His Bundle Pacing: Short Review of Literature and Technical Aspects

History of pacing has evolved from the primitive state of temporary transvenous pacing by large fixed machine to leadless modern technology. The pacing site has also been changed from traditional right ventricular apex to various other sites. The concept behind such experient was due to several complications in the long term from traditional Right Ventricular Apical Pacing (RVAP). The His Bundle pacing results in conduction and contraction similar to and and more often called physiological pacing. This mini review describes short history of evolution of concept of His Bundle pacing and its technical aspects of successful implantation.

Evaluation of the Mandibular Incisive Canal by Panoramic Radiography and Cone-Beam Computed Tomography

Background: Radiofrequency ablation (RFA) in Brugada syndrome (BrS) has been performed both endocardially and epicardially. The substrate in BrS is thus unclear. Objectives: To investigate the functional endocardial substrate and its correlation with clinical, electrophysiological and ECG findings in order to guide an endocardial ablation. Methods: Thirteen patients (38.7±12.3 years old) with spontaneous type 1 ECG BrS pattern, inducible VF with programmed ventricular stimulation (PVS) and syncope without prodromes were enrolled. Before to endocardial mapping the patients underwent flecainide testing with the purpose of measuring the greatest ST-segment elevation for to be correlated with the size and location of substrate in the electro-anatomic map. Patients underwent endocardial bipolar and electro-anatomic mapping with the purpose of identify areas of abnormal electrograms (EGMs) as target for RFA and determine the location and size of the substrate. Results: When the greatest ST-segment elevation was in the 3rd intercostal space (ICS), the substrate was located upper in the longitudinal plane of the right ventricular outflow tract (RVOT) and a greatest ST-segment elevation in 4th ICS correspond with a location of substrate in lower region of longitudinal plane of RVOT. A QRS complex widening on its initial and final part, with prolonged transmural and regional depolarization time of RVOT corresponded to the substrate locateded in the anterior-lateral region of RVOT. A QRS complex widening rightwards and only prolonged transmural depolarization time corresponded with a substrate located in the anterior, anterior-septal or septal region of RVOT. RFA of endocardial substrate suppressed the inducibility and ECG BrS pattern during 34.7±15.5 months. After RFA, flecainide testing confirmed elimination of the ECG BrS pattern. Endocardial biopsy showed a correlation between functional and ultrastructural alterations in two patients.

Health-Related Quality of life of Complete versus Infarct artery-only Percutaneous Coronary Revascularization in Multi-vessel Disease with ST-Segment Elevation Myocardial Infarction

Objective: The aim of this study was to evaluate the health-related quality of life (HRQoL) as measured by the EQ-5D (European quality of life-5 dimensions) self-report questionnaire in patients treated with complete revascularization versus infarct artery-only revascularization at index admission. Background: The revascularization strategies for multivessel disease while undergoing primary percutaneous coronary intervention (P-PCI) on HRQoL is uncertain. Methods and Results: STEMI patients with multivessel disease underwent either complete or between April 1, 2012, and March 31, 2014, were subdivided into those who underwent complete revascularization (n = 133) or infarct-related artery (IRA)-only revascularization (n = 139) at index admission. The EQ-5D assessed mobility, self-care, usual activity, pain or discomfort, and anxiety or depression. Patient groups were differed at baseline by gender and prevalence of heart failure. At 2-year follow-up, both mean (±SD) EQ-VAS and EQ-5D utility scores were lower for patients who underwent complete revascularization versus infarct artery-only revascularization (60.00 (±18.8) vs. 59.03 (±16.9), P < 0.03, and 0.68 (±0.02) vs. 0.54 (±0.02), P<0.004, respectively). Conclusion: The clinically significant improvement in QoL was seen in the complete revascularization group compared with treating only the IRA at 24 months.

Impact of Myocardial Revascularization on the Range of Joint Motion of the Superior and Inferior Members

Introduction: The surgical procedure for myocardial revascularization (MRI) may compromise chest stability, compliance and range of motion (ROM) of the shoulder joint due to sternotomy and knee joint due to saphenectomy. Objective: To evaluate the impact of myocardial revascularization surgery on upper and lower limb ROM Methodology: This is a prospective cohort study, performed with a group of patients submitted to cardiac surgery. In the preoperative period the ROM was evaluated through a goniometer, for flexion, horizontal abduction and vertical abduction of the right and left shoulder, as well as evaluation of the flexo-extension movement of the right knee. On the day of discharge from the Intensive Care Unit, the patients were reassessed. Results:Twenty patients were evaluated during the time of the study. The majority were men 14 (70%), with a mean age of 60 ± 10 years. Regarding ROM, it was verified that all the movements presented a significant reduction in the postoperative period. The right shoulder flexion (75 ± 11ºvs66 ± 8º, p = 0, p <0.01), right shoulder abduction (155 ± 17º vs127 ± 22º, p < (P = 0.02), right vertical abduction (142 ± 24º vs117 ± 22º, p <0.01), left vertical abduction (142 ± 24º vs121 ± 22º, p = 0), left horizontal abduction (79 ± 9º vs70 ± 5º, p=0,02), Knee flexion (100 ± 14º vs75 ± 19º, p <0.01) and knee extension (94 ± 13º vs79 ± 15º, p <0.01). Conclusion: It can be concluded that the surgery promote reduction of the range of joint motion in this sample of patients submitted to myocardial revascularization.

Prevalence of Subclinical Levt Ventricular Diastolic Dysfunction in Patient with Metabolic Syndrome in West Region of the Republic of Macedonia

Background: Metabolic Syndrome (MetS) has been associated with subclinical changes in cardiac structure and function, including left ventricular diastolic dysfunction (LVDD) and is strong risk factors for the future development of clinical heart failure, and specifically increases the risk of heart failure with preserved ejection fraction. To date, the evidence on the prevalence of subclinical LVDD in patient with MetS and relation to components of the MetS, in west region of the Republic of Macedonia are scarce. Objective: We sought to determine the prevalence of subclinical LVDD and relation to components of the MetS, in patient with MetS in our region. Methods: We conducted a multicenter observational cross-sectional study. Recruited were 550 consecutive participants,450 with MetS (mean age 50 years,49% women) and 100 controls (no risk factors for MetS; mean 51 years,57% women) , who attended outpatient visits at general cardiology Health Care Clinics in 6 town on western region Republic of Macedonia, during 1 calendar year. Pertcipans underwent echocardiography with tissue Doppler imaging. Results: Participants with MetS, have significantly increased frequency of subclical LVDD grade 1, in comparation with participants without MetS. (39, 7% vs. 6%, p=0.0005). The overall frequency of subclinical LVDD grade 1, in participants with MetS, was 39, 7%; p=0.0005). Subjects with MetS also had worse measures of diastolic function, including: higher Lev Atrial Volum index {(LAVI), (p=0.00), Lower E/A ratio (p=0.00),lower mean e’(p=0.00) and lower E/ e’ ratio(p=0.00), increased Deceleratio time {(DT),(p=0.00)} and Isovolumetric Relaxation time{(IVRT), (p=0.00). Overall, participants with subclinical LVDD, had a worse cardiovascular risk factor profile, including: higher BMI (p=0.001), higher blood pressure{(BP) (p=0.003)}, elevated Weist circumference{(WC)(p=0.001)} and dyslipidemia (p=0.000) in comparation with participants with normal diastolic function. Also, participants with subclinical LVDD,have more risk factors for MetS than participants with normal diastolic function (p=0.002). There was a significant assotiation between subclinical LVDD and: Age (OR=1.108; 95% CI 1.051 -1.168), Females (OR=3.633; 95% CI2.439-5.413), BMI (OR=7.474; 95% CI 4.881-11.443), control of BP (OR=1.763; 95% CI 1.204-2.580) and number of MetS risk factors (OR= 3.609; 95% CI 2.054-6.340). Conclusion: The prevalence of subclinical LVDD in the patients with MetS, in abscence of coronary disease and other well know heart disease, is considerablye high in western region of the Republic of Macedonia and seem to be significantly associated with age, gender, BMI, Levt Ventricular mass index (LVMI) and number of risk factors for MetS.

B-Lines on Chest Ultrasound Predicts Elevated Left Ventricular Diastolic Pressures

Background: Echocardiography and lung ultrasound are important tests for assessing left ventricular function in patients presented to the emergency department with acute pulmonary edema. Chest ultrasound is becoming an important tool in diagnosing acute pulmonary edema. Aim: To investigate the relationship between the B profile on ultrasound chest and Spectral tissue Doppler echocardiography (E/e’ ratio) in patients presented with the suspicion of acute pulmonary edema. Methods: This paper reports a prospective observational study of 61 consecutive patients, which was presented with symptoms and signs of pulmonary edema and B - profile detected by echocardiography with a 5 MHz curvilinear probe. Critical care physicians trained in ultrasound examination performed echocardiography and chest ultrasounds. Results: Sixty-one participants were included in the study. Forty-seven of the 61 patients had a B-profile and 14 patients had an A profile. The mean E/e’ level in the patients with B-profile was 20.8, compared with the mean level in the patients with an A-profile of 8.2 (CI = 0.33-0.82). The distribution in the two groups differed significantly (p=0.003). Based on the value of E/e’, the sensitivity and specificity were determined; the sensitivity of B profile on ultrasound was 92% (95% confidence interval (CI) = 0.812-0.968), and the specificity was 91% (CI =0.623-0.98). The positive predictive value of the B-profile was 97% (CI=0.889-0.996), and the negative predictive value was 71% (CI=0.454-0.883). The systolic function in the subjects with a B-profile was below 50% in 74.3% of the subjects and normal in 25.7% of the subjects. All the subjects with B profile and systolic function > 50% had elevated ProBNP and E/e’ > 15. An A-profile subjects had systolic function > 55%. Conclusions: Detecting the B-profile in lung ultrasound is highly sensitive and specific for elevated left ventricular diastolic pressures regardless of the systolic function of the left ventricle which may help in diagnosing pulmonary edema.