In this work, the high-pressure torsion (HPT) technique is used to fabricate bulk metallic glass and composite samples of magnesium-rich Mg72Ca12Zn16 and Mg72Ca12Zn14Sn2 alloys. Mg72Ca12Zn14Sn2 is a new glass-forming alloy, and its glass-forming ability is slightly lower than that of the Mg72Ca12Zn16 alloy. Amorphous and composite ribbons of both alloys were subjected to HPT processing with 25, 50, and 70 turns separately to prepare bulk samples. For the amorphous samples, a homogeneous microstructure is achieved throughout the sample after 50 turns, and for the composite samples, microstructure homogenization is achieved after 70 turns. After the entire HPT process, no strain-induced crystallization was detected in both amorphous and composite samples. This study indicates that Mg-based metallic glasses and composites can be fabricated into bulk components even with low glass-forming ability. The microstructural refinement leads to a higher hardness than the starting material.

The development of biocompatible and mechanically robust materials for long-term implant applications remains a central challenge in biomedical engineering. This research introduces a series of Ni-and Be-free Zr66.5M16.5Al10Fe5Ti2 bulk metallic glasses (BMGs; where M = Cu, Pt, Au, and Pd) that were designed and synthesized with the aim of overcoming the cytotoxic limitations associated with conventional Zr-based BMG systems. Structural investigations using X-ray diffraction and transmission electron microscopy on 2-mm suction-cast rods confirm the fully amorphous nature of the Cu-, Pd-, and Pt-containing alloys, while the Au-containing counterpart exhibits partial nanocrystallinity. Thermal characterization reveals a high glass-forming ability and extended supercooled liquid regions, particularly for Pt-and Pd-substituted systems. Mechanical testing demonstrates that the Zr-Pt alloy exhibits the highest hardness (7.17 GPa) and compressive strength (1767 +/- 35 MPa). In contrast, the Zr-Au alloy shows superior plastic strain (-4 %), ascribed to greater free volume and a minor fraction of-5-10 nm nanocrystallites. The corrosion performance in 3.5 wt% NaCl solution was assessed using potentiodynamic polarization and electrochemical impedance spectroscopy, indicating significantly improved passivation and pitting resistance for the Pt-and Pd-bearing alloys. Altogether, the findings highlight that partial substitution of Cu with noble metals enables tailored mechanical and electrochemical properties, positioning these novel Zr-based BMGs as promising candidates for next-generation implantable devices.

Phase separation arises from the substitution of Y in Zr70-xAl12.5Fe17.5Yx (x = 0-25 at.%) metallic glasses (MGs), resulting in the formation of nano-amorphous domains within a glassy matrix. The glasses with x >= 10 show a typical liquid phase separation-induced two-glassy phase (Zr-rich and Y-rich) morphology with droplet-like microstructures (nano-amorphous domains). The size of the domains increases with increasing Y addition. Atom probe tomography (APT) analysis confirms the formation of nanometer-sized Y-enriched clusters for x =15 and 20. The effect of microstructural variation due to phase separation on the mechanical properties was studied using micro- and nano-indentation techniques. The micro-hardness and nano-hardness are found to be in the range of 4.58-5.73 GPa and 5.22-6.11 GPa for the alloys with x = 0-25. The hardness and elastic modulus decrease gradually with the increase in Y content. The Zr-based MGs exhibit Young's moduli in the range of 81-91 GPa, which are lower than that of Co-Cr-Mo, 316L SS and Ti-6Al-4V commercial implant alloys. Evaluation of the cytocompatibility of the MG ribbons reveals high metabolic activity and well-spread human gingival fibroblast (HGF) cells on the surface of x = 10 and 15 samples. Thus, the two glassy-phase Zr-based MGs free of toxic elements (Ni and Cu) exhibit suitable mechanical properties and biocompatibility, making them strong contenders for use in implant applications.

The glass-forming ability, mechanical and magnetic properties of Ce60Ni25Al15-xGax (x=0, 4, 8 and 15) melt-spun alloys have been investigated. All the alloys show the formation of glassy phase. The supercooled liquid region increases with increase in Ga addition and becomes maximum for x=15 indicating its better glass-forming ability for this composition. A new metallic glass (MG) composition Ce60Ni25Ga15 has been found upon complete substitution of Al by Ga. The mechanical behavior of these alloys has been studied by determining various indentation parameters such as micro-hardness, yield strength and Meyer's exponent. The microhardness property of the Ce-Ni-Al alloy is improved by the addition of Ga. The difference in the formation of shear bands for x=0 and 15 alloys are discussed by estimating the pile-up parameter. The magnetization (M-H) curves of all the samples at 5 K show paramagnetic characteristics with no magnetic hysteresis. The findings reveal that the concentration of Ga has a significant impact on the properties of these alloys.

Phase-separated metallic glasses (MGs) have attracted a lot of interest recently because they offer a unique opportunity to design composites or alloys with hierarchical microstructure at various length scales. Phase-separated MGs differ from other MGs in terms of their structure and physical properties. Though a lot of theoretical work has been done, there is still a lack of understanding regarding the mechanism underlying phase separation in MGs. In general, phase separation in many MG systems is explained on the basis of nucleation and growth or spinodal decomposition mechanisms. On the other hand, the phase separation in Ce-based MGs is examined based on changes in the electronic structure of Ce atoms. This opens up a new direction of research for delineating issues pertaining to phase separation in amorphous systems. The present brief review aims to provide a comprehensive overview of the phase separation phenomenon in Ce- and Zr-based MG systems. It is broadly divided into two sections: the first section gives a brief introduction into the phase separation in MG systems, mechanisms of phase separation, micro-structural and thermal characteristics, and advantages of phase separation. The second section discusses some of the recent work on Ce- and Zr-based phase-separated MGs with respect to their design and properties.

We present a new phase-separated Zr-based metallic glass (MG) composition, free of toxic elements (Ni and Cu) prepared in a glass-forming system by alloying addition. The substitution of Y in Zr70-xAl12.5Fe17.5Yx (x = 0-15 at. %) results in phase separation, giving rise to nano-amorphous domains in a glassy matrix. A homogeneous MG feature is observed for low concentrations of Y up to x = 5. Microstructure and thermal property analysis indicate that the glasses with x = 10 and 15 at.% Y exhibit a typical liquid phase separation-induced two-glassy phase (Zrrich and Y-rich) with droplet-like microstructures (nano-amorphous domains). With increasing Y addition, the domain size increases. The microstructural evolution arising due to phase separation in these alloys is confirmed by a combination of transmission electron microscopy (TEM) and atom probe tomography (APT) analysis. The formation of nanometer-size Y-enriched clusters is confirmed by APT for x = 15.

This study aim to investigate if remote intensive coaching for the first 6 months post-AMI will improve adherence to the twice-a-day antiplatelet medication, ticagrelor. Between July 8, 2015, to March 29, 2019, AMI patients were randomly assigned to remote intensive management (RIM) or standard care (SC). RIM participants underwent 6 months of weekly then two-weekly consultations to review medication side effects and medication adherence coaching by a centralized nurse practitioner team, whereas SC participants received usual cardiologist face-to-face consultations. Adherence to ticagrelor were determined using pill counting and serial platelet reactivity measurements for 12 months. A total of 149 (49.5

Dear Sir, A 20-year-old Indian man presented with exercise-induced myalgia. He is the only child of non-consanguineous parents and had no family history of neuromuscular diseases. Growing up, his developmental milestones were noted to be normal. His parents, however, observed that he had difficulties performing prolonged exercise, ‘tiring out’ more easily than his peers and preferring indoor activities. He had frequent exertional leg cramps requiring analgesics. In addition, he struggled to pass fitness tests in school. On clinical examination, no muscle fasciculations were observed and sensation was intact. Power was relatively preserved. He had a markedly elevated creatine kinase level at 13,223 U/L (normal range 30–350 U/L). Nerve conduction studies and electromyography were normal. He underwent left vastus lateralis muscle biopsy, which demonstrated rounded fibres with significant fibre size variability and the presence of myopathic grouping. There was no endomysial fibrosis on biopsy. Furthermore, a reduction of dystrophin-N staining raised the possibility of dystrophinopathy. Subsequent genetic tests confirmed a pathogenic in-frame deletion in the DMD gene at Exon 10–18. He was diagnosed with Becker muscular dystrophy (BMD). This patient was subsequently referred to the cardiology clinic to be screened for associated cardiomyopathy. On questioning, he did not report any heart failure symptoms such as worsening effort tolerance, orthopnoea, paroxysmal nocturnal dyspnoea or lower limb swelling. He also did not have a history of unexplained syncope. Cardiovascular examination was unremarkable. He was normotensive and had normal heart rate at rest. Jugular venous pressure was not elevated and heart sounds were dual with no murmurs. Lung fields were clear and there was no evidence of lower limb oedema. Electrocardiography (ECG) showed sinus rhythm with normal conduction intervals [Figure 1]. However, a subsequent transthoracic echocardiogram incidentally revealed a left ventricular ejection fraction (LVEF) of 30% and dilated left heart chambers. He was diagnosed with dilated cardiomyopathy and stage B heart failure. In view of the structural abnormalities seen on imaging, he was promptly started on neuro-hormonal cardiac therapies with perindopril, an angiotensin-converting enzyme inhibitor (ACE-I).Figure 1: ECG shows sinus rhythm with normal PR and QRS intervals.Cardiac magnetic resonance imaging (CMR) was performed 12 weeks after the initiation of perindopril. CMR demonstrated improvement in LVEF to 44% and normal right ventricular ejection fraction. The previously noted left heart chamber dilatation had also resolved. Upon administration of gadolinium, there was linear sub-epicardial late gadolinium enhancement (LGE) along the basal to apical lateral and inferior walls. Mid-myocardial LGE of the mid-ventricular septum was also noted [Figure 2].Figure 2: Cardiac MR images. (a) 3-chamber view shows sub-epicardial late gadolinium enhancement (LGE) in the inferolateral wall of the left ventricle (LV) (white arrowheads); (b) 4-chamber view shows sub-epicardial LGE in the anterolateral wall (white arrowheads) and mid-wall LGE in the inferior septum (black arrowheads); (c) Short-axis view shows sub-epicardial LGE of lateral/inferior LV walls (white arrowheads) and mid-wall LGE in the inter-ventricular septum (black arrowheads).The patient has had no new symptoms since his diagnosis of dilated cardiomyopathy. Low blood pressure following the initiation of perindopril prevented the up-titration of perindopril or the addition of other heart failure therapies, specifically beta-blockers or eplerenone. After weighing the pros and cons of long-term steroid use in a young patient, a decision was made not to start the patient on corticosteroids due to the relative absence of muscle weakness., A repeat CMR was planned one year later to assess LVEF and progression of myocardial fibrosis. Dystrophin is a protein encoded by the DMD gene. It is a component of the dystroglycan complex, which is present in skeletal muscle and myocardial cells. This complex provides mechanical support to the plasma membrane during muscular contraction.[1] Complete absence of dystrophin results in Duchenne muscular dystrophy (DMD), a severe neuromuscular disorder, while a partial deficiency in dystrophin manifests as BMD, a milder form of the disease. Collectively, these conditions are termed dystrophinopathies. BMD is an X-linked inherited disorder that was first described in 1955.[2] BMD mutations occur in-frame, resulting in misfolded dystrophin rather than a total absence of dystrophin, thus its milder muscular phenotype compared to DMD. Over 70% of patients with BMD develop cardiomyopathy, which is the leading cause of death in BMD. Dystrophin-deficient cardiomyopathies tend to present late, with its severity dissociated from the skeletal muscle symptoms. Our patient had cardiomyopathy diagnosed at a young age, immediately after the diagnosis of BMD. This is due to proactive screening for cardiomyopathy using cardiac imaging, despite the patient being asymptomatic and having a normal ECG. In the absence of active cardiac screening, BMD patients are likely to be diagnosed with cardiac involvement only when they present with heart failure symptoms at an older age. Histologically, there is fibrous or fatty replacement of dysfunctional cardiomyocytes.[3] As seen in our patient, this change is typically distributed in the sub-epicardial layer and initially starts in the postero-basal left ventricular free wall, eventually spreading throughout all the myocardium, leading to dilated cardiomyopathy.[4] CMR with LGE is the best non-invasive tool for early identification of this fibrotic change. Its advantages over echocardiography are clear, including the ability to detect early fibrosis, accuracy in imaging technique and reproducibility. These are of paramount importance for longitudinal monitoring of cardiomyopathy progression or response to treatment. Serial CMR will allow us to look for extension of myocardial fibrosis, worsening of ventricular functions or progressive dilatation of cardiac chambers, which will confer a poorer prognosis from the cardiomyopathy point of view. Medical therapy remains the best treatment to halt the progression of fibrosis. ACE-I is the standard of care in the treatment of severe cardiomyopathies and heart failure. The benefits of ACE-I are also seen in dystrophin-deficient cardiomyopathy. In a study by Duboc et al., 28 participants were randomised to ACE-I versus placebo for three years.[5] At ten years, 93% of the ACE-I group were alive vs. 66% of the placebo group. This study also showed that early initiation of treatment with ACE-I conferred 27% of absolute risk reduction in all-cause mortality. For beta-blockers, Kajimoto et al. studied the use of a combination therapy of ACE-I with carvedilol in a broad range of neuromuscular disorders, including BMD.[6] The dual therapy group had increased left ventricular fractional shortening and decreased left ventricular dimensions when compared to the ACE-I only group. Furthermore, the study found that the earlier the treatment was initiated, the better the outcome. Ogata et al. studied DMD patients with asymptomatic vs. symptomatic heart failure.[7] The asymptomatic group who were initiated on treatment had a ten-year survival rate of 72% compared to 0% for those treated after the onset of symptoms. Lastly, eplerenone was also studied in a cohort of 40 DMD patients. The addition of eplerenone to the standard therapy of ACE-I or angiotensin receptor blockers in this cohort of DMD patients with preserved LVEF was associated with attenuation of decline in LVEF at 12 months as compared to placebo.[8] We have seen how early detection and early initiation of therapy are the key strategies in the management of patients with dystrophin-deficient cardiomyopathies. However, screening should not stop there. In a European cohort of 130 female dystrophinopathy carriers, up to 14% of these subjects were found to have abnormal cardiac findings on echocardiogram.[9] In a Japanese cohort of female dystrophinopathy carriers, dilated cardiomyopathy was diagnosed using echocardiography in 15 out of the 28 subjects studied.[10] Out of these 15 individuals diagnosed with cardiomyopathy, six underwent further CMR evaluation and LGE was detected in five of them. It is, therefore, important to also screen female carriers of the dystrophin gene mutation for cardiomyopathy. CMR is the preferred imaging modality in these patients.[11] In the long run, they will also benefit from close follow-up and initiation of early cardiac therapies. In summary, this case serves to highlight classical CMR imaging findings in dystrophin-deficient cardiomyopathy, reinforcing the importance of cardiac screening in this patient population and female dystrophinopathy carriers. It is important to initiate early treatment of heart failure therapies even before symptoms appear, as this leads to improved cardiac outcomes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Recent studies have shown that sodium/glucose cotransporter 2 (SGLT2) inhibitors might exert favourable changes on cardiac parameters as observed on cardiovascular imaging. We conducted a systematic review and meta-analysis to determine the effects of SGLT2 inhibitors on cardiac imaging parameters. Four electronic databases (PubMed, Embase, Cochrane, Scopus) were searched for studies in which the effects of SGLT2 inhibitors on cardiac imaging parameters were examined. Studies in which a population was administered SGLT2 inhibitors and analysed by echocardiography and/or cardiac magnetic resonance (CMR) imaging were included. Random-effects pair-wise meta-analysis models were utilized to summarize the studies. A total of 11 randomized controlled trials was included with a combined cohort of 910 patients. Comparing patients receiving SGLT2 inhibitors with subjects receiving placebo, the mean change in CMR-measured left ventricular mass (LVM) was -3.87 g (95% confidence interval [CI], -7.77 to 0.04), that in left ventricular end-systolic volume (LVESV) was -5.96 mL (95% CI, -10.52 to -1.41) for combined LVESV outcomes, that in left atrial volume index (LAVi) was -1.78 mL/m² (95% CI, -3.01 to -0.55) for combined LAVi outcomes, and that in echocardiography-measured E/e' was -0.73 (95% CI, -1.43 to -0.03). Between-group differences were not observed in LVM and LVESV after indexation. The only between-group difference that persisted was for LAVi. Treatment with SGLT2 inhibitors resulted in reduction in LAVi and E/e' on imaging, indicating they might have an effect on outcomes associated with LV diastolic function.

To combat the coronavirus disease 2019 (COVID-19) pandemic, many countries have started population vaccination programs using messenger ribonucleic acid (mRNA) vaccines. With the widespread use of such vaccines, reports are emerging worldwide, of the vaccine's association with the development of myocarditis. Younger men are more likely to develop postvaccine myocarditis, which usually presents as self-limiting chest pain within a week after the second dose. We present a case of myocarditis following vaccination with tozinameran (BNT162b2, Pfizer-BioNTech), which presented late, with ventricular tachycardia (VT) reduced left ventricular ejection fraction (LVEF).

Sarcoidosis is a multisystem, granulomatous disorder of unknown aetiology. It affects the lungs in 90% of cases, but is also known to affect other organs including the skin, liver, spleen, kidneys and heart.1 Cardiac sarcoidosis (CS) is thought to clinically affect 5% of those with sarcoidosis, manifesting as conduction abnormalities, ventricular arrhythmias, heart failure and

IMPORTANCE There are few data on remote postdischarge treatment of patients with acute myocardial infarction. OBJECTIVE To compare the safety and efficacy of allied health care practitioner-led remote intensive management (RIM) with cardiologist-led standard care (SC). DESIGN, SETTING, AND PARTICIPANTS This intention-to-treat feasibility trial randomized patients with acute myocardial infarction undergoing early revascularization and with N-terminal-pro-B-type natriuretic peptide concentration more than 300 pg/mL to RIM or SC across 3 hospitals in Singapore from July 8, 2015, to March 29, 2019. RIM participants underwent 6 months of remote consultations that included beta-blocker and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-I/ARB) dose adjustment by a centralized nurse practitioner team while SC participants were treated face-to-face by their cardiologists. MAIN OUTCOMES AND MEASURES The primary safety end point was a composite of hypotension, bradycardia, hyperkalemia, or acute kidney injury requiring hospitalization. To assess the efficacy of RIM in dose adjustment of beta-blockers and ACE-I/ARBs compared with SC, dose intensity scores were derived by converting comparable doses of different beta-blockers and ACE-I/ARBs to a scale from 0 to 5. The primary efficacy end point was the 6-month indexed left ventricular end-systolic volume (LVESV) adjusted for baseline LVESV. RESULTS Of 301 participants, 149 (49.5%) were randomized to RIM and 152 (50.5%) to SC. RIM and SC participants had similar mean (SD) age (55.3 [8.5] vs 54.7 [9.1] years), median (interquartile range) N-terminal-pro-B-type natriuretic peptide concentration (807 [524-1360] vs 819 [485-1320] pg/mL), mean (SD) baseline left ventricular ejection fraction (57.4% [11.1%] vs 58.1% [10.3%]), and mean (SD) indexed LVESV (32.4 [14.1] vs 30.6 [11.7] mL/m(2)); 15 patients [5.9%] had a left ventricular ejection fraction <40%. The primary safety end point occurred in 0 RIM vs 2 SC participants (1.4%) (P = .50). The mean beta-blocker and ACE-I/ARB dose intensity score at 6 months was 3.03 vs 2.91 (adjusted mean difference, 0.12 [95% CI, -0.02 to 0.26; P = .10]) and 2.96 vs 2.77 (adjusted mean difference, 0.19 [95% CI, -0.02 to 0.40; P = .07]), respectively. The 6-month indexed LVESV was 28.9 vs 29.7 mL/m(2) (adjusted mean difference, -0.80 mL/m(2) [95% CI, -3.20 to 1.60; P = .51]). CONCLUSIONS AND RELEVANCE Among low-risk patients with revascularization after myocardial infarction, RIM by allied health care professionals was feasible and safe. There were no differences in achieved medication doses or indices of left ventricular remodeling. Further studies of RIM in higher-risk cohorts are warranted.

In this chapter, results of our recent investigations on the structural, microstructural and magnetic properties of Cu-based Heusler alloys and MFe2O4 (M = Mn, Fe, Co, Ni, Cu, Zn) nanostructures will be discussed. The chapter is divided into two parts, the first part describes growth and different characterizations of Heusler alloys while in the second part magnetic properties of nano-ferrites are discussed. The Cu50Mn25Al25-xGax (x = 0, 2, 4, 8 and 10 at %) alloys have been synthesized in the form of ribbons. The alloys with x ≤ 8 show the formation of Heusler single phase of the Cu2MnAl structure. Further increase of Ga content gives rise to the formation of γ-Cu9Al4 type phase together with Cu2MnAl Heusler phase. The alloys are ferromagnetically ordered and the saturation magnetization (Ms) decreases slightly with increasing Ga concentration. Annealing of the ribbons significantly changes the magnetic properties of Cu50Mn25Al25-xGax alloys. The splitting in the zero field cooled (ZFC) and field cooled (FC) magnetization curves at low temperature has been observed for alloys. Another important class of material is Nanoferrites. The structural and magnetization behaviour of spinel MFe2O4 nanoferrites are quite different from that of bulk ferrites. X-ray diffraction study revealed spinel structure of MFe2O4 nanoparticles. The observed ferromagnetic behaviour of MFe2O4 depends on the nanostructural shape as well as ferrite inversion degree. The magnetic interactions in Ce doped CoFe2O4 are antiferromagnetic that was confirmed by zero field/field cooling measurements at 100 Oe. Log R (Ω) response measurement of MgFe2O4 thin film was taken for 10–90% relative humidity (% RH) change at 300 K.

Traditionally, the emphasis of agricultural sector has increasing revenue through maximum crop yield. Energy and water costs are significantly less as compared to equipment's, thereby generally ignored. However, irrigation energy costs are growing and can be worsened with diminishing water levels. This leads motivation to many farmers to reconnoitre ecological irrigation energy practices. Presently, farmsteads are converting into net electricity generators along with increased renewables penetration into the power grid; thereby involve other loads to maintain grid balance. Agriculture sector can be rationalized to operate large extents of renewable energy which provides sustainable flexibility to the power grid. In this context, demand management strategy is developed based on the present and future needs of grid, electricity consumption/generating farm equipment that supports the agricultural sector during this conversion. Optimization outcomes reveal that the strategy enables farmsteads in extending their services to the power grid consecutively unlocking new revenue options.

In this chapter, the results of our recent studies on the role of Ga substitution in place of Al in Ce75Al25 − xGax (x = 0, 0.01, 0.1, 0.5, 1, 2, 4, and 6) metallic glasses (MGs) have been discussed with the aim to understand the genesis of phase separation. X-ray diffraction (XRD) study reveals two broad diffuse peaks corresponding to the coexistence of two amorphous phases. In order to see any change in the behavior of 4f electron of Ce, X-ray absorption spectroscopy (XAS) has been carried out for Ce75Al25 − xGax MGs. From the XAS results, it is evident that for x = 0, the spectrum exhibits only a 4f1 component, which basically shows a pure localized configuration of electron. After the addition of Ga, 4f electrons of Ce atoms denoted by 4f0 are getting delocalized. Thus, the phase separation in Ce75Al25 − xGax is taking place, owing to the formation of two types of amorphous phases having localized and delocalized 4f electrons of Ce atoms, respectively. It has been discussed how change in the electronic structure of Ce atoms may lead to phase separation in Ce75Al25 − xGax alloys. Extensive TEM investigations have been done to study the phase separation in these alloys. The microstructural features have been compared with those obtained by phase field modeling.

This randomized clinical trial compares the safety and efficacy of nurse practitioner–led remote intensive management with cardiologist-led standard care for low-risk patients with acute myocardial infarction.

BACKGROUND Optimal left ventricular (LV) lead placement improves response to cardiac resynchronization therapy (CRT) but can be hindered by unfavorable venous anatomy. Interventional procedures in the coronary veins have been described with promising short-term outcomes. OBJECTIVE The purpose of this study was to establish the safety and efficacy of percutaneous coronary venoplasty (PCV) during CRT implantation and assess medium-term lead performances and clinical outcomes against matched controls not requiring PCV. METHODS Each consecutive PCV case was matched according to age, gender, and bundle branch morphology to 2 controls from a large prospective registry of CRT recipients. Demographics, procedural success, lead performance, and response to CRT were tracked using a comprehensive electronic medical records system. RESULTS Of 422 consecutive CRT recipients treated between 2012 to 2018, 29 patients (6.9%; mean age 65.7 +/- 10.7 years; 7 female; 17 ischemic cardiomyopathy; 22 left bundle branch block) required PCV, which was successful in 21 cases (72%). Target veins measuring 1.1 +/- 0.6 mm were dilated by noncompliant balloons with mean diameter 2.8 +/- 0.5 mm. No complications occurred. Fluoroscopic and procedural durations were longer in the PCV group (P <.01) Over mean follow-up of 33.0 +/- 25.0 months, no differences in lead performance, CRT response, or 2-year survival were observed compared to the control group. CONCLUSION PCV during CRT device implant is typically successful, safe and associated with long-term clinical outcomes comparable to patients who did not need PCV. This is an important technique to optimize LV lead placement and maximize CRT response.

Digoxin is a commonly prescribed drug in the management of heart failure and atrial fibrillation. Despite its widespread use, most clinicians have little experience with recognising clinical signs and symptoms that might suggest a potentially lethal drug toxicity. We herein describe two cases with specific reference to the electrocardiographic changes induced by digoxin and discuss the predisposing factors for toxicity, recognition of possible toxicity and treatment approaches.