(1/174) Randomised comparison of electrode positions for cardioversion of atrial fibrillation.

OBJECTIVE: To compare the relative efficacy of anteroanterior v anteroposterior electrode pad positions for external cardioversion of atrial fibrillation. DESIGN: Prospective randomised trial. SETTING: Tertiary referral cardiology centre in the United Kingdom. PATIENTS: 90 patients undergoing elective cardioversion for atrial fibrillation. INTERVENTIONS: Cardioversion was attempted with self adhesive electrode pads with an area of 106 cm2 placed either in the anteroanterior (AA) or anteroposterior (AP) positions. Initial shock was 100 J which, if unsuccessful, was followed by 200 J, 300 J, and 360 J if required. Peak current and transthoracic impedance were measured. MAIN OUTCOME MEASURES: Cardioversion success rate and energy requirements. RESULTS: Cardioversion was successful in 81% of the patients (73/90). There was no statistically significant difference in the cardioversion success rate (AA 84%, 38/45 patients; AP 78%, 35/45 patients; p = 0.42) or mean (SD) energy requirement for all patients (AA 223 (96.1) J; AP 232 (110) J) or for patients who were successfully cardioverted (AA 197.9 (82.4) J; AP 195.4 (97.2) J; p = 0.9) between the two pad positions. The mean transthoracic impedance (TTI) for the first shock (AA 77.5 (18.4) ohms; AP 73.7 (18.7) ohms; p = 0.34) was not significantly different between the two groups. TTI correlated significantly with body mass index, percentage body fat, and chest AP diameter. There was a progressive decrease in TTI with serial shocks. While aetiology and TTI were the two independent significant predictive factors for energy requirement, duration of atrial fibrillation was the only independent predictor of cardioversion success in a multivariate analysis. CONCLUSIONS: Electrode pad position is not a determinant of cardioversion success rate or energy requirement.  (+info)

(2/174) Cyclic changes in right ventricular output impedance during mechanical ventilation.

In a context such as acute respiratory distress syndrome, where optimum tidal volume and airway pressure levels are debated, the present study was designed to differentiate the right ventricular (RV) consequences of increasing lung volume from those secondary to increasing airway pressure during tidal ventilation. The study was conducted by combined two-dimensional echocardiographic and Doppler studies in 10 patients requiring mechanical ventilation in the controlled mode because of acute respiratory failure. Continuous monitoring of airway pressure on echocardiographic and Doppler recordings provided accurate timing of each cardiac event during the respiratory cycle, with particular attention being paid to end-expiratory and end-inspiratory atrial diameters, RV dimensions, and pulmonary artery and tricuspid flow estimated by the velocity-time integral (PA(VTI) and T(VTI), respectively). At baseline, lung inflation during the inspiratory phase of mechanical ventilation produced a drop in PA(VTI) from 14.3 +/- 2.6 cm at end expiration to 11.3 +/- 2.1 cm at end inspiration. This drop occurred without reduction in right atrial diameter or in RV diastolic dimensions. It was not preceded but was followed by a decrease in T(VTI), thus confirming an increase in RV outflow impedance. Manipulation of tidal volume without changing airway pressure and manipulation of airway pressure without changing tidal volume demonstrated that tidal volume, but not airway pressure, was the main determinant factor of RV afterloading during mechanical ventilation.  (+info)

(3/174) Three-dimensional endocardial impedance mapping: a new approach for myocardial infarction assessment.

Precise identification of infarcted myocardial tissue is of importance in diagnostic and interventional cardiology. A three-dimensional, catheter-based endocardial electromechanical mapping technique was used to assess the ability of local endocardial impedance in delineating the exact location, size, and border of canine myocardial infarction. Electromechanical mapping of the left ventricle was performed in a control group (n = 10) and 4 wk after left anterior descending coronary artery ligation (n = 10). Impedance, bipolar electrogram amplitude, and endocardial local shortening (LS) were quantified. The infarcted area was compared with the corresponding regions in controls, revealing a significant reduction in impedance values [infarcted vs. controls: 168.8 +/- 11. 7 and 240.7 +/- 22.3 Omega, respectively (means +/- SE), P < 0.05] bipolar electrogram amplitude (1.8 +/- 0.2 mV, 4.4 +/- 0.7 mV, P < 0. 05), and LS (-2.36 +/- 1.6%, 11.9 +/- 0.9%, P < 0.05). The accuracy of the impedance maps in delineating the location and extent of the infarcted region was demonstrated by the high correlation with the infarct area (Pearson's correlation coefficient = 0.942) and the accurate identification of the infarct borders in pathology. By accurately defining myocardial infarction and its borders, endocardial impedance mapping may become a clinically useful tool in differentiating healthy from necrotic myocardial tissue.  (+info)

(4/174) Relations of stroke volume and cardiac output to body composition: the strong heart study.

BACKGROUND: Although cardiac output (CO) plays the vital role of delivering nutrients to body tissues, few data are available concerning the relations of stroke volume (SV) and CO to body composition in large population samples. METHODS AND RESULTS: Doppler and 2D echocardiography and bioelectric impedance in 2744 Strong Heart Study participants were used to calculate SV and CO and to relate them to fat-free body mass (FFM), adipose mass, and demographic variables. Both SV and CO were higher in men than women and in overweight than normal-weight individuals, but these differences were diminished or even reversed by normalization for FFM or body surface area. In both sexes, SV and CO were more strongly related to FFM than adipose mass, other body habitus measures, arterial pressure, diabetes, or age. In multivariate analyses using the average of Doppler and left ventricular SV to minimize measurement variability, FFM was the strongest correlate of SV and CO; other independent correlates were adipose mass, systolic pressure, diabetes, age, and use of digoxin and calcium channel and beta-blockers. CONCLUSIONS: In a population-based sample, SV and CO are more strongly related to FFM than other variables; increased FFM may be the primary determinant of increased SV and CO in obesity.  (+info)

(5/174) Ventricular afterload and ventricular work in fontan circulation: comparison with normal two-ventricle circulation and single-ventricle circulation with blalock-taussig shunts.

BACKGROUND: Recent studies have indicated that there are inherent limitations associated with Fontan physiology. However, there have been no quantitative analyses of the effects of right heart bypass on ventricular afterload, hydraulic power, and resultant overall hemodynamics. Methods and Results- During routine cardiac catheterization, aortic impedance and ventricular hydraulic power were determined, both at rest and under increased ventricular work induced by dobutamine, in 17 patients with Fontan circulation, 15 patients with a single ventricle whose pulmonary circulation was maintained only by Blalock-Taussig shunts, and 13 patients who had normal 2-ventricle circulation. Both vascular resistance (nonpulsatile load on the ventricle) and pulsatile components of ventricular afterload (represented by low-frequency impedance) were significantly higher in the Fontan group than in the other groups (P<0.01), and this was associated with decreased cardiac output in the Fontan patients. In addition, hydraulic power cost per unit forward flow was 40% lower in the 2-ventricle circulation than in the single-ventricle circulation, suggesting lower ventricular efficiency in single-ventricle circulation attributable to the lack of a pulmonary ventricle. Furthermore, in the Fontan group, beta-adrenergic reserve was markedly decreased because of a limited preload reserve. CONCLUSIONS: Fontan physiology is associated with disadvantageous ventricular power and afterload profiles and has limited ventricular reserve capacity. Thus, to improve the long-term prognosis of patients after Fontan surgery, future research should be conducted into medical interventions that can overcome these limitations inherent in Fontan circulation.  (+info)

(6/174) Endocardial and epicardial steroid lead pacing in the neonatal and paediatric age group.

AIM: To compare the performance of steroid eluting epicardial and endocardial leads in infants and children requiring permanent pacing. METHODS: Evaluation of pacing and sensing characteristics, impedances, and longevity of 159 steroid eluting leads implanted in 95 children. Group A consisted of 24 children weighing less than 15 kg with 15 endocardial leads (five atrial, 10 ventricular) and 19 epicardial leads (five atrial, 14 ventricular). Group B consisted of 71 children weighing more than 15 kg with 106 endocardial leads (56 atrial, 58 ventricular) and 19 epicardial leads (nine atrial, 10 ventricular). RESULTS: Group A: Stimulation thresholds were lower for ventricular endocardial leads at implant (mean (SD) 0.84 (0.54) v 1.59 (0.64) V, p < 0.014) and at two year follow up (ventricular 0.64 (0.24) v 1.65 (0.69) V, p < 0.003). Impedance and sensing thresholds did not differ significantly at implant and follow up. Group B: Stimulation thresholds were lower for ventricular endocardial leads at implant (0.72 (0.48) v 1.48 (0.58) V, p < 0.001) and at follow up (0.88 (0.46) v 1.55 (0.96) V, p < 0.009). Impedance did not differ. Sensing thresholds were also better for ventricular endocardial leads at follow up (9.1 (5.2) v 14.2 (6.4) mV, p < 0.02). Complications requiring intervention occurred in both groups (n = 7 for endocardial v n = 18 for epicardial leads). CONCLUSIONS: Endocardial and epicardial steroid eluting leads have comparable performance in the paediatric population.  (+info)

(7/174) Changes in the transthoracic impedance signal predict the outcome of a 70 degrees head-up tilt test.

We determined whether early changes in central haemodynamics, as determined by transthoracic impedance, induced by a 70 degrees head-up tilt (HUT) test could predict syncope. Heart rate, arterial blood pressure and central haemodynamics [pre-ejection period and rapid left ventricular ejection time ( T (1)), slow ejection time ( T (2)) and d Z /d t (max) (where Z is thoracic impedance), assessed by the transthoracic impedance technique], were recorded during supine rest and during a 45 min 70 degrees HUT test in 68 patients (40+/-2 years) with a history of unexplained recurrent syncope. We found that 38 patients (42+/-3 years) had a symptomatic outcome to 70 degrees HUT (fainters) and 30 (39+/-2 years) had a negative outcome (non-fainters). When measured between 5 and 10 min of 70 degrees HUT, T (2) had increased significantly only in the fainters, and a change in T (2) of >40 ms from baseline predicted a positive outcome with a sensitivity of 68% and a specificity of 70%. During supine rest prior to 70 degrees HUT, the fainters exhibited a shorter T (2) than non-fainters (183+/-10 compared with 233+/-14 ms; P <0.01), and a T (2) of <199 ms predicted a positive outcome to 70 degrees HUT with a sensitivity of 68% and a specificity of 63%. Incorporation of the changes that occurred from rest to 70 degrees HUT in other haemodynamic variables (heart rate >11 beats/min, systolic pressure <2 mmHg, diastolic pressure <7 mmHg and pulse pressure <-3 mmHg) increased the specificity to 97% and the positive predictive value to 93%. Thus transthoracic impedance could detect differences in central haemodynamics between fainters and non-fainters during supine rest and during the initial period of 70 degrees HUT with a consistent sensitivity and specificity when combined with peripheral haemodynamic variables.  (+info)

(8/174) Respiratory sinus arrhythmia during speech production.

The amplitude of the respiratory sinus arrhythmia (RSA) was investigated during a reading aloud task to determine whether alterations in respiratory control during speech production affect the amplitude of RSA. Changes in RSA amplitude associated with speech were evaluated by comparing RSA amplitudes during reading aloud with those obtained during rest breathing. A third condition, silent reading, was included to control for potentially confounding effects of cardiovascular responses to cognitive processes involved in the process of reading. Calibrated respiratory kinematics, electrocardiograms (ECGs), and speech audio signals were recorded from 18 adults (9 men, 9 women) during 5-min trials of each condition. The results indicated that the increases in respiratory duration, lung volume, and inspiratory velocity associated with reading aloud were accompanied by similar increases in the amplitude of RSA. This finding provides support for the premise that sensorimotor pathways mediating metabolic respiration are actively modulated during speech production.  (+info)