Category: Volume 1 Number 2

Table of Contents Volume 1 Number 2

New Issue of Cardiovascular Innovations and Applications Journal Published with Special Focus on Electrophysiology

Beijing, February 5, 2016: The new journal Cardiovascular Innovations and Applications (CVIA) has just published its second issue, with a special focus on Electrophysiology. CVIA is the official journal of the Great Wall International Congress of Cardiology (GW-ICC) and its first issue was published in October 2015 to coincide with the 26th GW-ICC in Beijing, China.

The CVIA Special Issue on Electrophysiology has been Guest Edited by Dr. Jamie B. Conti of the University of Florida and brings together contributions from leading cardiologists from the United States and China.

Featured papers in this issue are:

Stroke Prevention in Atrial Fibrillation: Current Strategies and Recommendations by Gerald V. Naccarelli, Gregory Caputo, Thomas Abendroth, Samuel Faber, Mauricio Sendra-Ferrer, Deborah Wolbrette , Soraya Samii, Sarah Hussain and Mario Gonzalez. This review considers the growing incidence of atrial fibrillation (AF) which is expected to double over the next 30 years and already accounts in the United States for one third of cardiac arrhythmia hospitalizations and

70% of Medicare arrhythmia admissions. Registry data suggests that almost half of patients who should be on therapeutic anticoagulation for stroke prevention in AF (SPAF) are not.  Warfarin and more recently developed agents, the “novel anticoagulants” (NOACs) reduce the risk of embolic strokes.  In addition, the NOACS also reduce intracranial hemorrhage (ICH) by over 50% compared to warfarin. Anticoagulation and bridging strategies involving cardioversion, catheter ablation, and invasive/surgical procedures are reviewed.  The development of reversal agents for NOACS and the introduction of left atrial appendage occluding devices will evolve the use of newer strategies for preventing stroke in high risk AF patients.

Atrial Fibrillation Ablation: Indications, New Advances, and Complications by Chang-Sheng Ma.

This review considers catheter ablation as a cornerstone in the management of atrial fibrillation. As new strategies and technologies are implemented to improve the success rates of this procedure, prevention and early detection of complications will contribute to reduction of adverse outcomes with this technology

Other papers in this issue include:

REVIEWS

Current Management of Ventricular Tachycardia: Approaches and Timing by Roy M. John and William Stevenson. This review considers Ventricular tachycardia (VT) which in the presence of structural heart disease is associated with sudden cardiac death and warrants prompt attention. Implantable cardioverter defibrillators, although highly effective in terminating sustained ventricular arrhythmias and reducing mortality, have no effect on the arrhythmia substrate, and recurrent shocks for VT termination occur in approximately 20% of patients. Antiarrhythmic drugs, mainly in the form of beta-blockers or amiodarone, are moderately effective in reducing the need for implantable cardioverter defibrillator therapies, but drug intolerance and serious toxic effects of amiodarone necessitate drug cessation in a quarter of patients. Catheter ablation has emerged as an effective treatment for control of frequent VT episodes and can be lifesaving in cases of incessant VT or VT storm.

Principles of Arrhythmia Management During Pregnancy by Thomas Adam Burkart, William M. Miles and Jamie Beth Conti. Serious arrhythmias that threaten the lives of both the mother and the unborn child during pregnancy are fortunately rare. Documentation of the arrhythmias and correlation of findings with symptoms is imperative before initiation of any therapy. Women with previously diagnosed arrhythmias will frequently experience worsening of their arrhythmia during pregnancy. However, advances in fluoro-less mapping technologies are opening the door to the possibility of performing advanced, invasive arrhythmia therapies during any stage of pregnancy without subjecting the mother and fetus to high doses of radiation.

Changing the Way We “See” Scar: How Multimodality Imaging Fits in the Electrophysiology Laboratory by Anita Wokhlu. Substrate characterization is the mainstay of ablation for ventricular tachycardia (VT). Although the use of electro anatomic voltage mapping (EAVM) in the electrophysiology (EP) laboratory has enabled real-time approximation of myocardial scar, it has limitations. Various non-invasive methods of scar assessment have emerged, with magnetic resonance imaging (MRI) being the most accurate. Integrated MRI and electro anatomic voltage mapping studies demonstrate good correlation, although MRI has numerous advantages.

Syncope and Early Repolarization: A Benign or Dangerous ECG Finding? by Matthew McKillop and William M. Miles. Electrocardiographic ER patterns are common in the normal adult population, especially in young athletes. However, the most frequently observed pattern, the rapidly ascending/upward sloping variety, is not associated with negative outcomes. There are uncommon morphologies, including the type 1 Brugada pattern and type 2 or 3 ER pattern with horizontal/descending ST segments, that have associations with sudden cardiac death, although the event rate in such patients is still very low.

Inherited Wolff–Parkinson–White Syndrome by Yang Liu, Yumei Xue, Shulin Wu and Dan Hu. Recent studies have identified several rare genetic variants associated with WPW syndrome. Present data account for only a limited percentage of the heritability of WPW syndrome. Patients with heritable WPW syndrome have a phenotype that is clearly different from that of those with sporadic WPW syndrome, who typically have structurally normal hearts. No gene defect associated with typical WPW syndrome has yet been identified. In most well-recognized cases, ventricular preexcitation is accompanied by various cardiac or noncardiac clinical manifestations. Integration of next-generation sequencing technologies, improved identification of disease causing genetic variants, and a more complete understanding of causative mechanisms behind WPW syndrome risk loci will be required.

The Subcutaneous Implantable Cardioverter-Defibrillator: A Practical Review and Real-World Use and Application by Mark E. Panna Jr and William M. Miles. The subcutaneous implantable cardioverter-defibrillator (ICD) is a novel technology using a subcutaneous (extrathoracic) system for treatment of potential lethal ventricular arrhythmias. This paper reviews patient selection, system components, the implantation technique, and screening considerations for subcutaneous ICD implantation. Its uses in specific patient populations, including children, patients with congenital heart disease, hypertrophic cardiomyopathy, or end-stage renal disease, and patients with pre-existing pacemakers, are highlighted. Areas of future investigation are reviewed, including potential use with leadless pacing and magnetic resonance imaging.

Athletes and Arrhythmias by Michael J. Jansen and Floyd W. Burke. This review considers the medical management of athletes which presents many unique challenges. The normal cardiac adaptations that occur with intense physical training can be misinterpreted and lead to unnecessary testing and withdrawal from competition. Athletes, however, can have underlying asymptomatic cardiac disease which can be exacerbated by exercise and, rarely, results in sudden cardiac death. Preventative strategies such as preparticipation cardiac screening to better identify those athletes at higher risk of sudden death are currently under investigation and remain controversial.

COMMENTARY

Implantable Cardiac Defibrillators: Who Needs Them and Who Does Not? by C. Richard Conti. ICD implantation is a subject that needs much consideration before proceeding. Dr. Conti writes: ‘When the physician is advising an individual patient about the implantation of an ICD, the patient is entitled to know the benefits and the risks. It is also imperative that the physician knows the patient’s expectations about life expectancy and quality of life…Finally, my advice to those who implant ICDs is “think before you implant an ICD” and have the patient and the family think before an ICD is implanted.’

Led by Editor-in-chief C. Richard Conti, Professor Emeritus of Medicine at the University of Florida and former president of the American College of Cardiology and its founding editor Professor Hu Dayi of Peking University, CVIA is a high-profile peer-reviewed journal with an international Editorial Board. The journal publishes focused articles and original clinical research that explore novel developments in cardiovascular disease, effective control and rehabilitation in cardiovascular disease, and promote cardiovascular innovations and applications for the betterment of public health globally.

CVIA is available on the IngentaConnect platform and at https://dhn.zgc.mybluehostin.me/cvia/. Submissions may be made using ScholarOne Manuscripts (https://mc04.manuscriptcentral.com/cvia-journal). There are no author submission or article processing fees.

 

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Editorial on the Development of a New Journal

Editorial on the Development of a New Journal

Author: Conti, C. Richard

Developing a new journal is not an easy task. I can think of four good reasons, and there are probably more. These reasons are as follows:

  • Potential authors may be reluctant to send manuscripts to an unknown “new journal.”
  • Potential authors may be concerned about the lack of an “impact factor.”
  • Potential authors may have concerns about readership of the authors’ work.
  • Potential reviewers may be reluctant to review manuscripts sent to a new journal because most have multiple manuscripts to review sent to them from known journals. Read More

Document Type: Commentary

DOI: http://dx.doi.org/10.15212/CVIA.2016.0003

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Current Management of Ventricular Tachycardia: Approaches and Timing

Current Management of Ventricular Tachycardia: Approaches and Timing

Authors: John, Roy M.; Stevenson, William

Ventricular tachycardia (VT) in the presence of structural heart disease is associated with sudden cardiac death and warrants prompt attention. Implantable cardioverter defibrillators (ICDs) while highly effective in terminating sustained ventricular arrhythmias and reducing mortality, have no effect on the arrhythmia substrate and recurrent shocks for VT termination occur in approximately 20% of patients. Shocks worsen quality of life and are associated with progression of heart failure and increased mortality. Antiarrhythmic drugs, mainly in the form of beta-blockers or amiodarone, are moderately effective in reducing ICD therapies but drug intolerance and serious toxicities of amiodarone necessitate drug cessation in a quarter of patients. Catheter ablation has emerged as an effective treatment for control of frequent VT episodes and can be life saving in cases of incessant VT or VT storm. As experience increases, it is being used increasingly earlier, rather than a last resort therapy. Efficacy varies with the nature of the underlying heart disease. Intramural arrhythmia substrate and failure to create permanent ablation lesions remain challenges and repeat procedures are necessary in a third to a half of patients. For idiopathic VTs or PVCs that are symptomatic or worsen LV function, catheter ablation is often an effective therapy.

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Principles of Arrhythmia Management During Pregnancy

Principles of Arrhythmia Management During Pregnancy

Authors: Burkart, Thomas Adam; Miles, William M.; Conti, Jamie Beth

This paper reviews current recommendations on the appropriate evaluation and management of cardiac arrhythmias in the pregnant patient. Most arrhythmias during pregnancy are benign and require no intervention. When required, the decision to treat should be based on symptom severity and the associated risk to mother and fetus posed by potentially recurring arrhythmia episodes throughout the pregnancy. Any treatment strategy in this patient population has inherent risk to both mother and unborn child. Before the initiation of any intervention, documentation of a clinical arrhythmia and correlation with clinical symptoms should be obtained. There is no role for empiric therapy.

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Stroke Prevention in Atrial Fibrillation: Current Strategies and Recommendations

Stroke Prevention in Atrial Fibrillation: Current Strategies and Recommendations

Authors: Naccarelli, Gerald V.; Caputo, Gregory; Abendroth, Thomas; Faber, Samuel; Sendra-Ferrer, Mauricio; Wolbrette, Deborah; Samii, Soraya; Hussain, Sarah; Gonzalez, Mario

Stroke is the most common complication of atrial fibrillation (AF). Guidelines recommend anticoagulant treatment in patients with CHA2DS2VASc scores of >2. Registry data suggests that almost half of patients who should be on therapeutic anticoagulation for stroke prevention in AF (SPAF) are not. Warfarin and more recently developed agents, the “novel anticoagulants” (NOACs) reduce the risk of embolic strokes. In addition, the NOACs also reduce intracranial hemorrhage (ICH) by over 50% compared to warfarin. Anticoagulation and bridging strategies involving cardioversion, catheter ablation, and invasive/surgical procedures are reviewed. The development of reversal agents for NOACs and the introduction of left atrial appendage occluding devices will evolve the use of newer strategies for preventing stroke in high risk AF patients.

Keywords: anticoagulants; atrial fibrillation; stroke

Document Type: Research Article

DOI: http://dx.doi.org/10.15212/CVIA.2016.0005

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Atrial Fibrillation Ablation: Indications, New Advances, and Complications

Atrial Fibrillation Ablation: Indications, New Advances, and Complications

 Author: Ma, Chang-Sheng
Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting millions of people worldwide with increasing incidence and prevalence. Radiofrequency catheter ablation has evolved as the treatment of choice for both paroxysmal and persistent AF. Several studies have been reported on catheter ablation as the first-line treatment for paroxysmal AF and different strategies for persistent AF. New technologies such as contact-force sensing catheters and cryoballoon have been recently used and the procedure carries the risk of complications like hematoma, arteriovenous fistula, cardiac tamponade, pulmonary vein stenosis, atrio-esophageal fistula and death.

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Changing the Way We “See” Scar: How Multimodality Imaging Fits in the Electrophysiology Laboratory

Changing the Way We “See” Scar: How Multimodality Imaging Fits in the Electrophysiology Laboratory

Author: Wokhlu, Anita

Substrate characterization is the mainstay of ablation for ventricular tachycardia (VT). Although the use of electroanatomic voltage mapping (EAVM) in the electrophysiology (EP) laboratory has enabled real-time approximation of myocardial scar, it has limitations. This is related to the subjective and tedious nature of voltage mapping and the challenges of defining the transmurality of scar. Various noninvasive methods of scar assessment have emerged, with magnetic resonance imaging (MRI) being the most accurate. Integrated MRI and electroanatomic voltage mapping studies demonstrate good correlation. Nonetheless, MRI has advantages. These include (1) preprocedure identification of epicardial and intramural scar, (2) assessment of ablative lesion formation after unsuccessful ablations, (3) identification of heterogeneous regions of scar, where critical conducting channels are likely to occur, and (4) predictive value in the assessment of sudden cardiac death (SCD). Integration of scar imaging in ventricular tachycardia ablation and risk stratification has great potential to advance the practice of arrhythmia management.

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Syncope and Early Repolarization: A Benign or Dangerous ECG Finding?

Syncope and Early Repolarization: A Benign or Dangerous ECG Finding?

Authors: McKillop, Matthew; Miles, William M.

Early repolarization is a well-described, common electrocardiographic variant. It was initially felt to be benign, but in the last twenty years a suggested a link between specific types of early repolarization and sudden cardiac death has emerged. This association was has been termed the J wave syndrome and includes both the high risk early repolarization and Brugada ECG patterns. The odds of early repolarization change being associated with poor outcomes are still exceedingly small. Nevertheless, the association of a fairly ubiquitous ECG finding with fatal or near fatal clinical outcomes has raised concern. How can we identify the truly high-risk patients? If a patient has a significant clinical event with a concerning ECG repolarization pattern, what should be done next? The authors of this review present current information regarding the Early Repolarization and Brugada Syndromes and how to proceed with diagnosis, management, and risk stratification when early repolarization change is observed on ECG.

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Inherited Wolff‐Parkinson‐White Syndrome

Inherited Wolff‐Parkinson‐White Syndrome

Authors: Liu, Yang; Xue, Yumei; Wu, Shulin; Hu, Dan

Wolff‐Parkinson‐White (WPW) syndrome is a congenital disorder of cardiac conduction system characterized by electrocardiographic preexcitation and episodes of paroxysmal supraventricular tachycardia. It is caused by a cardiac developmental defect in the electrical insulation between the atria and the ventricles due to the presence of an accessory pathway. WPW syndrome is a common cause of supraventricular tachycardia with benign prognosis. However, this clinical entity also predisposes patients to an increased risk of sudden cardiac death, especially in the setting of preexcited atrial fibrillation. WPW syndrome is usually sporadic and of unknown etiology in most cases. During the past 10 years, a significant heritable factor is increasingly recognized. Identification of the genetic basis among patients with WPW syndrome has important implications for understanding the molecular mechanism of ventricular preexcitation and the development of therapeutic strategies for risk stratification and management. The goal of this review is to examine the previous studies on hereditary variants, as well as to outline potential future avenues toward defining the heritability of WPW syndrome.

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Subcutaneous Implantable Cardioverter-Defibrillator

The Subcutaneous Implantable Cardioverter-Defibrillator: A Practical Review and Real-World Use and Application

Authors: Panna, Mark E.; Miles, William M.

The subcutaneous implantable cardioverter-defibrillator (ICD) is a novel technology using a subcutaneous (extrathoracic) system for treatment of potential lethal ventricular arrhythmias. It avoids many of the risks of transvenous ICD implantation. It may be considered in patients having an ICD indication who do not have a pacing and/or cardiac resynchronization therapy indication, and who are unlikely to benefit from antitachycardia pacing therapy. We review patient selection, system components, the implantation technique, and screening considerations for subcutaneous ICD implantation. Its uses in specific patient populations, including children, patients with congenital heart disease, hypertrophic cardiomyopathy, or end-stage renal disease, and patients with preexisting pacemakers, are highlighted. Areas of future investigation are reviewed, including potential use with leadless pacing and magnetic resonance imaging.

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