assessed 542 consecutive patients presenting for the new implantation of a CRT device. Patients were placed into one of three groups based on the preimplantation electrocardiogram morphology: LBBB, RBBB, or IVCD. Patients with a narrow QRS or paced ventricular rhythm were excluded. The primary endpoint was long-term survival. Secondary endpoints were changes in EF, left ventricular end-diastolic and systolic diameter, mitral regurgitation, and New York Heart Association (NYHA) functional class. Results: Three hundred and thirty-five patients met inclusion criteria of which 204 had LBBB, 38 RBBB, and 93 IVCD. There were 32 deaths in the LBBB group, 10 in the RBBB, and 27 in the IVCD group over a mean follow up of 3.4 ± 1.2 years. In multivariate analysis, no mortality difference amongst the three groups was noted. Patients with LBBB had greater improvements in most echocardiographic endpoints and NYHA functional class than those with IVCD and RBBB. Conclusion: There is no difference in 3-year survival in patients undergoing CRT based on baseline native QRS morphology. Patients with RBBB and IVCD derive less reverse cardiac remodeling and symptomatic benefit from CRT compared with those with a native LBBB. (PACE 2010; 590,595) [source] | ||||||||||||||||||||||||||||