- Cardiac Electrophysiology
- Cardiology (Heart)
- Atrial Fibrillation
- Cardiac Arrhythmias
- Implantable Defibrillators
- Hypertrophic Cardiomyopathy
- Clinical Cardiac Electrophysiology
Fellowship:Brigham and Women's Hospital Harvard Medical School (1989) MA
Medical Education:College of Physicians and Surgeons Columbia University (1983) NY
Internship:New York Presbyterian Medical Center (1984) NY
Board Certification: Clinical Cardiac Electrophysiology, American Board of Internal Medicine (1992)
Board Certification: Internal Medicine, American Board of Internal Medicine (1986)
Board Certification: Cardiovascular Disease, American Board of Internal Medicine (1989)
Residency:New York Presbyterian Medical Center (1986) NY
MD, Columbia University, Medicine (1983)
BA, Harvard University, Biochemical Sciences (1979)
Current Research and Scholarly Interests
Dr. Wang's research centers on the development of innovative approaches to the treatment of arrhythmias, including more effective catheter ablation techniques, more reliable implantable devices, and less invasive treatments. Dr. Wang's clinical research interests include atrial fibrillation, ventricular tachycardia, syncope, and hypertrophic cardiomyopathy. Dr. Wang has active collaborations with Bioengineering, Mechanical Engineering, and Electrical Engineering Departments at Stanford. Some of the goals of his research program are: 1) to create a more effective methods of catheter ablation, 2) to create implantable pacemakers and leads that are more reliable, 3) to create a combined surgical-catheter approach to ablation, 4) to create noninvasive methods of ablation, 5) to make defibrillation painless.
Intracardiac CrYoablation for AtrioVentricular Nodal Reentrant Tachycardia
ICY-AVNRT (Intracardiac CrYoablation for AtrioVentricular Nodal Reentrant Tachycardia) is a prospective multi-center, nonrandomized, single arm, controlled, unblinded, investigational clinical study. The purpose of this clinical study is to demonstrate the safety and effectiveness of the Freezor® Xtra Cardiac CryoAblation Catheter for the cryoablation of the conducting tissues of the heart in the treatment of patients with atrioventricular nodal reentrant tachycardia (AVNRT) using an endocardial approach.
Dual Epicardial Endocardial Persistent Atrial Fibrillation(AF) Study (Staged DEEP)
The purpose of this study is to assess the safety and technical feasibility of treating subjects with Persistent Atrial Fibrillation or Longstanding Persistent Atrial Fibrillation in a minimally invasive thoracoscopic ablation procedure utilizing the AtriCure Bipolar System, with mapping and additional lesion creation/ gap closure (as needed) provided by currently approved catheter technology, when the epicardial and endocardial phases are performed in a staged manner within 1-10 days apart, during the same hospitalization.
Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial
The (Catheter Ablation Versus Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial) CABANA Trial has the overall goal of establishing the appropriate roles for medical and ablative intervention for atrial fibrillation (AF). The CABANA Trial is designed to test the hypothesis that the treatment strategy of left atrial catheter ablation for the purpose of eliminating atrial fibrillation (AF) will be superior to current state-of-the-art therapy with either rate control or rhythm control drugs for decreasing the incidence of the composite endpoint of total mortality, disabling stroke, serious bleeding, or cardiac arrest in patients with untreated or incompletely treated AF.
Pivotal Clinical Study of the CardioFocus Endoscopic Ablation System - Adaptive Contact (EAS-AC) (HeartLight) in Patients With Paroxysmal Atrial Fibrillation (PAF)
The purpose of this study is to demonstrate the safety and effectiveness of the CardioFocus Endoscopic Ablation System with Adaptive Contact (HeartLight) in the treatment of atrial fibrillation by creating electrical isolation of the pulmonary veins.
- BIODESIGN FOR MOBILE HEALTH
BIOE 273, MED 273 (Aut)
- Introduction to Bioengineering Research
BIOE 390, MED 289 (Aut)
Independent Studies (6)
- Bioengineering Problems and Experimental Investigation
BIOE 191 (Win, Spr, Sum)
- Directed Reading in Medicine
MED 299 (Aut, Win, Spr, Sum)
- Early Clinical Experience in Medicine
MED 280 (Aut, Win, Spr, Sum)
- Graduate Research
MED 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
MED 370 (Aut, Win, Spr, Sum)
- Undergraduate Research
MED 199 (Aut, Win, Spr, Sum)
- Bioengineering Problems and Experimental Investigation
Prior Year Courses
- BIODESIGN FOR MOBILE HEALTH
BIOE 273, MED 273 (Aut)
- Introduction to Bioengineering Research
BIOE 390, MED 289 (Aut)
- BIODESIGN FOR MOBILE HEALTH
BIOE 273, MED 273 (Aut)
- Introduction to Bioengineering Research
BIOE 390, MED 289 (Aut)
- BIODESIGN FOR MOBILE HEALTH
Outcomes from a Postgraduate Biomedical Technology Innovation Training Program: The First 12 Years of Stanford Biodesign
ANNALS OF BIOMEDICAL ENGINEERING
2013; 41 (9): 1803-1810
The Stanford Biodesign Program began in 2001 with a mission of helping to train leaders in biomedical technology innovation. A key feature of the program is a full-time postgraduate fellowship where multidisciplinary teams undergo a process of sourcing clinical needs, inventing solutions and planning for implementation of a business strategy. The program places a priority on needs identification, a formal process of selecting, researching and characterizing needs before beginning the process of inventing. Fellows and students from the program have gone on to careers that emphasize technology innovation across industry and academia. Biodesign trainees have started 26 companies within the program that have raised over $200 million and led to the creation of over 500 new jobs. More importantly, although most of these technologies are still at a very early stage, several projects have received regulatory approval and so far more than 150,000 patients have been treated by technologies invented by our trainees. This paper reviews the initial outcomes of the program and discusses lessons learned and future directions in terms of training priorities.
View details for DOI 10.1007/s10439-013-0761-2
View details for Web of Science ID 000323736800002
View details for PubMedID 23404074
- ATP during charging: A failure of therapy? HEART RHYTHM 2013; 10 (7): 1091-1093
Drug screening using a library of human induced pluripotent stem cell-derived cardiomyocytes reveals disease-specific patterns of cardiotoxicity.
2013; 127 (16): 1677-1691
Cardiotoxicity is a leading cause for drug attrition during pharmaceutical development and has resulted in numerous preventable patient deaths. Incidents of adverse cardiac drug reactions are more common in patients with preexisting heart disease than the general population. Here we generated a library of human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) from patients with various hereditary cardiac disorders to model differences in cardiac drug toxicity susceptibility for patients of different genetic backgrounds.Action potential duration and drug-induced arrhythmia were measured at the single cell level in hiPSC-CMs derived from healthy subjects and patients with hereditary long QT syndrome, familial hypertrophic cardiomyopathy, and familial dilated cardiomyopathy. Disease phenotypes were verified in long QT syndrome, hypertrophic cardiomyopathy, and dilated cardiomyopathy hiPSC-CMs by immunostaining and single cell patch clamp. Human embryonic stem cell-derived cardiomyocytes (hESC-CMs) and the human ether-a-go-go-related gene expressing human embryonic kidney cells were used as controls. Single cell PCR confirmed expression of all cardiac ion channels in patient-specific hiPSC-CMs as well as hESC-CMs, but not in human embryonic kidney cells. Disease-specific hiPSC-CMs demonstrated increased susceptibility to known cardiotoxic drugs as measured by action potential duration and quantification of drug-induced arrhythmias such as early afterdepolarizations and delayed afterdepolarizations.We have recapitulated drug-induced cardiotoxicity profiles for healthy subjects, long QT syndrome, hypertrophic cardiomyopathy, and dilated cardiomyopathy patients at the single cell level for the first time. Our data indicate that healthy and diseased individuals exhibit different susceptibilities to cardiotoxic drugs and that use of disease-specific hiPSC-CMs may predict adverse drug responses more accurately than the standard human ether-a-go-go-related gene test or healthy control hiPSC-CM/hESC-CM screening assays.
View details for DOI 10.1161/CIRCULATIONAHA.113.001883
View details for PubMedID 23519760
Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study.
American heart journal
2013; 165 (1): 93-101 e1
Atrial fibrillation and flutter (AF, collectively) cause stroke. We evaluated whether treating specialty influences warfarin prescription in patients with newly diagnosed AF.In the TREAT-AF study, we used Veterans Health Administration health record and claims data to identify patients with newly diagnosed AF between October 2004 and November 2008 and at least 1 internal medicine/primary care or cardiology outpatient encounter within 90 days after diagnosis. The primary outcome was prescription of warfarin.In 141,642 patients meeting the inclusion criteria, the mean age was 72.3 ± 10.2 years, 1.48% were women, and 25.8% had cardiology outpatient care. Cardiology-treated patients had more comorbidities and higher mean CHADS2 scores (1.8 vs 1.6, P < .0001). Warfarin use was higher in cardiology-treated vs primary care only-treated patients (68.6% vs 48.9%, P < .0001). After covariate and site-level adjustment, cardiology care was significantly associated with warfarin use (odds ratio [OR] 2.05, 95% CI 1.99-2.11). These findings were consistent across a series of adjusted models (OR 2.05-2.20), propensity matching (OR 1.98), and subgroup analyses (OR 1.58-2.11). Warfarin use in primary-care-only patients declined from 2004 to 2008 (51.6%-44.0%, P < .0001), whereas the adjusted odds of warfarin receipt with cardiology care (vs primary care) increased from 2004 to 2008 (1.88-2.24, P < .0001).In patients with newly diagnosed AF, we found large differences in anticoagulation use by treating specialty. A divergent 5-year trend of risk-adjusted warfarin use was observed. Treating specialty influences stroke prevention care and may impact clinical outcomes.
View details for DOI 10.1016/j.ahj.2012.10.010
View details for PubMedID 23237139
Effects of Postmenopausal Hormone Therapy on Incident Atrial Fibrillation The Women's Health Initiative Randomized Controlled Trials
CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY
2012; 5 (6): 1108-1116
Atrial fibrillation (AF) is less prevalent in women versus men, but associated with higher risks of stroke and death in women. The role hormone therapy plays in AF is not well understood.The Women's Health Initiative randomized postmenopausal women to placebo or conjugated equine estrogens (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) if they had a uterus (N=16 608) or to conjugated equine estrogens only if they had prior hysterectomy (N=10 739). Incident AF was identified by ECG and diagnosis codes from Medicare claims or hospitalization records. Hazard ratios for incident AF were estimated using Cox proportional hazards regression. After excluding participants with baseline AF, there were 611 incident AF cases over a mean of 5.6 years among 16 128 estrogen plus progestin participants, and 683 cases over a mean of 7.1 years among 10 251 conjugated equine estrogens alone participants. Incident AF was more frequent in the active groups of both trials, reaching statistical significance in the trial of conjugated equine estrogens alone in women with prior hysterectomy (hazard ratio, 1.17; CI, 1.00-1.36; P=0.045) and in the pooled analysis (hazard ratio, 1.12; CI, 1.00-1.24; P=0.05), but not in the estrogen plus progestin trial (hazard ratio, 1.07; CI, 0.91-1.25; P=0.44). These results were only minimally affected by adjustment for incident stroke, coronary heart disease, and heart failure.Incident AF was modestly elevated in hysterectomized women randomized to postmenopausal E-alone, and in the pooled group randomized to E-alone or estrogen plus progestin. The trend in women with intact uterus receiving estrogen plus progestin, considered separately, was not statistically significant.ClinicalTrials.gov; Identifier: NCT00000611.
View details for DOI 10.1161/CIRCEP.112.972224
View details for Web of Science ID 000313586900018
View details for PubMedID 23169946
- Abrupt bradycardia and grouped beating during treadmill testing: A mimic of upper rate behavior HEART RHYTHM 2012; 9 (7): 1165-1167
Ability of microvolt T-wave alternans to modify risk assessment of ventricular tachyarrhythmic events: A meta-analysis
AMERICAN HEART JOURNAL
2012; 163 (3): 354-364
Prior studies have indicated that the magnitude of risk association of microvolt T-wave alternans (MTWA) testing appears to vary with the population studied. We performed a meta-analysis to determine the ability of MTWA to modify risk assessment of ventricular tachyarrhythmic events (VTEs) and sudden cardiac death (SCD) across a series of patient risk profiles using likelihood ratio (LR) testing, a measure of test performance independent of disease prevalence.We identified original research articles published from January 1990 to January 2011 that investigate spectrally derived MTWA. Ventricular tachyarrhythmic event was defined as the total and arrhythmic mortality and nonfatal sustained or implantable cardioverter-defibrillator-treated ventricular tachyarrhythmias. Summary estimates were created for positive and nonnegative MTWA results using a random-effects model and were expressed as positive (LR+) and negative (LR-) LRs.Of 1,534 articles, 20 prospective cohort studies met our inclusion criteria, consisting of 5,945 subjects predominantly with prior myocardial infarction or left ventricular dysfunction. Although there was a modest association between positive MTWA and VTE (relative risk 2.45, 1.58-3.79) and nonnegative MTWA and VTE (3.68, 2.23-6.07), test performance was poor (positive MTWA: LR+ 1.78, LR- 0.43; nonnegative MTWA: LR+ 1.38, LR- 0.56). Subgroup analyses of subjects classified as prior VTE, post-myocardial infarction, SCD-HeFT type, and MADIT-II type had a similar poor test performance. A negative MTWA result would decrease the annualized risk of VTE from 8.85% to 6.37% in MADIT-II-type patients and from 5.91% to 2.60% in SCD-HeFT-type patients.Despite a modest association, results of spectrally derived MTWA testing do not sufficiently modify the risk of VTE to change clinical decisions.
View details for DOI 10.1016/j.ahj.2011.11.021
View details for Web of Science ID 000301597200010
View details for PubMedID 22424005
Catheter ablation of atrial fibrillation: state-of-the-art techniques and future perspectives
JOURNAL OF CARDIOVASCULAR MEDICINE
2012; 13 (2): 108-124
The impact of atrial fibrillation on the healthcare systems of Western countries is overwhelming, due to its independent association with death, systemic thromboembolism, impaired quality of life and hospitalizations. Catheter ablation is the only treatment thus far demonstrated capable of achieving cure in a substantial proportion of patients. Pulmonary vein antrum isolation (PVAI) is the cornerstone of current atrial fibrillation ablation techniques, with the greatest efficacy as a stand-alone procedure in patients with paroxysmal atrial fibrillation. Use of general anesthesia, open-irrigated ablation catheters and maintenance of periprocedural therapeutic warfarin has been demonstrated to increase the safety and effectiveness of PVAI. In patients with paroxysmal atrial fibrillation, the systematic addition of superior vena cava isolation increases the long-term freedom from atrial fibrillation recurrence. A more extensive ablation approach extending to the entire left atrial posterior wall and to complex fractionated electrograms (CFAEs) is warranted in nonparoxysmal atrial fibrillation patients, in whom nonpulmonary vein trigger sites are frequently identified. Up to one-third of these patients experiencing atrial fibrillation recurrence after ablation have evidence of triggers from the left atrial appendage. Isolation of this structure is the best treatment strategy to improve the long-term success rate. In recent years, in addition to the development of ablation techniques to increase the success rate, outcomes of atrial fibrillation treatment trials have been reconsidered. In particular, reduction of hospitalization, stroke and mortality, as well as economic factors, have all been considered relevant to evaluate the effectiveness of atrial fibrillation treatment. Large ongoing trials are specifically evaluating the impact of atrial fibrillation ablation on these outcomes. This article will summarize the state-of-the art techniques for atrial fibrillation ablation, and will discuss the contribution of ongoing studies to the future of atrial fibrillation ablation.
View details for DOI 10.2459/JCM.0b013e32834f2371
View details for Web of Science ID 000299652200004
View details for PubMedID 22193837
Procedural Complications, Rehospitalizations, and Repeat Procedures After Catheter Ablation for Atrial Fibrillation
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2012; 59 (2): 143-149
The purpose of this study was to estimate rates and identify predictors of inpatient complications and 30-day readmissions, as well as repeat hospitalization rates for arrhythmia recurrence following atrial fibrillation (AF) ablation.AF is the most common clinically significant arrhythmia and is associated with increased morbidity and mortality. Radiofrequency or cryotherapy ablation of AF is a relatively new treatment option, and data on post-procedural outcomes in large general populations are limited.Using data from the California State Inpatient Database, we identified all adult patients who underwent their first AF ablation from 2005 to 2008. We used multivariable logistic regression to identify predictors of complications and/or 30-day readmissions and Kaplan-Meier analyses to estimate rates of all-cause and arrhythmia readmissions.Among 4,156 patients who underwent an initial AF ablation, 5% had periprocedural complications, most commonly vascular, and 9% were readmitted within 30 days. Older age, female, prior AF hospitalizations, and less hospital experience with AF ablation were associated with higher adjusted risk of complications and/or 30-day readmissions. The rate of all-cause hospitalization was 38.5% by 1 year. The rate of readmission for recurrent AF, atrial flutter, and/or repeat ablation was 21.7% by 1 year and 29.6% by 2 years.Periprocedural complications occurred in 1 of 20 patients undergoing AF ablation, and all-cause and arrhythmia-related rehospitalizations were common. Older age, female sex, prior AF hospitalizations, and recent hospital procedure experience were associated with a higher risk of complications and/or 30-day readmission after AF ablation.
View details for DOI 10.1016/j.jacc.2011.08.068
View details for Web of Science ID 000298796600009
View details for PubMedID 22222078
Subcutaneous Implantable Cardioverter-Defibrillator Technology
HEART FAILURE CLINICS
2011; 7 (2): 287-?
The advent of subcutaneous implantable cardioverter-defibrillator (ICD) systems represents a paradigm shift for the detection and therapy of ventricular tachyarrhythmias. Despite advances in transvenous lead technology, problems remain that notably include requirement for technical expertise; periprocedural complications during implantation and explantation; and long-term lead failure. Although subcutaneous ICD systems may mitigate some of these risks, they provide new shortcomings, such as inability to provide pacing therapy for bradyarrhythmias, ventricular tachyarrhythmias, and cardiac resynchronization. Ongoing clinical evaluation and development are required before the role of subcutaneous ICDs as an adjunctive or primary therapy can be defined. This article examines studies investigating the subcutaneous ICD and discusses its possible advantages and disadvantages as compared with current transvenous ICD systems.
View details for DOI 10.1016/j.hfc.2011.01.005
View details for Web of Science ID 000307488700016
View details for PubMedID 21439506
Effectiveness of Cardiac Resynchronization Therapy by QRS Morphology in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT)
2011; 123 (10): 1061-1072
This study aimed to determine whether QRS morphology identifies patients who benefit from cardiac resynchronization therapy with a defibrillator (CRT-D) and whether it influences the risk of primary and secondary end points in patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) trial.Baseline 12-lead ECGs were evaluated with regard to QRS morphology. Heart failure event or death was the primary end point of the trial. Death, heart failure event, ventricular tachycardia, and ventricular fibrillation were secondary end points. Among 1817 patients with available sinus rhythm ECGs at baseline, there were 1281 (70%) with left bundle-branch block (LBBB), 228 (13%) with right bundle-branch block, and 308 (17%) with nonspecific intraventricular conduction disturbances. The latter 2 groups were defined as non-LBBB groups. Hazard ratios for the primary end point for comparisons of CRT-D patients versus patients who only received an implantable cardioverter defibrillator (ICD) were significantly (P < 0.001) lower in LBBB patients (0.47; P < 0.001) than in non-LBBB patients (1.24; P = 0.257). The risk of ventricular tachycardia, ventricular fibrillation, or death was decreased significantly in CRT-D patients with LBBB but not in non-LBBB patients. Echocardiographic parameters showed significantly (P < 0.001) greater reduction in left ventricular volumes and increase in ejection fraction with CRT-D in LBBB than in non-LBBB patients.Heart failure patients with New York Heart Association class I or II and ejection fraction ? 30% and LBBB derive substantial clinical benefit from CRT-D: a reduction in heart failure progression and a reduction in the risk of ventricular tachyarrhythmias. No clinical benefit was observed in patients with a non-LBBB QRS pattern (right bundle-branch block or intraventricular conduction disturbances).URL: http://www.clinicaltrials.gov. Unique identifier: NCT00180271.
View details for DOI 10.1161/CIRCULATIONAHA.110.960898
View details for Web of Science ID 000288369900011
View details for PubMedID 21357819
Cost-Effectiveness of Dabigatran Compared With Warfarin for Stroke Prevention in Atrial Fibrillation
ANNALS OF INTERNAL MEDICINE
2011; 154 (1): 1-U129
Warfarin reduces the risk for ischemic stroke in patients with atrial fibrillation (AF) but increases the risk for hemorrhage. Dabigatran is a fixed-dose, oral direct thrombin inhibitor with similar or reduced rates of ischemic stroke and intracranial hemorrhage in patients with AF compared with those of warfarin.To estimate the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with adjusted-dose warfarin for preventing ischemic stroke in patients 65 years or older with nonvalvular AF.Markov decision model.The RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial and other published studies of anticoagulation. The cost of dabigatran was estimated on the basis of pricing in the United Kingdom.Patients aged 65 years or older with nonvalvular AF and risk factors for stroke (CHADS? score ?1 or equivalent) and no contraindications to anticoagulation.Lifetime.Societal.Warfarin anticoagulation (target international normalized ratio, 2.0 to 3.0); dabigatran, 110 mg twice daily (low dose); and dabigatran, 150 mg twice daily (high dose).Quality-adjusted life-years (QALYs), costs (in 2008 U.S. dollars), and incremental cost-effectiveness ratios.The quality-adjusted life expectancy was 10.28 QALYs with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Total costs were $143 193 for warfarin, $164 576 for low-dose dabigatran, and $168 398 for high-dose dabigatran. The incremental cost-effectiveness ratios compared with warfarin were $51 229 per QALY for low-dose dabigatran and $45 372 per QALY for high-dose dabigatran.The model was sensitive to the cost of dabigatran but was relatively insensitive to other model inputs. The incremental cost-effectiveness ratio increased to $50 000 per QALY at a cost of $13.70 per day for high-dose dabigatran but remained less than $85 000 per QALY over the full range of model inputs evaluated. The cost-effectiveness of high-dose dabigatran improved with increasing risk for stroke and intracranial hemorrhage.Event rates were largely derived from a single randomized clinical trial and extrapolated to a 35-year time frame from clinical trials with approximately 2-year follow-up.In patients aged 65 years or older with nonvalvular AF at increased risk for stroke (CHADS? score ?1 or equivalent), dabigatran may be a cost-effective alternative to warfarin depending on pricing in the United States.American Heart Association and Veterans Affairs Health Services Research & Development Service.
View details for Web of Science ID 000285830900001
View details for PubMedID 21041570
Cost-Effectiveness of Genetic Testing in Family Members of Patients With Long-QT Syndrome
CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES
2011; 4 (1): 76-84
Family members of patients with established long-QT syndrome (LQTS) often lack definitive clinical findings, yet may have inherited an LQTS mutation and be at risk of sudden death. Genetic testing can identify mutations in 75% of patients with LQTS, but genetic testing of family members remains controversial.We used a Markov model to assess the cost-effectiveness of 3 strategies for treating an asymptomatic 10-year-old, first-degree relative of a patient with clinically evident LQTS. In the genetic testing strategy, relatives undergo genetic testing only for the mutation identified in the index patient, and relatives who test positive for the mutation are treated with ?-blockers. This strategy was compared with (1) empirical treatment of relatives with ?-blockers and (2) watchful waiting, with treatment only after development of symptoms. The genetic testing strategy resulted in better survival and quality-adjusted life years at higher cost, with a cost-effectiveness ratio of $67 400 per quality-adjusted life year gained compared with watchful waiting. The cost-effectiveness of the genetic testing strategy improved to less than $50 000 per quality-adjusted life year gained when applied selectively either to (1) relatives with higher clinical suspicion of LQTS (pretest probability 65% to 81%), or to (2) families with a higher than average risk of sudden death, or to (3) larger families (2 or more first-degree relatives tested).Genetic testing of young first-degree relatives of patients with definite LQTS is moderately expensive, but can reach acceptable thresholds of cost-effectiveness when applied to selected patients.
View details for DOI 10.1161/CIRCOUTCOMES.110.957365
View details for Web of Science ID 000286311700014
View details for PubMedID 21139095
A Novel Method for Patient-Specific QTc-Modeling QT-RR Hysteresis
ANNALS OF NONINVASIVE ELECTROCARDIOLOGY
2011; 16 (1): 3-12
Cardiac repolarization adaptation to cycle length change is patient dependent and results in complex QT-RR hysteresis. We hypothesize that accurate patient-specific QT-RR curves and rate corrected QT values (QTc) can be derived through patient-specific modeling of hysteresis.Model development was supported by QT-RR observations from 1959 treadmill tests, allowing extensive exploration of the influences of autonomic function on QT adaptation to rate changes. The methodology quantifies and then removes patient-specific repolarization adaptation rates. The estimated average 95% QT confidence limit was approximately 1 msec for the studied population. The model was validated by comparing QT-RR curves derived from a submaximal exercise protocol with rapid exercise and recovery phases, characterized by high hysteresis, with QT-RR values derived from an incremental stepped protocol that held heart rate constant for 5 minutes at each stage of exercise and recovery.The underlying physiologic changes affecting QT dynamics during the transitions from rest to exercise to recovery are quite complex. Nevertheless, a simple patient-specific model, comprising only three parameters and based solely on the preceding history of RR intervals and trend, is sufficient to accurately model QT hysteresis over an entire exercise test for a diverse population. A brief recording of a resting ECG, combined with a short period of submaximal exercise and recovery, provides sufficient information to derive an accurate patient-specific QT-RR curve, eliminating QTc bias inherent in population-based correction formulas.
View details for DOI 10.1111/j.1542-474X.2010.00401.x
View details for Web of Science ID 000286428400002
View details for PubMedID 21251128
Inappropriate pacing in a patient with managed ventricular pacing: What is the cause?
2010; 7 (9): 1336-1337
A case of inappropriate atrial pacing in a patient with a pacemaker programmed with Managed Ventricular Pacing (MVP) mode, a proprietary algorithm in Medtronic devices, is presented. The patient was an 84-year-old woman who presented in sinus rhythm with complete atrioventricular block. A dual-chamber pacemaker was implanted and programmed to an MVP pacing mode. After the implant, the patient developed a relatively slow atrial tachyarrhythmia with 2:1 atrioventricular block and inappropriate atrial pacing, followed by a delay in tracking of the atrial tachyarrhythmia. The mechanisms for these behaviors are described.
View details for DOI 10.1016/j.hrthm.2010.04.028
View details for Web of Science ID 000281444100033
View details for PubMedID 20435165
Measurement Precision in the Optimization of Cardiac Resynchronization Therapy
2010; 3 (3): 395-404
Cardiac resynchronization therapy improves morbidity and mortality in appropriately selected patients. Whether atrioventricular (AV) and interventricular (VV) pacing interval optimization confers further clinical improvement remains unclear. A variety of techniques are used to estimate optimum AV/VV intervals; however, the precision of their estimates and the ramifications of an imprecise estimate have not been characterized previously.An objective methodology for quantifying the precision of estimated optimum AV/VV intervals was developed, allowing physiologic effects to be distinguished from measurement variability. Optimization using multiple conventional techniques was conducted in individual sessions with 20 patients. Measures of stroke volume and dyssynchrony were obtained using impedance cardiography and echocardiographic methods, specifically, aortic velocity-time integral, mitral velocity-time integral, A-wave truncation, and septal-posterior wall motion delay. Echocardiographic methods yielded statistically insignificant data in the majority of patients (62%-82%). In contrast, impedance cardiography yielded statistically significant results in 84% and 75% of patients for AV and VV interval optimization, respectively. Individual cases demonstrated that accepting a plausible but statistically insignificant estimated optimum AV or VV interval can result in worse cardiac function than default values.Consideration of statistical significance is critical for validating clinical optimization data in individual patients and for comparing competing optimization techniques. Accepting an estimated optimum without knowledge of its precision can result in worse cardiac function than default settings and a misinterpretation of observed changes over time. In this study, only impedance cardiography yielded statistically significant AV and VV interval optimization data in the majority of patients.
View details for DOI 10.1161/CIRCHEARTFAILURE.109.900076
View details for Web of Science ID 000277825800009
View details for PubMedID 20176716
Finite element modeling of subcutaneous implantable defibrillator electrodes in an adult torso
2010; 7 (5): 692-698
Total subcutaneous implantable subcutaneous defibrillators are in development, but optimal electrode configurations are not known.We used image-based finite element models (FEM) to predict the myocardial electric field generated during defibrillation shocks (pseudo-DFT) in a wide variety of reported and innovative subcutaneous electrode positions to determine factors affecting optimal lead positions for subcutaneous implantable cardioverter-defibrillators (S-ICD).An image-based FEM of an adult man was used to predict pseudo-DFTs across a wide range of technically feasible S-ICD electrode placements. Generator location, lead location, length, geometry and orientation, and spatial relation of electrodes to ventricular mass were systematically varied. Best electrode configurations were determined, and spatial factors contributing to low pseudo-DFTs were identified using regression and general linear models.A total of 122 single-electrode/array configurations and 28 dual-electrode configurations were simulated. Pseudo-DFTs for single-electrode orientations ranged from 0.60 to 16.0 (mean 2.65 +/- 2.48) times that predicted for the base case, an anterior-posterior configuration recently tested clinically. A total of 32 of 150 tested configurations (21%) had pseudo-DFT ratios =1, indicating the possibility of multiple novel, efficient, and clinically relevant orientations. Favorable alignment of lead-generator vector with ventricular myocardium and increased lead length were the most important factors correlated with pseudo-DFT, accounting for 70% of the predicted variation (R(2) = 0.70, each factor P < .05) in a combined general linear model in which parameter estimates were calculated for each factor.Further exploration of novel and efficient electrode configurations may be of value in the development of the S-ICD technologies and implant procedure. FEM modeling suggests that the choice of configurations that maximize shock vector alignment with the center of myocardial mass and use of longer leads is more likely to result in lower DFT.
View details for DOI 10.1016/j.hrthm.2010.01.030
View details for Web of Science ID 000277354400024
View details for PubMedID 20230927
Dyssynchrony Assessment with Tissue Doppler Imaging and Regional Volumetric Analysis by 3D Echocardiography Do Not Predict Long-Term Response to Cardiac Resynchronization Therapy.
Cardiology research and practice
2010; 2011: 568918-?
Background. Currently there are no reliable predictors of response to cardiac resynchronization therapy (CRT) before implantation. We compared pre-CRT left ventricular (LV) dyssynchrony by tissue Doppler imaging (TDI) and regional volumetric analysis by 3-dimensional transthoracic echocardiography (3DTTE) in predicting response to CRT. Methods. Thirty-eight patients (79% nonischemic cardiomyopathy) with symptomatic heart failure who underwent CRT were enrolled. Clinical and echocardiographic responses were defined as improvement in one NYHA class and reduction in LV end-systolic volume by ?15% respectively. Functional status was assessed by Minnesota Living with Heart Failure questionnaire and 6-minute walk distance. Results. In 33 patients, after CRT for 7.86 ± 2.27 months, there were 24 (73%) clinical and 19 (58%) echocardiographic responders. Functional parameters, LV dimensions, volumes and synchrony by TDI and 3DTTE improved significantly in responders. There was no difference in the number of responders and nonresponders when cut-off values for dyssynchrony by different measurements validated in other trials were applied. Area under receiver-operating-characteristic curve ranged from 0.4 to 0.6. Conclusion. CRT improves clinical and echocardiographic parameters in patients with systolic heart failure. The dyssynchrony measurements by TDI and 3DTTE are not comparable and are unable to predict response to CRT.
View details for DOI 10.4061/2011/568918
View details for PubMedID 21234100
Electrocardiographic predictors of atrial fibrillation
AMERICAN HEART JOURNAL
2009; 158 (4): 622-628
Atrial fibrillation (AF) is the most prevalent arrhythmia in the United States and accounts for more than 750,000 strokes per year. Noninvasive predictors of AF may help identify patients at risk of developing AF. Our objective was to identify the electrocardiographic characteristics associated with onset of AF.This was a retrospective cohort analysis of 42,751 patients with electrocardiograms (ECGs) ordered by physician's discretion and analyzed using a computerized system. The population was followed for detection of AF on subsequent ECGs. Cox proportional hazard regression analysis was performed to test the association between these ECG characteristics and development of AF.For a mean follow-up of 5.3 years, 1,050 (2.4%) patients were found to have AF on subsequent ECG recordings. Several ECG characteristics, such as P-wave dispersion (the difference between the widest and narrowest P waves), premature atrial contractions, and an abnormal P axis, were predictive of AF with hazard ratio of approximately 2 after correcting for age and sex. P-wave index, the SD of P-wave duration across all leads, was one of the strongest predictors of AF with a concordance index of 0.62 and a hazard ratio of 2.7 (95% CI 2.1-3.3) for a P-wave index >35. These were among the several independently predictive markers identified on multivariate analysis.Several ECG markers are independently predictive of future onset of AF. The P index, a measurement of disorganized atrial depolarization, is one of the strongest predictors of AF. The ECG contains valuable prognostic information that can identify patients at risk of AF.
View details for DOI 10.1016/j.ahj.2009.08.002
View details for Web of Science ID 000270706100020
View details for PubMedID 19781423
Visualizing ablation gaps in vitro using a deflectable fiber optic endocardial visualization catheter
JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY
2009; 25 (2): 107-110
The efficacy of pulmonary vein isolation for the treatment of atrial fibrillation may be limited by the ability to make continuous and transmural lesions utilizing an ablation catheter. Gaps often persist between ablation lesions leading to failed electrical isolation and thus failed ablation. Recently, a deflectable fiberoptic endocardial visualization catheter has been introduced for use in imaging the coronary sinus using light in the visible spectrum. We utilize this catheter to visualize the endocardial surface and examine radiofrequency ablation lesions in porcine endocardium to determine the presence of gaps between radiofrequency lesions.Videos were taken of the lesions and shown to two readers who were asked to identify the gaps ranging from less than 0.1 mm-9.8 mm.Ninety-four lesion gaps were reviewed. The readers demonstrated a combined accuracy of 98.4% at identifying gaps.Gaps between ablation lesions can be accurately identified down to less than 1 mm distances in vitro using a direct visualization catheter. Further studies are warranted to confirm these finding in vivo.
View details for DOI 10.1007/s10840-008-9338-7
View details for Web of Science ID 000267683500004
View details for PubMedID 19148727
Worsening of Left Ventricular End-Systolic Volume and Mitral Regurgitation without Increase in Left Ventricular Dyssynchrony on Acute Interruption of Cardiac Resynchronization Therapy
ECHOCARDIOGRAPHY-A JOURNAL OF CARDIOVASCULAR ULTRASOUND AND ALLIED TECHNIQUES
2009; 26 (7): 759-765
Responders to cardiac resynchronization therapy (CRT) have greater left ventricular (LV) dyssynchrony than nonresponders prior to CRT.We conducted this study to see whether the long term responders have more worsening of LV dyssynchrony and LV function on acute interruption of CRT.We identified 22 responders and 13 nonresponders who received CRT as per standard criteria for 23.73 +/- 7.9 months (median 24.5 months). We assessed the acute change in LV function, mitral regurgitation (MR) and compared LV dyssynchrony in CRT on and off modes.On turning off CRT, there was no significant worsening of LV dyssynchrony in both responders and nonresponders. The dyssynchrony measurements by SPWMD, TDI and 3D echocardiography did not correlate significantly. LVESV increased (p = 0.02) and MR (p = 0.01) worsened in CRT-off mode in responders only without significant change in LVEF or LV dimensions. Discussion andIn long-term responders to CRT, there is alteration in the function of remodeled LV with acute interruption of CRT, without significant worsening of LV dyssynchrony. The role of different echocardiographic parameters in the assessment of LV dyssynchrony remains controversial. Even after long-term CRT reversely remodels the LV, the therapy needs to be continued uninterrupted for sustained benefits.
View details for DOI 10.1111/j.1540-8175.2008.00887.x
View details for Web of Science ID 000268457100002
View details for PubMedID 19558521
Direct Visualization of Cardiac Radiofrequency Ablation Lesions
JOURNAL OF CARDIOVASCULAR TRANSLATIONAL RESEARCH
2009; 2 (2): 198-201
Effective ablation of atrial fibrillation and other cardiac arrhythmias requires precise catheter navigation and controlled delivery of energy to cardiac tissue. In this study, we summarize our initial experience using a fiber optic direct visualization catheter to evaluate and guide placement of endocardial radiofrequency (RF) ablation lesions. RF lesions were created in cadaveric porcine hearts and examined in a blood-filled field using a direct visualization catheter. Direct visualization of RF lesions was repeated in vivo using an ovine model. Lesions and interlesion gaps were clearly identifiable using the direct visualization catheter. It was possible to place lesions in proximity to anatomical landmarks and in relation to one another. Catheter-generated images correlated well with lesion appearance on gross examination. Direct catheter-based visualization is a feasible technique for guiding RF lesion placement, estimating lesion size, and identifying interlesion gaps. Future work is needed to correlate surface appearance with transmurality and electrical isolation.
View details for DOI 10.1007/s12265-009-9094-9
View details for Web of Science ID 000284690100010
View details for PubMedID 20559988
The Efficacy of Implantable Cardioverter-Defibrillators in Heart Transplant Recipients Results From a Multicenter Registry
2009; 2 (3): 197-201
Sudden cardiac death among orthotopic heart transplant recipients is an important mechanism of death after cardiac transplantation. The role for implantable cardioverter-defibrillators (ICDs) in this population is not well established. This study sought to determine whether ICDs are effective in preventing sudden cardiac death in high-risk heart transplant recipients.We retrospectively analyzed the records of all orthotopic heart transplant patients who had ICD implantation between January 1995 and December 2005 at 5 heart transplant centers. Thirty-six patients were considered high risk for sudden cardiac death. The mean age at orthotopic heart transplant was 44+/-14 years, the majority being male (n=29). The mean age at ICD implantation was 52+/-14 years, whereas the average time from orthotopic heart transplant to ICD implant was 8 years +/-6 years. The main indications for ICD implantation were severe allograft vasculopathy (n=12), unexplained syncope (n=9), history of cardiac arrest (n=8), and severe left ventricular dysfunction (n=7). Twenty-two shocks were delivered to 10 patients (28%), of whom 8 (80%) received 12 appropriate shocks for either rapid ventricular tachycardia or ventricular fibrillation. The shocks were effective in terminating the ventricular arrhythmias in all cases. Three (8%) patients received 10 inappropriate shocks. Underlying allograft vasculopathy was present in 100% (8 of 8) of patients who received appropriate ICD therapy.Use of ICDs after heart transplantation may be appropriate in selected high-risk patients. Further studies are needed to establish an appropriate prevention strategy in this population.
View details for DOI 10.1161/CIRCHEARTFAILURE.108.814525
View details for Web of Science ID 000269161600007
View details for PubMedID 19808340
Statin Use and Ventricular Arrhythmias During Clinical Treadmill Testing
JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY
2009; 20 (2): 193-199
Premature ventricular complexes (PVCs) during exercise are associated with adverse prognosis, particularly in patients with intermediate treadmill test findings. Statin use reduces the incidence of resting ventricular arrhythmias in patients with coronary artery disease; however, the relationship between statin use and exercise-induced ventricular arrhythmias has not been investigated.We evaluated the association between statin use and PVCs in 1,847 heart-failure-free patients (mean age 58, 95% male) undergoing clinical exercise treadmill testing between 1997 and 2004 in the VA Palo Alto Health Care System. PVCs were quantified in beats per minute and frequent PVCs were defined as PVC rates greater than the median value (0.43 and 0.60 PVCs per minute for exercise and recovery, respectively). Propensity-adjusted logistic regression was used to evaluate the odds of developing PVCs during exercise and recovery periods associated with statin use. There were 431 subjects who developed frequent PVCs during exercise and 284 subjects had frequent recovery PVCs. After propensity score adjustment, subjects treated with statins (n = 145) had 42% lower odds of developing frequent PVCs during exercise (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37-0.93) and 44% lower odds of developing frequent PVCs during recovery (OR 0.56, 95% CI 0.30-0.94). These effects were not modified by age, prior coronary disease, hypercholesterolemia, exercise-induced angina, or exercise capacity.Statin use was associated with reduced odds of frequent PVCs during and after clinical exercise testing in a manner independent of associations with coronary disease or ischemia in our study population.
View details for DOI 10.1111/j.1540-8167.2008.01284.x
View details for Web of Science ID 000262889000012
View details for PubMedID 18775041
A New Approach for ICD Rhythm Classification based on Support Vector Machines
IEEE. 2009: 2478-2481
Inappropriate shocks due to misclassification of supraventricular and ventricular arrhythmias remain a major problem in the care of patients with Implantable Cardioverter Defibrillators (ICDs). The purpose of this study was to investigate the ability of a new covariance-based support vector machine classifier, to distinguish ventricular tachycardia from other rhythms such as supraventricular tachycardia. The proposed algorithm is applicable on both single and dual chamber ICDs and has a low computational demand. The results demonstrate that suggested algorithm has considerable promise and merits further investigation.
View details for Web of Science ID 000280543601357
View details for PubMedID 19964965
Optimal Programming of ICDs for Prevention of Appropriate and Inappropriate Shocks.
Current treatment options in cardiovascular medicine
2008; 10 (5): 408-416
Expansion of indications for implantable cardioverter-defibrillators (ICDs) has led to a significant increase in the number of patients receiving ICDs and the number of lives saved because of ICD therapy. However, appropriate or inappropriate shocks are frequent and may result in a significant decrease in quality of life in patients with ICDs. Atrial fibrillation with rapid ventricular response, sinus tachycardia, atrial tachycardia or atrial flutter with rapid conduction, and other supraventricular tachycardias are the most common arrhythmias causing inappropriate therapy. Other causes include oversensing of diaphragmatic potentials or myopotentials, T-wave oversensing, double or triple counting of intracardiac signals, lead fractures or header connection problems, lead chatter or noise, and electromagnetic interference. Strategies to reduce inappropriate therapy using device programming rely on the ability to distinguish supraventricular and atrial arrhythmias from ventricular tachycardia. Avoiding therapy for nonsustained ventricular arrhythmias and increasing the role of antitachycardia pacing to terminate ventricular tachycardia are key approaches to reducing shocks for ventricular arrhythmias. Optimal programming holds great promise for decreasing the overall incidence of shock therapy and increasing ICD acceptance.
View details for PubMedID 18814830
- Pacemaker alternans terminated by telemetry wand: What is the mechanism? HEART RHYTHM 2008; 5 (7): 1080-1082
Genetics of Arrhythmia: Disease Pathways Beyond Ion Channels
JOURNAL OF CARDIOVASCULAR TRANSLATIONAL RESEARCH
2008; 1 (2): 155-165
Diseases of the electrical conduction system that lead to irregularities in cardiac rhythm can have morbid and often lethal clinical outcomes. Linkage analysis has been the principal tool used to discover the genetic mutations responsible for Mendelian arrhythmic disease. Although the majority of arrhythmias can be accounted for by mutations in genes encoding ion channels, linkage analysis has also uncovered the role of other gene families such as those encoding members of the desmosome. With a list of candidates in mind, mutational analysis has helped confirm the suspicion that proteins found in caveolae or gap junctions also play a role in arrhythmogenesis. Atrial fibrillation and sudden cardiac death are relatively common arrhythmias that may be caused by multiple factors including common genetic variants. Genome-wide association studies are already revealing the important and poorly understood role of intergenic regions in atrial fibrillation. Despite the great advancements that have been made in our understanding of the genetics of these diseases, we are still far from able to routinely use genomic data to make clinical management decisions. There remain several hurdles in the study of genetics of arrhythmia, including the costs of genotyping, the need to find large affected families for linkage analysis, or to recruit large numbers of patients for genome-wide studies. Novel techniques that incorporate epigenetic information, such as known gene-gene interactions, biologic pathways, and experimental gene expression, will need to be developed to better interpret the large amount of genetic data that can now be generated. The study of arrhythmia genetics will continue to elucidate the pathophysiology of disease, help identify novel therapies, and ultimately allow us to deliver the individualized medical therapy that has long been anticipated.
View details for DOI 10.1007/s12265-008-9030-4
View details for Web of Science ID 000207734800012
View details for PubMedID 20559910
Time-resolved three-dimensional imaging of the left atrium and pulmonary veins in the interventional suite - A comparison between muttisweep gated rotational three-dimensional reconstructed fluoroscopy and multislice computed tomography
2008; 5 (4): 513-519
Cardiac computed tomography (CT) is commonly used to visualize left atrial (LA) anatomy for ablation of atrial fibrillation. We have developed a new imaging technique that allows acquisition and visualization of three-dimensional (3D) cardiac images in the catheter lab.We sought to compare LA and pulmonary vein (PV) dimensions acquired using gated multisweep rotational fluoroscopy (C-arm CT) system and multislice computed tomography (MSCT) in an in vivo porcine model.A Siemens AXIOM Artis dTA C-arm system (Siemens AG, Medical Solutions) was modified to allow acquisition of four bidirectional sweeps during synchronized acquisition of the electrocardiogram signal to allow retrospective gating. C-arm CT image volumes were then reconstructed. Gated MSCT (SOMATOM Sensation 16 and 64, Siemens AG, Medical Solutions) and C-arm CT images were acquired in six animals. The two main PV diameters were measured in orthogonal axes. LA volumes were calculated. C-arm CT measurements were compared with the MSCT measurements.The average PV diameters using the C-arm CT were 2.24 x 1.35 cm, versus 2.27 x 1.38 cm for CT. The average difference was 0.034 cm (1.9%) between the C-arm CT and standard CT. The average LA volume using MSCT was 49.1 +/- 12.7 cm(3), as compared with 51.0 +/- 8.7 cm(3) obtained by the C-arm CT. The average difference between the C-arm CT and the MSCT was 1.9 cm(3) (3.7%). There were no significant differences in either the PV or LA measurements.Visualization of 3D cardiac anatomy during ablation procedures is possible and highly accurate. The 3D cardiac reconstructions acquired during ablation procedures will be valuable for procedural planning and guidance.
View details for DOI 10.1016/j.hrthm.2007.12.027
View details for Web of Science ID 000254596600003
View details for PubMedID 18362018
A Covariance-Based Algorithm: A Novel Technique for Rhythm Discrimination in ICDs
2008 30TH ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY, VOLS 1-8
Inappropriate shocks due to misclassification of supraventricular and ventricular arrhythmias remain a major problem in the care of patients with Implantable Cardioverter defibrillators (ICDs). In this study we have investigated the ability of a new covariance-based algorithm, to distinguish Ventricular Tachycardia from other rhythms such as Supraventricular Tachycardia. The proposed algorithm has a low computational demand and with a small adjustment is applicable on both single-chamber and dual-chamber ICDs. The results are promising and suggest that the new covariance-based algorithm may be an effective method for ICD rhythm classification and may decrease inappropriate shocks.
View details for Web of Science ID 000262404503170
View details for PubMedID 19163957
Characterization of human coronary sinus valves by direct visualization during biventricular pacemaker implantation
PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY
2008; 31 (1): 78-82
The precise reasons for failure to cannulate the coronary sinus during biventricular device implantation are unknown. Visualization of the coronary sinus ostium during electrophysiology procedures may enhance understanding of how unusual anatomy can affect successful cannulation of the coronary sinus.The aim of this study was to describe the morphology of valves at the coronary sinus ostium (CSO) visualized directly with an illuminated fiberoptic endoscope during implantation of biventricular devices.The coronary sinus anatomy of one hundred consecutive patients undergoing implantation of biventricular devices was investigated using a fiberoptic endocardial visualization catheter (EVC).The CSO was clearly visualized in 98 patients using the EVC. A Thebesian valve was seen in 54% of these. Almost all Thebesian valves were positioned at the inferior (61%) or posterior (33%) aspect of the CSO. Only six patients had Thebesian valves that covered more than 70% of the CSO, but all were successfully implanted with a transvenous left ventricular pacing lead after cannulating the coronary sinus under direct visualization.Over half of patients undergoing biventricular device implantation have identifiable Thebesian valves. Even valves covering the majority of the ostial area may be traversed using direct visualization and modern catheterization techniques.
View details for Web of Science ID 000253373400015
View details for PubMedID 18181913
Cardiac device infections complicated by erosion
JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY
2007; 19 (2): 133-137
Implantation of pacemakers and implantable cardioverter-defibrillators (ICDs) can be complicated by infection and device erosion. It is unclear if the clinical features of patients who have device erosion differ from those without erosion.We retrospectively examined the records of all patients referred for explantation of a pacemaker or defibrillator from January 2000 to May 2005. We examined demographic variables including age, gender, and body mass index (BMI) as well as clinical variables related to erosion and procedural variables.Seventy-two patients with infected pacemakers or ICDs were identified. Of these cases, 30 (42%) developed infection complicated by erosion, of which 8/28 (29%) were related to ICDs, and 22/44 (50%) were related to pacemakers.Device erosion was significantly associated with the presence of a non-systemic infection as opposed to cases without erosion. This finding may have implications in the timing of device re-implantation.
View details for DOI 10.1007/s10840-007-9143-8
View details for Web of Science ID 000249009800008
View details for PubMedID 17668305
- VF and fatal cardiac arrest following ICD therapy delivery: What is the cause? PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY 2007; 30 (4): 551-553
The effect of gender on mortality or appropriate shock in patients with nonischemic cardiomyopathy who have implantable cardioverter-defibrillators
PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY
2007; 30 (3): 390-394
As heart disease is increasingly recognized in women and as important studies have elucidated the benefit of implantable cardioverter defibrillators (ICDs) in patients with nonischemic cardiomyopathy (NICM), little is known regarding the effect of gender difference on arrhythmic risk in this population. We sought to determine if there are gender differences in arrhythmic risk and potential defibrillator benefit in patients with NICM.The records of 767 consecutive patients who underwent ICD implant at the Stanford Medical Center from 1984 to 2002 were reviewed. Only patients with NICM were considered (n = 201, 26.2%). Of these, 140 patients had clinical follow-up information available. Baseline variables were examined, including age, baseline heart rate, ejection fraction, and medications. We evaluated the time to first shock as well as all-cause mortality in this patient population. Kaplan-Meier survival curves were plotted, a log-rank test was used to evaluate significance, and Cox-proportional hazards test was used for multivariate analysis.There were 88 (62.9%) men and 52 (37.1%) women. Between male and female patients, there were no significant differences in baseline mean age (54.8 +/- 1.9 years vs 53.1 +/- 2.3 years, respectively), ejection fraction (35.2 +/- 2.0% vs 33.3 +/- 2.3%, respectively), and mean left ventricular end-diastolic dimension (6.4 +/- 0.3 cm vs 5.9 +/- 0.2 cm, respectively). Mean follow-up time was 30.8 months. Thirty-two male patients (36.4 +/- 0.05%) received appropriate shocks compared with 20 female patients (38.5 +/- 0.07%). Mean time to the first appropriate shock was 11.9 +/- 3.9 months for male patients and 21.3 +/- 5.8 months for female patients (P = 0.2). Nineteen male patients (21.6 +/- 0.05%) died or received heart transplant during the follow-up period compared with 6 female patients (11.5 +/- 0.04%) (P = 0.11).Male and female patients with NICM who received ICDs had similar rate of appropriate shock and mortality. In this population gender does not appear to be an important risk factor for mortality or arrhythmic events.
View details for Web of Science ID 000244886500013
View details for PubMedID 17367359
Inappropriate shock: A failure of SVT discriminators in a dual chamber ICD?
PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY
2006; 29 (12): 1413-1415
Inappropriate shock remains a major issue in patients with implantable cardioverter defibrillators. We examine an inappropriate shock delivered in a patient with atrial tachycardia that conducted 1:1. We reconstruct the device algorithms that led to therapy delivery and discuss programming changes that could be considered.
View details for Web of Science ID 000243530800015
View details for PubMedID 17201851
Isolated giant cell myocarditis in the atrium: An incidental finding?
PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY
2006; 29 (10): 1179-1180
Giant cell myocarditis (GCM) is an uncommon disorder that affects ventricular myocardium causing severe left ventricular dysfunction and ventricular arrhythmias. We report a case of GCM that only affected the atrium sparing the ventricle.
View details for Web of Science ID 000241995100019
View details for PubMedID 17038151
Early human experience with use of a deflectable fiberoptic endocardial visualization catheter to facilitate coronary sinus cannulation
2006; 3 (8): 875-878
Despite improvements in cardiac resynchronization therapy (CRT) implantation techniques, a significant minority of CRT attempts are unsuccessful. Inability to cannulate the coronary sinus (CS) because of difficult anatomy is a major reason for unsuccessful CRT implantation. Direct visualization of intracardiac structures during the implant may facilitate access into the CS. The present study describes CRT implantation with the aid of an endocardial visualization catheter (EVC).Fifty-eight consecutive patients (mean age 72 +/- 12 years; ejection fraction 26.2% +/- 7.0%; New York Heart Association [NYHA] class 2.9) underwent CRT implantation using a steerable fiberoptic EVC (Acumen Medical, Inc., Sunnyvale, CA).The EVC was able to visualize the CS ostium in all cases. The CS was successfully cannulated in 57 (98.3%) of 58 patients. The time from vascular access to CS visualization was 6 +/- 5 minutes, and the total time to CS access was 8 +/- 6 minutes. Successful left ventricle (LV) lead implantation was accomplished in 55 (94.8%) of 58 patients. Three patients who had a previous history of failed LV lead implantation were successfully implanted using the EVC.Fiberoptic imaging of intracardiac structures during CRT implantation may be performed rapidly in a wide range of patients with an EVC. The ability to visualize right atrial anatomy may aid CS access and LV lead implantation.
View details for DOI 10.1016/j.hrthm.2006.04.029
View details for Web of Science ID 000239746400001
View details for PubMedID 16876731
- Improvement in quality of life after radiofrequency ablation PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY 2006; 29 (4): 341-342
- Supraventricular tachycardia vs ventricular tachycardia: What is the rhythm HEART RHYTHM 2006; 3 (4): 490-491
- Premature ventricular contractions causing pacemaker-mediated tachycardia: A failure of postventricular atrial refractory period after premature ventricular contraction extension? HEART RHYTHM 2005; 2 (12): 1389-1390
- Delivery of antitachycardia pacing after a full-energy shock during the same ventricular tachycardia episode: Appropriate device function? HEART RHYTHM 2005; 2 (11): 1266-1267
Use of the implantable cardioverter-defibrillator in long-term survivors of orthotopic heart transplantation
2005; 2 (9): 931-933
Orthotopic heart transplantation is considered an effective treatment for patients with refractory heart failure. The long-term survival of orthotopic heart transplantation recipients has increased over the last several decades, but many long-term survivors of orthotopic heart transplantation develop graft atherosclerosis and associated left ventricular dysfunction. The risk of sudden cardiac death in long-term survivors of orthotopic heart transplantation with these complications is believed to be high. There are no data on the usefulness of implantable cardioverter-defibrillators (ICDs) in this population; therefore, we report our early experience with ICD placement in such patients.The purpose of this study was to examine the use of ICDs in adults who are long-term survivors of heart transplantation.We retrospectively reviewed all adult patients who underwent orthotopic heart transplantation at Stanford University Hospital (Stanford, CA, USA) from 1980 to 2004. All patients who received an ICD after transplant were included in this study. We reviewed demographic data, medical history, ejection fraction, presence of graft atherosclerosis, indication for ICD placement, and any device therapy delivered.Of the 925 patients who had orthotopic heart transplantation during this time period, 493 patients were alive at the beginning of the year 2000. Of these patients, 10 ( approximately 2%) had subsequent placement of an ICD. All 10 patients were male. The average age at orthotopic heart transplantation was 37.8 years. The average age at ICD placement was 50.5 years. The average time from orthotopic heart transplantation to ICD placement was 14.6 years. The average ejection fraction at the time of implant was 46.5%. Five of the 10 patients had a low ejection fraction (within this subgroup, the average ejection fraction was 31%, range 15%-45%) and graft atherosclerosis. ICDs were placed because of symptomatic episodes of ventricular tachycardia (3 patients), low ejection fraction and severe graft atherosclerosis without symptoms (3 patients), and after thorough evaluation for otherwise unexplained syncope (4 patients). The average follow-up after device implantation was 13 months. Complications related to ICD placement were an infected ICD system requiring explant in one patient and a lead fracture in another patient. Three patients had subsequent appropriate shocks for ventricular arrhythmias, and one patient underwent a second orthotopic heart transplantation. One patient died of malignancy.Use of the ICD in long-term survivors of orthotopic heart transplantation should be considered in appropriately selected patients. Further data are needed regarding ICD use in this population.
View details for DOI 10.1016/j.hrthm.2005.06.018
View details for Web of Science ID 000231986200008
View details for PubMedID 16171746
T-wave abnormalities are a better predictor of cardiovascular mortality than ST depression on the resting electrocardiogram
ANNALS OF NONINVASIVE ELECTROCARDIOLOGY
2005; 10 (2): 146-151
ST depression and T-wave amplitude abnormalities are known to be independent predictors of cardiovascular (CV) death, but a direct comparison between them has not been described.Analyses were performed on the first electrocardiogram (ECG) digitally recorded on 46,950 consecutive patients at the Palo Alto Veterans Affairs Medical Center since 1987. Females and patients with electrocardiograms exhibiting bundle branch block, left ventricular hypertrophy, electronic pacing, diagnostic Q waves, or Wolff-Parkinson-White syndrome were excluded, leaving 31,074 male patients for analysis (mean age 55 +/- 14). There were 1878 (6.0%) cardiovascular deaths (mean follow-up of 6 +/- 4 years). Electrocardiograms were classified using Minnesota code according to the degree of ST depression and T-wave abnormality, and the nine possible combinations of ST segment and T-wave abnormalities were recoded for analysis.The combination of major abnormalities in ST segments and T-waves carried the greatest hazard [3.2 (CI 2.7-3.8)]. Minor ST depression combined with more severe T-wave abnormalities carried a hazard of 3.1 (CI 2.5-3.7), whereas minor T-wave abnormalities combined with more severe ST depression carried a hazard of only 1.9 (CI 1.6-2.3).While both ST segment depression and abnormal T-wave amplitude are clinically important, T-wave abnormalities appear to be greater predictors of cardiovascular mortality.
View details for Web of Science ID 000228826100005
View details for PubMedID 15842426
Early experience with a computerized robotically controlled catheter system
JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY
2005; 12 (3): 199-202
Recently, the use of robotic assisted surgery has been utilized in cardiac surgical procedures. The use of robotics may offer benefits in precision, stability and control of instruments remotely. We report early experience with a novel remote robotic catheter control system (CCS).We used a computerized robotically controlled catheter system that enables the user to remotely manipulate the tip of a catheter precisely in three dimensions. We tested the robotic catheter control systems ability to navigate within the heart and to make precise, rapid and repeatable movements. We compared the CCS with the ability of a standard quadripolar steerable ablation catheter placed in a deflectable sheath to navigate and make precision movements. Twelve ex-vivo porcine hearts were utilized to permit accurate measurements of navigation and precision. Eight targets were selected for navigation and precision testing. Time was measured for the catheter to reach the predefined target from a specific starting point to test navigation. In addition, time was measured to contact a discrete 0.8 mm target in order to test precision.The use of the CCS reduced the time needed for both navigation (8.5 +/- 13.9 sec vs. 22.7 +/- 26.7 sec, p = 0.002) and significantly decreased the time for precision targeting (10.1 +/- 6.9 sec vs. 29.6 +/- 26.4 sec, p < 0.001) in the specific RA and LA sites in the ex-vivo hearts.The use of a computerized robotically assisted catheter control system is feasible and shows promise in rapid precision movement of the catheter. Further study is needed to elucidate the role of such a system in-vivo and in patient specific catheter ablation and mapping.
View details for DOI 10.1007/s10840-005-0325-y
View details for Web of Science ID 000228972600004
View details for PubMedID 15875110
- Atrial pacing above the sensor rate: What is the cause? HEART RHYTHM 2005; 2 (2): 210-211
Spatial QRS-T angle predicts cardiac death in a clinical population
2005; 2 (1): 73-78
The purpose of this study was to validate the prognostic value of computer-derived measurements of the spatial alignment of ventricular depolarization and repolarization from the standard 12-lead ECG in a general medical population.Analyses were performed on the first ECG digitally recorded from 46,573 consecutive patients since 1987. QRS and T vector were synthesized by deriving XYZ leads from the 12 leads using the inverse Dower weighting matrix. Subset analyses were considered in patients with and those without standard ECG diagnoses (i.e., atrial fibrillation, Q waves, left ventricular hypertrophy, prolonged QRS duration). The main outcome measure was cardiovascular mortality.During a mean follow-up of 6 years, 4,127 cardiovascular deaths occurred. After adjusting for age, heart rate, and gender in a Cox regression analysis, spatial QRS-T angle was the most significant predictor of cardiovascular mortality, outperforming all other ECG measurements and diagnostic statements. In the subset with ECGs free of any standard diagnoses, annual cardiovascular mortality was 0.8% for normal (0-50 degrees ), 2.3% for borderline (50-100 degrees ), and 5.1% for abnormal (100-180 degrees ) QRS-T angle groups. The borderline and abnormal angle groups had 1.5- and 1.9-fold higher risk, respectively, relative to the normal QRS-T angle group after adjustment for age, gender, and heart rate. Similar results were found when patients with standard ECG diagnosis were included or compared.Spatial QRS-T angle is a significant and independent predictor of cardiovascular mortality that provides greater prognostic discrimination than any of the commonly utilized ECG diagnostic classifications.
View details for DOI 10.1016/j.hrthm.2004.10.040
View details for Web of Science ID 000226446500014
View details for PubMedID 15851268
- Loss of biventricular pacing: What is the cause? HEART RHYTHM 2005; 2 (1): 110-111
Electrocardiographic arrhythmia risk testing
CURRENT PROBLEMS IN CARDIOLOGY
2004; 29 (7): 365-432
Among the most compelling challenges facing cardiologists today is identification of which patients are at highest risk for sudden death. Automatic implantable cardioverter-defibrillators are now indicated in many of these patients, yet the role of noninvasive risk stratification in classifying patients at high risk is not well defined. The purpose of this review is to evaluate the various electrocardiographic (ECG) techniques that appear to have potential in assessment of risk for arrhythmia. The resting ECG (premature ventricular contractions, QRS duration, damage scores, QT dispersion, and ST segment and T wave abnormalities), T wave alternans, late potentials identified on signal-averaged ECGs, and heart rate variability are explored. Unequivocal evidence to support the widespread use of any single noninvasive technique is lacking; further research in this area is needed. It is likely that a combination of risk evaluation techniques will have the greatest predictive power in enabling identification of patients most likely to benefit from device therapy.
View details for DOI 10.1016/j.cpcardiol.2004.02.007
View details for Web of Science ID 000222170600002
View details for PubMedID 15192691
Cardiovascular screening of athletes
CLINICAL JOURNAL OF SPORT MEDICINE
2004; 14 (3): 127-133
Cardiovascular screening of athletes is a challenging aspect of the preparticipation evaluation. While sudden cardiac death in young athletes is uncommon, preparticipation screening may identify some predisposing conditions that place individuals at increased risk. The most common pre-existing cardiac abnormalities in athletes causing sudden death in the United States are hypertrophic cardiomyopathy, congenital coronary anomalies, and Marfan syndrome. Preparticipation cardiovascular screening should pursue any history of cardiac symptoms or family history of premature cardiac disease, as well as abnormal cardiovascular physical findings. Positive findings should be investigated; an electrocardiogram, echocardiogram, or consultation with a specialist should be considered. Recommendations are then available to guide athletic participation according to the cardiovascular diagnosis.
View details for Web of Science ID 000230327200004
View details for PubMedID 15166900
Frequent ICD shocks due to double sensing in patients with bi-ventricular implantable cardioverter defibrillators
JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY
2003; 9 (3): 377-381
Biventricular pacing has emerged as a modality for treatment of patients with heart failure. Combined biventricular pacers and implantable cardioverter defibrillators offer treatment of heart failure as well as protection from sudden cardiac death. However, inappropriate ICD shocks as a result of double sensing due to widely spaced ventricular bipoles may pose a significant problem in these patients. We examined the ICD records of twenty-three patients with biventricular ICDs, and evaluated all episodes of double sensing that resulted in aborted or delivered therapy. In follow-up of 3.7 +/- 2.6 months, thirty-three shocks in fifteen episodes occurred in five patients (21.7%) due to double sensing. Four patients (17.4%) had aborted shocks due to double sensing. All episodes resulting in shock occurred because of sinus tachycardia or supraventricular tachycardia above the upper programmed pacing rate of the device with resultant AV conduction and double sensing of the nonpaced ventricular depolarization. In conclusion, double sensing of the R-wave is a common and clinically important cause of inappropriate ICD detection and shock in patients with biventricular ICDs. Appropriate programming of the ICD can prevent episodes of inappropriate shocks.
View details for Web of Science ID 000186420900011
View details for PubMedID 14618060