Background:The 2015 European Society of Cardiology guidelines propose algorithms for faster rule-in or rule-out of AMI in patients admitted in the acute care setting, and for the management of NSTEMI.Serial measurements with high sensitivity troponin I assays will more accurately and precisely measure changes in cardiac troponin I (cTnI) concentrations providing useful data to assist with identifying acute versus chronic cTnI elevations, and providing acceptable rule-in and rule-out performance within 1 to 3-hours of presentation.The performance of Siemens high sensitivity troponin I assay1 (TNIH) being developed for use on the ADVIA Centaur family of immunoassay analyzers is presented.The assay is a dual-capture sandwich immunoassay using preformed magnetic latex particles, a proprietary acridinium ester for chemiluminescence detection, and three monoclonal antibodies.Method: The assay limit of blank, LoB, and limit of detection, LoD, were determined using 3 reagent lots on 2 ADVIA Centaur XP and 2 ADVIA Centaur XPT systems, collecting 60 replicate measurements for each of 10 serum and 10 lithium heparin samples per lot and per system.The limit of blank, LoB, was determined non-parametrically by rank order calculating the 95th percentile.99th percentile cutoff values were established non-parametrically using a well characterized population of apparently healthy subjects.Clinical correlation of cTnI levels above the 99% percentile to adjudicated AMI diagnosis was assessed in all-comer emergency department (ED) subjects in both lithium-heparin and serum samples.Results: The LoB results ranged from 0.11 to 0.90 ng/L with a typical value of 0.5 ng/L, and the LoD results ranged from 1.10 ng/L to 2.21 ng/L (95% Confidence Interval 1.05 to 2.54 ng/L).The assay measuring range is from the LoD to 25,000 ng/L.The limit of quantification, LoQ, defined as the cTnI concentration at 20% CV had a pooled value of 2.50 ng/L.The 99th percentile estimated with an apparently healthy population of n=2026 having an equal number of males and females had a gender-combined 99th percentile of 48 ng/L.The 99th percentile for females ranged from 37 to 41ng/L and for males 57 to 64 ng/L.There were no differences between matched Lithium Heparin plasma and Serum samples.The With-In Lab CV at the 99th percentile is less than 3%.Clinical sensitivity and clinical specificity in pooled-genders at 1, 2 and 3-hour post ED presentation ranged from 87.6%-93.2%and 90.0%-91.5% respectively. Conclusion:The ADVIA Centaur TNIH assay in development by Siemens has a 10% Total CV at a cTnI concentration 10-fold lower than the 99th percentile.This new assay allows the establishment of gender specific 99th percentile cutoffs and shows acceptable clinical utility in an all-comer ED population.[1] Under development.Future availability cannot be guaranteed.

Introduction: The aim of this study was to compare the outcome of anatomical pulmonary vein (PV) radiofrequency (RF) ablation with that of an integrated approach (anatomical with electrophysiological confirmation of PV disconnection). Methods: Sixty consecutive patients affected by drug‐refractory paroxysmal (39), persistent (13), and permanent (8) atrial fibrillation (AF) were assigned to an anatomical (group A: 30 patients; 25 male, 5 female, mean age: 55 ± 7 years) or integrated approach (group B: 30 patients; 26 male, 4 female, mean age: 52 ± 9 years). In all cases, RF ablation was performed by means of the Carto system in order to anatomically create circumferential lines around PVs. In group B, the persistence of PV potentials was then assessed with a multipolar circular catheter. If PV potentials persisted, RF pulses targeting the electrophysiological breakthroughs were delivered to disconnect PVs. Results: Total procedure duration, fluoroscopy time, and RF delivery time were similar in both groups: 227 ± 43, 50 ± 23, and 43 ± 16 minutes (group A); 232 ± 32, 55 ± 15, and 42 ± 10 minutes (group B), respectively (ns). One asymptomatic PV stenosis and one pericardial effusion occurred in group A and B, respectively. After 15.4 ± 7.4 months, 17 (57%) group A patients and 25 (83%) group B patients were in stable sinus rhythm (P = 0.02) (RR 1.78; 95% CI: 1.7–2.9). Conclusions: PV ablation by means of an integrated anatomical and electrophysiological approach seems more effective than a purely anatomical RF ablation approach. Electrophysiological confirmation of PV disconnection could be a useful marker of successful RF treatment of AF.

OBJECTIVE:To evaluate the comparative diagnostic value of harmonic imaging (HI) in the assessment of patients with suspected infective endocarditis (IE).SETTING:Tertiary referral centre.DESIGN:139 consecutive patients were evaluated with three imaging modalities: transthoracic echocardiography with fundamental imaging (FI); HI; and transoesophageal echocardiography (TOE). Image quality was assessed for each modality by semiquantitative scoring (0, poor, to 3, excellent). Presence, dimension, and characteristics of vegetations were assessed separately for each imaging modality, as well as presence of abscesses.RESULTS:35 patients had definite IE. TOE was positive in 33 patients, HI in 28, and FI in 12 (p < 0.001 for FI v HI and v TOE). Mean image quality was 1.4 (0.7) for FI, 2.1 (0.6) for HI (p < 0.01 v FI), and 2.6 (0.4) for TOE (p < 0.001 v HI). The association between FI and TOE findings was Phi = 0.35 (chi2 = 17.57, p = 0.0014) and between HI and TOE it was Phi = 0.95 (chi2 = 125.72, p < 0.0001; p < 0.0001 v FI). The global echo score of vegetations was 7.1 (3.3) with FI, 8.5 (3.4) with HI, and 11.3 (3.9) with TOE (p < 0.001 v HI). Compared with TOE, FI identified only one of seven abscesses (sensitivity 14%) and HI identified two of seven abscesses (sensitivity 28%).CONCLUSIONS:HI provides an accurate assessment of suspected IE. TOE achieves superior definition of IE related abnormalities.

UNLABELLED:Supraventricular arrhythmias are often observed in patients before and after atrial septal defect repair. Although several papers report different incidences of sustained supraventricular arrhythmias, postoperative 'incisional' macroreentrant tachycardias have not been systematically investigated.METHODS:We reviewed 136 consecutive patients (79 female, 57 male, mean age 36.8+/-17.8 years) who underwent atrial septal defect repair at our institutions between January 1990 and January 1999. Coexisting valve disease requiring surgical intervention was noted in 13 patients (9.5%). The mean follow-up period was 78.8+/-30.1 months.RESULTS:Sustained supraventricular arrhythmias occurred in 12 patients (8.8%) before surgery (atrial fibrillation in 11 patients). Using multivariate analysis the occurrence of arrhythmia significantly correlated with the presence of coexisting heart disease (P< 0.001) and age at surgery (P=0.011) After surgery sustained supraventricular arrhythmias were recorded in 16 patients (11.7%). Eleven of them had atrial fibrillation, permanent in 8 cases, 4 'incisional' macroreentrant atrial tachycardia and 1 atrioventricular re-entry tachycardia. There was a significant correlation between pre and postoperative arrhythmia (P< 0.001). Two of the 4 patients with macroreentrant atrial tachycardia underwent successful radiofrequency catheter ablation, whereas the arrhythmia was controlled medically in the remaining 2 patients.CONCLUSIONS:Atrial fibrillation remains the most frequent form of arrhythmia before and after surgical closure of atrial septal defects in adulthood, and relates to age at the time of repair and coexisting heart disease. Incisional macroreentrant atrial tachycardia is an identifiable, albeit less common, form of tachycardia, which can be treated by transcatheter ablation.

Noninvasive techniques often provide controversial results in patients who have coronary artery bypass grafts (CABGs). Vasodilator stress echocardiography allows semi-simultaneous imaging of CABG flow and segmental left ventricular wall motion. To assess the comparative and additive value of regional flow and function for noninvasive evaluation of graft patency status, we evaluated 110 consecutive patients who underwent CABG and who were scheduled for coronary angiography. All patients underwent stress echocardiography with dipyridamole (0.84 mg/kg) and atropine (1 mg), including wall motion analysis by 2-dimensional echocardiography and Doppler evaluation of flow reserve of each CABG. Echocardiographic findings were compared with angiographic data. Four patients had inadequate acoustic windows. The remaining 106 patients had 226 grafts performed. Stress echocardiography showed 67% sensitivity, 91% specificity, and 71% accuracy for identification of 50% to 100% stenosis in the graft or in the recipient coronary vessel. There was a fair agreement with angiography (kappa coefficient 0.60). Identification of impaired coronary bypass flow reserve (i.e., <1.9 for internal mammary grafts and <1.6 for saphenous vein grafts) by Doppler had 91% sensitivity, 88% specificity, and 89% accuracy for graft stenosis. There was good agreement with angiographic findings (kappa 0.77). The combination of the 2 techniques achieved 93% sensitivity, 93% specificity, and 93% accuracy, showing a very good agreement with the patency status of the grafts as evaluated at angiography (kappa 0.85). The combined assessment of wall motion and flow reserve in patients who underwent CABG is feasible and provides an accurate estimate of graft patency status by increasing sensitivity of stress echocardiography and specificity of Doppler flow reserve.

Animal studies have suggested that the temperature of the electrode-tissue interface during radiofrequency (RF) catheter ablation accurately predict lesion size.Clinical studies have showed that convective cooling of the catheter by blood flow influences power delivery.METHODS: We used RF catheter ablation as an alternative to surgical incisions, to perform AF surgery in patients with AF who underwent mitral surgery.We randomized patients to receive RF ablation (group 1) or conventional therapy (group 2) for AF.We performed endocardial bilateral isolation of pulmonary veins from the left atrium using an electrosurgical probe with malleable shaft and 7 electrodes, that is able to create a linear lesion up to 95ram in a single RF pulse (ThermaLine, Boston Scientific).We excluded left atrial appendage with a RF linear lesion.RESULTS.We randomized 4 patients (3F, 1M mean age 69 + 7 yrs) in group 1 and 4 patients (2F, 2M mean age 66 + 9 yrs) in group 2, All patients had permanent AF with a duration time more than 1 year.The mean left atrial diameter was 51mm in group 1 and 49ram in group 2. Electrical cardioversion was ineffective in all patients.The mean duration of procedure with concomitant mitral surgery was 75 minutes and 73 minutes in group 1 and 2 respectively.The mean duration time for RF ablation was 7 + 2 minutes with a 1 RF pulse up to 2 minutes for each ablation line for a total of 3 RF pulses for each patient (right pulmonary veins, left pulmonary veins, left atrial appendage).Sinus rhythm was restored in all patients in group 1 with echocardiographic documentation of left and right atria contraction.In a mean follow-up of 6 ± 2 months, 1 AF recurrence occurred in group 1, successfully cardioverted.All patients in group 1 are in sinus rhythm, one with concomitant antiarrhythmic drug.All patients in group 2 are in AF.No complications were observed in both groups.The mean power needed to achieve a temperature of 50°C was 5W, with a mean impedance of 72 Ohm.CONCLUSIONS: Peculiarity of intraoperative use of RF energy is the lower power needed to achieve the target temperature to create transmural lesions (50°C).Without convective cooling of the catheter by blood flow, larger electrodes can be used for larger and deeper lesions.

A 53 year old man suffered severe head and blunt chest trauma as a result of a fall (from four metres high). On arrival at the emergency room he was unconscious with hypovolaemic circulatory shock. Following orotracheal intubation and resuscitation with blood, inotropic agents, and crystalloid, he was transferred to the neurosurgical intensive care unit. Analysis of arterial blood gases revealed a Pao2 of 50 mm Hg, Paco 2 35 mm Hg, and pHa 7.47. Increase in FIo2 up to 1.0 did not result in any increase in Pao2. Ventilation with positive end expiratory pressure made the hypoxaemia more severe. Pulmonary embolism was excluded by lung scintigraphy, mild right pulmonary contusion was evident on computed tomography; pneumothorax was not evident using …