A neonate on day 1 of life presented with tachypnea with ECG showing narrow complex tachycardia with a heart rate of 167 beats per minute with AV dissociation, and Echo showing features suggestive of tachycardiomyopathy. The diagnostic approach and management of this case is discussed in detail.
Out-of-hospital cardiac arrest (OHCA) is a major public health challenge in India. Cardiopulmonary resuscitation (CPR) awareness, training, and bystander response rates remain critically low across the country. Objective This Indian Society of Electrocardiology position statement aims to promote nationwide CPR awareness, strengthen community response to sudden cardiac arrest (SCA) and improve survival in OHCA, with measures adapted to India-specific systems of care and bystander training. Main Themes The statement highlights the SCA burden, early recognition, rapid response, barriers to community CPR training in India, dispatcher-assisted CPR, and public access defibrillation (PAD). It emphasizes school-based CPR education, corporate social responsibility partnerships, legislative support, and development of a national CPR ecosystem. Role of digital innovations, mobile applications, virtual reality, mobile CPR training units, psychological barriers and the bystander effect are emphasized. Conclusion The position statement advocates transforming CPR from a medical skill into a societal responsibility and improve OHCA survival in India.
BACKGROUND:Accurate assessment of volume status is essential in heart failure (HF). This study evaluated the association between cardiac implantable electronic device (CIED)-derived fluid monitoring and bioelectrical impedance analysis (BIA) for systemic volume assessment. METHODS:In this prospective cross-sectional study, 57 patients with HF carrying implantable cardioverter-defibrillators or cardiac resynchronization therapy devices with intrathoracic impedance-based fluid monitoring were enrolled. Patients were classified according to the presence of device-detected fluid alerts. Body composition and total body water (TBW) percentage were assessed by BIA (Tanita). Clinical, laboratory, echocardiographic, and device-derived data were compared. Logistic regression identified variables independently associated with fluid alerts. RESULTS:Patients with device-detected fluid alerts had higher TBW and lower body fat percentages than those without alerts (both p < 0.001). TBW showed a strong positive correlation with device-detected fluid alerts (r = 0.675, p < 0.001). A TBW threshold of 57.15% predicted fluid alerts with 80% sensitivity and 80% specificity (AUC 0.938, 95% CI 0.856-0.999; p < 0.001). Patients with fluid alerts also demonstrated more pronounced echocardiographic signs of right-sided congestion. In multivariable analysis, TBW remained the only independent predictor of device-detected fluid alerts (OR 1.33, 95% CI 1.07-1.66; p = 0.011). CONCLUSION:BIA-derived TBW was strongly associated with device-detected fluid alerts and may serve as a practical complementary method for systemic volume assessment, particularly when device-based fluid monitoring is unavailable.
A 63-year-old male with prior aortic valve replacement and Bentall procedure for E. faecalis endocarditis developed paroxysmal atrioventricular (AV) block after repeat Bentall surgery. Telemetry demonstrated PVC-triggered phase 4 block leading to high-grade AV block, prolonged pauses, and polymorphic ventricular tachycardia. A temporary permanent pacemaker was implanted, followed by ventricular leadless pacemaker placement. This case highlights the malignant potential of phase 4 block, particularly when combined with postoperative conduction system disease, and underscores the importance of early recognition and pacing support.
BACKGROUND:Patients with persistent atrial fibrillation (AF) associated with scarred/low voltage left atrial myocardium have suboptimal outcomes following pulmonary vein isolation (PVI). In the LAUDABLE study, we showed that PVI durability in these patients is poor. Here, we report follow-up outcomes from LAUDABLE, including relevance of posterior wall isolation (PWI), quality of life (QOL) and cardiac dysfunction as measured by N-terminal pro-B-type natriuretic peptide (NT-proBNP). METHODS:LAUDABLE was a single-centre, pilot randomised controlled study. Patients with persistent AF were randomised to cryoballoon (CB) PVI or contact force and local impedance guided radiofrequency (RF) PVI. Patients underwent a protocol mandated 2-month redo procedure to isolate reconnected PVs. The index RF group additionally underwent PWI during the redo procedure. Arrhythmia follow-up included daily handheld ECGs, clinical review, QOL questionnaires and NT-proBNP analysis at 12 months. RESULTS:38 patients underwent both procedures (17 CB/PVI-only, 21 RF/PVI + PWI). Over median 303 day follow-up, arrhythmia-free survival was observed in 23 (61%) patients, similar between arms (Kaplan-Meier estimate: CB/PVI-only 58.8% [95% CI 38.8-87.5%] vs RF/PVI + PWI 61.9% [95% CI 44.3-86.6%]; p = 0.788). Significant improvements in QOL (AFEQT baseline: 61 vs follow-up: 96; p < 0.001) and NT-proBNP (baseline: 535 pg/mL vs follow-up: 151 pg/mL; p = 0.004) were observed. CONCLUSION:The majority of patients with significant left atrial scar at index ablation, who may be considered unsuitable for redo, derived significant benefit following durable PVI in terms of arrhythmia burden, QOL and NT-proBNP. Accepting low patient numbers, PWI offered no additive benefits.
Electrical storm (ES) refers to a life-threatening state of cardiac electrical instability, and occurrence of three or more episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24-h period. Contemporary management extends beyond antiarrhythmic therapy and catheter ablation to include autonomic modulation, rehabilitation, and longitudinal patient engagement. We present two illustrative cases: one with non-ischemic cardiomyopathy with refractory VT storm, and the other with post-myocardial infarction VF storm, to demonstrate a practical stepwise management framework from acute stabilization to long-term surveillance. These cases highlight the importance of early sedation, optimized pharmacologic therapy, neuromodulation, tailored ablation strategies, rehabilitation, and structured continuity of care.
An 80-year-old woman with diabetes and hypertension presented with crescendo angina. Initial electrocardiogram during chest pain showed biphasic T waves in leads V2-V3. Follow-up electrocardiogram after symptom resolution demonstrated deep symmetric T-wave inversions in the same leads. Coronary angiography revealed critical proximal left anterior descending artery stenosis. The evolution from Wellen Type A to Type B pattern has rarely been described in current literature. (Level of Difficulty: Intermediate).
BACKGROUND:Reports on catheter ablation for atrial fibrillation (AF) in patients with intracardiac tumors are scarce. CASE SUMMARY:We report a case of persistent AF in which the procedure was completed simply, and safely, using the FARAVIEW system, which is a 3D-integrated pulsed field ablation (PFA) system incorporating the FARAPULSE PFA system, alongside intracardiac echocardiography (ICE). The simplicity was evident in the relatively short procedure time, despite careful navigation around the cardiac tumor using FARAVIEW and ICE. Safety was paramount; we successfully performed pulmonary vein isolation, posterior wall isolation, and post-ablation mapping without causing symptomatic cerebral embolism. The FIELDTAG feature on the 3D-CT fusion image allowed for precise prediction of the isolation area and visualization of the tumor's location. This integrated approach led to the efficient termination of AF and subsequent improvement in heart failure status. CONCLUSIONS:This case demonstrates that the combination of ICE, and the 3D-integrated PFA system ensures safe left atrial ablation in the presence of a cardiac mass. Specifically, FIELDTAG on 3D-CT provided crucial visualization of the spatial relationship between the tumor and ablation lesions, enhancing procedural safety.
Takotsubo cardiomyopathy is a transient form of stress-induced cardiomyopathy triggered by emotional or physical stressors. Although cardiac complications occur in nearly half of patients, atrioventricular conduction disturbances are rare, and the optimal management strategy, including the decision regarding pacemaker implantation and its timing, remains uncertain. We report the case of an 80-year-old woman who presented with Takotsubo cardiomyopathy and persistent complete heart block requiring pacemaker implantation with conduction system pacing despite recovery of the left ventricular systolic function.
Cardiac electrograms form the foundation of contemporary clinical electrophysiology and are essential for activation mapping, substrate characterization and catheter ablation of cardiac arrhythmias. Electrogram morphology, however, is not solely determined by myocardial electrophysiology, but also by multiple technological factors related to signal acquisition and processing. Electrode size, interelectrode spacing, electrode orientation, tissue coupling, filtering settings and annotation algorithms all influence electrogram morphology, voltage and activation timing. Consequently, identical myocardial activation patterns may generate markedly different electrograms depending on the recording configuration used. Recent advances in high-density mapping technologies, multi-electrode electrogram reconstruction and advanced signal-processing techniques have further expanded the possibilities and complexity of electrogram interpretation. This review discusses the biophysical principles underlying cardiac electrogram formation and examines the technological determinants that influence electrogram characteristics. In addition, the properties, advantages and limitations of different electrogram types, including unipolar, bipolar, multipolar, omnipolar and Laplacian electrograms, are reviewed together with their implications for voltage and activation mapping. A comprehensive understanding of both the physiological basis and technological limitations of electrogram acquisition remains essential for accurate electrogram interpretation and responsible advancement of cardiac arrhythmia mapping and ablation strategies.
