high. We intend to continue follow-up for the next two to five years, while looking for evidence of any long-term sequelae. The utility of endomyocardial biopsy after smallpox vaccination is uncertain. Given the inherent risks and low diagnostic yield of endomyocardial biopsy (1,4), as well as the high likelihood of full objective recovery after smallpox vaccine-associated myopericarditis (3), we would be remiss to recommend a potentially harmful procedure in all patients with depressed left ventricular function. Although there has been one case of eosinophilic myocarditis that improved shortly after receiving corticosteroids (5), this one case is insufficient to conclude that corticosteroids will always be beneficial, even when eosinophils are seen on biopsy. However, the possibility that corticosteroids may uniquely benefit patients with eosinophilic myocarditis does warrant continued evaluation. Therefore, although we support endomyocardial biopsy in patients with symptomatic moderate or worse left-ventricular dysfunction related temporally to smallpox vaccination, we caution that every case must be considered individually.

During Operation Enduring Freedom, the US military began deploying a dedicated theater cardiology consultant to Afghanistan in an effort to increase rates of return to duty in service members with cardiovascular complaints. This study was designed to categorize these complaints and determine the effect on both aeromedical evacuation and return to duty rates during a 2.5 year observation period. A total of 1,495 service members were evaluated, with 43% presenting due to chest pain followed by arrhythmias/palpitations (24.5%) and syncope (13.5%). Eighty-five percent of individuals returned to duty, most commonly with complaints of noncardiac chest pain, palpitations, or abnormal electrocardiograms. Fifteen percent were evacuated out of theater, most often with acute coronary syndrome, pulmonary embolus, or ventricular tachycardia. The forward-deployed theater cardiology consultant is vital in the disposition of military members by effectively parsing out life threatening cardiovascular conditions versus low risk diagnoses that can safely return to duty.

Background. Transesophageal echocardiography (TEE) is used for the evaluation of the presence of left atrial appendage (LAA) thrombus prior to pulmonary vein isolation (PVI), while coronary computed tomography angiography (CCTA) is used for anatomic mapping during PVI. Methods. We compared the diagnostic performance of single phase CCTA to TEE in excluding the presence of LAA thrombus in patients undergoing PVI in 172 subjects performed during index hospitalization. Results. The mean age was 51 ± 13 years, a median CHADS2 score of 1 [IQR25,75 0,1, range 0–3] and a mean periprocedural INR of 2.1 ± 0.6. The prevalence of an LAA filling defect on single phase CCTA was 9.3% (6/183) and on TEE was 1.2% (2/183). Sensitivity, specificity, positive predictive value, and negative predictive value were 100% (95% CI, 19.8–100%), 91.8% (95% CI, 94–99%), 12.5% (95% CI, 60–76%), and 91.8% (95% CI, 97–100%) for the detection of LAA filling defect, respectively. Conclusion. Given the utility of a preprocedural single phase CCTA for the performance of PVI, the absence of a filling defect negates the need for a subsequent TEE as an adjunct for exclusion of LAA thrombus.

Background: To evaluate supplement use, most notably ephedra, which has been temporally associated with sudden death. Animal models suggest increased myocardial irritability may predispose to primary arrhythmic death. Methods: Clinical, pathological, and investigative records from the Office of the Armed Forces Medical Examiner's Cardiovascular Death Registry were reviewed. Forty‐eight cases of those with known supplement use were compared to 144 age‐, gender‐, and socioeconomic‐matched controls in a 1:3 case:control manner. Results: Of the 48 sudden deaths temporally associated with supplement use, the mean age was 34.2 ± 10.0 years and predominantly male (n = 44, 91.7%). The underlying cause of death was fatal atherosclerotic coronary disease in 18 (37.5%), sudden unexplained death in 16 (33.3%), and hypertrophic cardiomyopathy in six (12.5%). Compared with controls, there were no statistically significant differences in adjudicated cause of death. On autopsy, there were no differences in cardiac mass, ventricular wall thickness, or presence of atherosclerosis in those known to be taking identified supplements compared to a control population. In the subject ≥35 years, and known to be taking supplements, there was a significant increase in causality of death as due to sudden unexplained death (relative risk = 5.1 [95% confidence interval, 1.4–18.7]). Conclusions: Active surveillance of mortality in an autopsy‐derived series of young adults finds atherosclerotic coronary disease and idiopathic sudden death are common etiologies of death when taking supplements, but no cardiac structural or histologic mechanism to suggest different pathologic process than a matched control population. (PACE 2012; 35:1332–1337)

In 1999, the largest court ordered verdict in history was levied against General Motors when a 1979 Malibu was hit from behind by a drunk driver and a fiery explosion engulfed 2 adults and 4 children on Christmas Eve in 1993. 1 Panish BJ. United States Senate Committee on the Judiciary: "Defective Products: Will Criminal Penalties Ensure Corporate Accountability?" March 10, 2006. Available from: http://www.judiciary.senate.gov/hearings/testimony.cfm. Accessed February 23, 2013. Google Scholar It was conclusively demonstrated that the vehicle actually exceeded National Highway Traffic Safety Administration standards and out of 7.5 million vehicles produced from 1978 to 1983, there were 52 deaths from similar rear-end explosions. The $4.9 billion verdict included $107 million for pain and suffering, and a $4.8 billion in punitive damages against General Motors. Scope and nature of sudden cardiac death before age 40 in Ontario: A report from the Cardiac Death Advisory Committee of the Office of the Chief CoronerHeart RhythmVol. 10Issue 4PreviewUnderstanding sudden cardiac death in the young may inform prevention strategies. Full-Text PDF

Device therapy is becoming common in those patients with renal insufficiency. Coexisting need for arteriovenous (AV) fistula placement is often contemplated relative to device placement. We describe the excimer laser lead extraction of a malfunctioning chronic atrial pacemaker lead ipsilateral to an AV fistula.

BACKGROUND:Myocarditis is a recognized but rare complication of smallpox immunization. It typically presents within 30 days of immunization and on initial presentation shares many characteristics with acute coronary syndrome. Electrocardiogram findings, elevated cardiac enzymes, and undifferentiated chest pain require immediate implementation of therapy directed towards an acute coronary syndrome. In an austere environment, access to advanced care may be limited.OBJECTIVES:Smallpox vaccine-mediated myocarditis may present, typically within 30 days of immunization, in such a fashion that it is impossible to distinguish from acute myocardial infarction. The purpose of this article is to alert the clinician to this problem and to provide information to assist in making a suitable diagnosis and disposition in the absence of an absolute diagnosis.CASE REPORT:We present a case of smallpox vaccine-associated myocarditis in an American serviceman deployed in Iraq, and review the literature to determine management of these cases in an emergency setting.CONCLUSIONS:This case serves to increase awareness of the association of vaccine-mediated myocarditis in the month after immunization, and the fact that it may present similar to infarction. If the clinical probability of myocarditis is greater than infarction, this will lead the clinician to different treatment modalities.

PURPOSE:The most common cardiac injuries in the United States are blunt trauma from motor vehicle accidents or low-velocity trauma from stabbings. During military conflict, high-velocity injuries, including gunshot wounds (GSW) and fragment injury from improvised explosive devices (IED), are relatively more common.METHODS:This is a retrospective review of cases with high-velocity penetrating injury and suspected myocardial involvement during a 6-month period in Baghdad, Iraq, at a United States Army hospital during Operation Iraqi Freedom.RESULTS:Eleven cases survived to admission (GSW in 5, IED in 6). The mean age of the all-male cohort was 27 years (range, 3-54 years). Eight of the 11 patients (73%) were victims of polytrauma. The entrance involved the right ventricle (n = 3), right atrium (n = 2), left ventricle (n = 1), or mediastinum and pericardial reflections (n = 5). Echocardiography was performed in all 11 patients. In 7 patients, no foreign body was identifiable, and in 2 patients the foreign body was identified within the pericardial fat pad. Three patients were identified as having a suspected ventricular septal defect, ranging in size from 2 to 8 mm. The most common electrocardiographic abnormality was atrioventricular block and right bundle branch block. In 4 patients, the management of the chest injury was nonsurgical, and in 1 patient the treatment was a chest tube only. Four of the patients underwent median sternotomy, 1 underwent emergent lateral thoracotomy, and 1 underwent an infradiaphragmatic approach.CONCLUSION:This case series is too small to draw definitive conclusions; however, a multidisciplinary approach to high-velocity injuries with potential for cardiac involvement augments preoperative assessment for myocardial injury and may allow selective nonoperative management.

Objectives The purpose of this study was to define the incidence and characterization of cardiovascular cause of sudden death in the young.Background The epidemiology of sudden cardiac death (SCD) in young adults is based on small studies and uncontrolled observations. Identifying causes of sudden death in this population is important for guiding approaches to prevention.Methods We performed a retrospective cohort study using demographic and autopsy data from the Department of Defense Cardiovascular Death Registry over a 10-year period comprising 15.2 million person-years of active surveillance.Results We reviewed all nontraumatic sudden deaths in persons 18 years of age and over. We identified 902 subjects in whom the adjudicated cause of death was of potential cardiac etiology, with a mean age of 38 +/- 11 years. The mortality rate for SCD per 100,000 person-years for the study period was 6.7 for males and 1.4 for females (p < 0.0001). Sudden death was attributed to a cardiac condition in 715 (79.3%) and was unexplained in 187 (20.7%). The incidence of sudden unexplained death (SUD) was 1.2 per 100,000 person-years for persons <35 years of age, and 2.0 per 100,000 person-years for those >= 35 years of age (p < 0.001). The incidence of fatal atherosclerotic coronary artery disease was 0.7 per 100,000 person-years for those < 35 years of age, and 13.7 per 100,000 person-years for those >= 35 years of age (p < 0.001).Conclusions Prevention of sudden death in the young adult should focus on evaluation for causes known to be associated with SUD (e. g., primary arrhythmia) among persons <35 years of age, with an emphasis on atherosclerotic coronary disease in those >= 35 years of age. (J Am Coll Cardiol 2011;58:1254-61) (C) 2011 by the American College of Cardiology Foundation

UNLABELLED:Clinical features of young patients presenting with syncope have been underreported. METHODS:Retrospective review using U.S. Military Health System's Theater Medical Data Store and Joint Medical Workstation identified patients evaluated for syncope from January 2005 to October 2007 while deployed to a combat zone. RESULTS:We identified 848 patients with syncope. The majority (80.8%) were under the age of 40. The diagnostic yield of the ECG was 2.0%. In those <40 years, there were no head CTs or transthoracic echocardiograms that identified a cause of syncope. There was no difference in evacuation out of theater between those <40 years and those >40 years (10.8% vs. 8.6%, p = 0.08). Patients with a prior episode of syncope were more likely to undergo medical evacuation outside of the combat zone (16.0% vs. 7.7%, p < 0.01). DISCUSSION:Evacuation of those <40 years to facilities with advanced imaging did not add diagnostic information.

Introduction: The rate of use of dietary supplements among young adults is significant. While the military makes significant restrictions on the use of certain pharmacologic drugs and actively tests for illegal drugs in a deployed environment, there is a near-unlimited supply of body-enhancing supplements available at military exchanges to deployed personnel. By emphasizing physical performance and providing these for purchase, the military leadership, perhaps unknowingly, endorses the use of these products. Cardiovascular symptoms represent one of the leading nontraumatic causes of aeromedical evacuation from a combat zone. Whether the use of supplements is associated with a differential presentation to cardiovascular complaint is unknown.Methods: Retrospective review using the US Department of Defense Military Health System data, we identified patients evaluated for cardiovascular complaints of syncope or palpitations while deployed to Iraq and Afghanistan.Results: There were 905 US military personnel who presented with complaint of syncope or palpitations (mean age 31 +/- 10 years, 77% male). There were 83 (9.2%) who self-reported taking an ergogenic supplement. The incidence of reported use of supplements among males was 10.8%, which was significantly higher than its use among females at 3.8% (P = 0.001). In those > 30 years, those on supplements had a higher resting pulse (90 +/- 28 vs 79 +/- 24 beats/min, P = 0.032), and the incidence of resting tachycardia was three-fold higher (35.0% vs 11.4%, P = 0.008). Supplement use was seen in 12.3% of those who presented with palpitations, which was significantly higher than those who presented without palpitations (7.8%, P = 0.043). In those taking supplements, symptoms were more likely during exertion (26.5% vs 15.0%, P < 0.001), and immediately postexertional (13.2% vs 4.6%, P < 0.001). An electrocardiogram was suggestive of diagnosis in 103 (16.3%), while head computed tomography, treadmill, and echocardiogram had no diagnostic utility in this patient population.Discussion: In a healthy population serving within a combat zone, there exists a differential expression of disease in those taking supplements. Further study of a prospective nature to determine the impact of supplement use in this environment may allow for a more refined policy toward use and medical evaluation. (PACE 2010; 33:286-289)

BACKGROUND We sought to determine whether aggressive education on evidence-based guidelines would affect the use of resources. Specifically, we sought to educate providers about the role of neuroimaging as well as sudden death risk stratification. METHODS We reviewed 1092 consecutive cases involving patients who were admitted for syncope. We retrospectively reviewed 30 months of admissions for baseline characteristics and then initiated an intensive monthly education campaign directed toward internal medicine physicians-in-training focusing on evidence-based guidelines for a 13-month period. RESULTS There were 721 patients (66.0%) evaluated before the education intervention and 371 patients (34.0%) evaluated after the education intervention. After the intervention, there was no change in the use of computed tomography (52.3% vs 55.5%; P = .31) or magnetic resonance imaging (20.2% vs 16.7%; P = .16) of the head or carotid ultrasonography (4.7% vs 6.2%; P = .30). The referral rate for electrophysiologic study significantly increased from 6.4% at baseline to 11.3% (P = .006) after intervention, with an overall diagnostic yield of 28.4%. Of those with identified structural heart disease, the referral rate went from 5.7% to 19.0% (P = .03). Only 66 of 1092 patients who presented with syncope ultimately required a pacemaker or defibrillator implantation during hospitalization. CONCLUSIONS With intensive education, there was no decrease in neuroimaging, despite a low diagnostic yield. We were able to increase sudden death risk stratification using electrophysiologic studies without evidence of overuse of implantable device-based therapy. Intensive education allows increased adherence to guidelines for mortality reduction; however, further attempts to reduce the lower yield imaging will require methods other than education of hospital-based physicians.

Introduction: The features of young patients presenting with syncope have typically been underreported. It is a tenet of the military to treat using the appropriate assets as far forward as possible, with rapid evacuation as clinically indicated. Methods: Retrospective review using the U.S. Department of Defense Military Health System’s Theater Medical Data Store and Joint Medical Workstation, we identified patients evaluated for complaint of syncope from January 2005 to October 2007 in support of conflict resolution in Iraq and Afghanistan while deployed to a combat zone. Results: We identified 848 patients (75.8% male, age 30.7±10.1 years) with syncope. The majority (n=685, 80.8%) were under the age of 40 years. A prior syncopal event was reported in 31.4% of those 685 (80.8%) patients 40 years (10.8% vs. 8.6%, p=0.08). Patients with a prior episode of syncope were significantly more likely to undergo medical evacuation outside of the combat zone (16.0% vs. 7.7%, p Discussion: In an environment where evacuation for definitive diagnosis of syncope may be more hazardous than the illness itself, we found that one-quarter of patients underwent escalation of care requiring medical evacuation. The evacuation of those

BACKGROUND:The prognostic importance of exercise-induced ventricular arrhythmia (EIVA) may be confounded by the presence of lower-risk idiopathic right ventricular outflow tract arrhythmias with left bundle-branch block (LBBB) morphology.OBJECTIVE:To determine whether right bundle-branch block (RBBB)-morphology EIVA was associated with increased mortality.DESIGN:Retrospective cohort.SETTING:Academic medical center.PATIENTS:585 unique patients with EIVA and 2340 patients without EIVA, matched by age, sex, and risk factor, who were referred for exercise testing in an academic medical center.MEASUREMENTS:Deaths and ischemia and infarction found on perfusion scan.RESULTS:During a mean follow-up of 24 months (SD, 13), 31 deaths occurred in the EIVA group compared with 43 deaths in the group without EIVA (5.3% vs. 1.8%; P < 0.001). Worse survival in patients with RBBB-morphology or multiple-morphology EIVA (6.9%) than in patients without EIVA caused this difference. Patients with LBBB-morphology EIVAs had a mortality rate (2.5%) similar to that of patients without EIVA (P = 0.93, log-rank test). Among patients without known atherosclerotic coronary artery disease, any RBBB-morphology EIVA was associated with death (hazard ratio, 2.73 [95% CI, 1.78 to 4.13]; P < 0.001), but LBBB-morphology EIVA was not (hazard ratio, 0.82 [CI, 0.18 to 2.04]; P = 0.72).LIMITATIONS:Not all LBBB-morphology EIVA can be dismissed, and not all RBBB-morphology EIVA is high risk. Further evaluation of patients for structural heart disease was clinically driven, not protocol-driven.CONCLUSION:Right bundle-branch block- or multiple-morphology EIVA is associated with increased mortality. Inclusion of patients with isolated LBBB-morphology EIVA, which often is idiopathic, may contribute to differences in the prognostic importance of EIVA in previous studies.

We present a 30‐year‐old US army soldier who had penetrating chest trauma from a road side explosive with focal cardiac injury. The soldier had penetration of his right atrium and subsequent traumatic membranous ventricular septal defect and complete heart block. He was brought to a Combat Support Hospital where fortuitously the assigned trauma surgeon on‐call was a cardiothoracic surgeon, and the assigned trauma intensivist on‐call was a cardiac electrophysiologist. Of course, the only source they knew of a pacemaker was halfway around the world. We discuss the management of this injury in an austere combat environment.

The development of the implantable cardioverter-defibrillator (ICD) is primarily the result of pioneering work by Michel Mirowski. First-generation devices consisted of a large generator placed in an abdominal pocket capable only of high-energy shocks. In the 25 years since the first implantation in humans (1), advances in technology have resulted in significantly smaller devices, with sophisticated detection algorithms and tiered therapies. Despite these advances, the primary goal of the ICD continues to be the rapid and effective treatment of ventricular arrhythmias.