Publications by authors named "Wael Alqarawi"

21 Publications

  • Page 1 of 1

High-power short-duration radiofrequency ablation of typical atrial flutter.

Heart Rhythm O2 2020 Dec 3;1(5):317-323. Epub 2020 Oct 3.

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada.

Background: High-power short-duration (HPSD) ablation has been explored for pulmonary vein isolation. Early data suggest similar efficacy with shorter procedure times and perhaps greater safety. Data are lacking on the use of this ablation strategy for other arrhythmias.

Objective: The purpose of this study was to evaluate the safety, efficacy, and clinical outcomes of HPSD ablation in patients with typical atrial flutter compared to those undergoing ablation with conventional settings.

Methods: Consecutive patients undergoing cavotricuspid isthmus (CTI) ablation using standard power settings were compared to those performed after transitioning to HPSD ablation. Demographics, procedural details, and ablation outcomes were prospectively collected. The primary endpoint was duration of radiofrequency energy delivery. Secondary endpoints were radiation duration and analgesia requirements.

Results: A total of 114 consecutive subjects undergoing CTI ablation (57 standard power, 57 HPSD) were included. HPSD ablation and electroanatomic mapping/contact force (EAM/CF) use were associated with 66% (95% confidence interval [CI] 58%-73%) and 50% (95% CI 37%-60%) shorter ablation times compared to standard power and not using EAM/CF, respectively. Patients in the HPSD group required 50 mcg less fentanyl relative to the standard ablation arm after adjusting for sex, age, and comorbidities ( = .048). At a median follow-up of 6 months, 4 patients (7%) in the standard arm had recurrence of atrial flutter, compared to none in HPSD group ( = .057).

Conclusion: HPSD is a safe and effective approach to CTI ablation. This strategy may reduce ablation time and analgesia requirements. Larger studies and longer follow-up are needed to further evaluate this strategy.
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http://dx.doi.org/10.1016/j.hroo.2020.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183899PMC
December 2020

Prevalence of Left Atrial Appendage Thrombus in Patients Anticoagulated With Direct Oral Anticoagulants: Systematic Review and Meta-analysis.

CJC Open 2021 May 24;3(5):658-665. Epub 2020 Dec 24.

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Background: Multiple studies have examined the prevalence of left atrial appendage thrombus (LAAT) in patients anticoagulated with direct oral anticoagulants (DOACs) and have reported conflicting results.

Methods: Studies reporting the prevalence of LAAT on transesophageal echocardiography (TEE) after 3 or more weeks of DOAC therapy were identified. The proportions of anticoagulated patients diagnosed with LAAT were pooled using random-effects models. Prespecified subgroup analyses by the indication of TEE (pre-atrial fibrillation [AF] ablation vs cardioversion) and TEE strategy (routine use vs selective) were conducted via stratification.

Results: Forty studies were identified: 22 full manuscripts and 18 abstracts. Only 11 studies performed TEE routinely. Most studies included patients with paroxysmal AF and low thromboembolic risk. The pooled prevalence of LAAT was 2.5% (95% confidence interval [1.6%-3.4%]). The prevalence of LAAT is lower in the pre-AF ablation group compared with pre-cardioversion (1.1% vs 4.0%,  = 0.033). Routine TEE strategy yielded a lower LAAT prevalence in both groups (0.1% vs 2.3%,  = 0.002 and 3.2% vs 5.8%,  = 0.432, respectively).

Conclusion: The reported prevalence of LAAT on TEE in patients treated with DOACs is highly variable. Factors associated with a high LAAT prevalence were pre-cardioversion indication and selective TEE strategy. Routine use of TEE before AF ablation may not be warranted.
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http://dx.doi.org/10.1016/j.cjco.2020.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8134939PMC
May 2021

Short-coupled ventricular fibrillation represents a distinct phenotype among latent causes of unexplained cardiac arrest: a report from the CASPER registry.

Eur Heart J 2021 May 19. Epub 2021 May 19.

Heart Rhythm Services, Department of Medicine, St-Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.

Aims : The term idiopathic ventricular fibrillation (IVF) describes survivors of unexplained cardiac arrest (UCA) without a specific diagnosis after clinical and genetic testing. Previous reports have described a subset of IVF individuals with ventricular arrhythmia initiated by short-coupled trigger premature ventricular contractions (PVCs) for which the term short-coupled ventricular fibrillation (SCVF) has been proposed. The aim of this article is to establish the phenotype and frequency of SCVF in a large cohort of UCA survivors.

Methods And Results : We performed a multicentre study including consecutive UCA survivors from the CASPER registry. Short-coupled ventricular fibrillation was defined as otherwise unexplained ventricular fibrillation initiated by a trigger PVC with a coupling interval of <350 ms. Among 364 UCA survivors, 24/364 (6.6%) met diagnostic criteria for SCVF. The diagnosis of SCVF was obtained in 19/24 (79%) individuals by documented ventricular fibrillation during follow-up. Ventricular arrhythmia was initiated by a mean PVC coupling interval of 274 ± 32 ms. Electrical storm occurred in 21% of SCVF probands but not in any UCA proband (P < 0.001). The median time to recurrent ventricular arrhythmia in SCVF was 31 months. Recurrent ventricular fibrillation resulted in quinidine administration in 12/24 SCVF (50%) with excellent arrhythmia control.

Conclusion : Short-coupled ventricular fibrillation is a distinct primary arrhythmia syndrome accounting for at least 6.6% of UCA. As documentation of ventricular fibrillation onset is necessary for the diagnosis, most cases are diagnosed at the time of recurrent arrhythmia, thus the true prevalence of SCVF remains still unknown. Quinidine is effective in SCVF and should be considered as first-line treatment for patients with recurrent episodes.
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http://dx.doi.org/10.1093/eurheartj/ehab275DOI Listing
May 2021

Defining idiopathic ventricular fibrillation: A systematic review of diagnostic testing yield in apparently unexplained cardiac arrest.

Heart Rhythm 2021 Mar 26. Epub 2021 Mar 26.

Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

Background: Idiopathic ventricular fibrillation (IVF) is diagnosed in patients with apparently unexplained cardiac arrest (UCA) after varying degrees of evaluation. This is largely due to the lack of a standardized approach to UCA.

Objective: We sought to develop an evidence-based diagnostic algorithm for IVF by systematically examining the yield of diagnostic testing in UCA probands.

Methods: Studies reporting the yield of diagnostic testing in UCA were identified in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and conference abstracts. Their methodological quality was assessed by the National Institutes of Health quality assessment tool. Meta-analyses were performed using the random effects model.

Results: A total of 21 studies were included. The pooled comprehensive diagnostic testing yield was 43% (95% confidence interval 39%-48%). A lower yield was seen when only definite diagnoses based on the prespecified criteria were used (32% vs 47%; P = .15). Epinephrine challenge, Holter monitoring, and family screening were associated with low yield (<5%), whereas cardiac magnetic resonance imaging, exercise treadmill test, and sodium-channel blocker challenge were associated with high yield (≥5%). Coronary spasm provocation, electrophysiology study, and systematic genetic testing were reported to be abnormal in a high proportion of UCA probands (>10%).

Conclusion: We developed a stepwise algorithm for UCA evaluation and criteria to assess the strength of IVF diagnosis on the basis of the diagnostic yield of UCA testing.
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http://dx.doi.org/10.1016/j.hrthm.2021.03.030DOI Listing
March 2021

High-power, short-duration atrial fibrillation ablation compared with a conventional approach: Outcomes and reconnection patterns.

J Cardiovasc Electrophysiol 2021 May 29;32(5):1219-1228. Epub 2021 Mar 29.

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada.

Background: The effectiveness, safety, and pulmonary vein (PV) reconnection patterns of point-by-point high-power, short-duration (HPSD) ablation relative to conventional force-time integral (FTI)-guided strategies for atrial fibrillation (AF) ablation are unknown.

Objectives: To compare 1-year freedom from atrial arrhythmia (AA), complication rates, procedural times, and PV reconnection patterns with HPSD AF AF ablation versus an FTI-guided low-power, long-duration (LPLD) strategy.

Methods: We compared consecutive patients undergoing a first ablation procedure for paroxysmal or persistent AF. The HPSD protocol utilized a power of 50 W and durations of 6-8 s posteriorly and 8-10 s anteriorly. The LPLD protocol was FTI-guided with a power of ≤25 W posteriorly (FTI ≥ 300g·s) and ≤35 W anteriorly (FTI ≥ 400g·s).

Results: In total, 214 patients were prospectively included (107 HPSD, 107 LPLD). Freedom from AA at 1 year was achieved in 79% in the HPSD group versus 73% in the LPLD group (p = .339; adjusted hazard ratio with HPSD, 0.67; 95% confidence interval, 0.36-1.23; p < .004 for non-inferiority). Procedure duration was shorter in the HPSD group (229 ± 60 vs. 309 ± 77 min; p < .005). Patients undergoing repeat ablation had a higher propensity for reconnection at the right PV carina in the HPSD group compared with the LPLD group (14/30 = 46.7% vs. 7/34 = 20.6%; p = .035). There were no differences in complication rates.

Conclusion: HPSD AF ablation resulted in similar freedom from AAs at 1 year, shorter procedure times, and a similar safety profile when compared with an LPLD ablation strategy. Patients undergoing HPSD ablation required more applications at the right carina to achieve isolation, and had a significantly higher rate of right carinal reconnections at redo procedures.
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http://dx.doi.org/10.1111/jce.14989DOI Listing
May 2021

The Hearts in Rhythm Organization: A Canadian National Cardiogenetics Network.

CJC Open 2020 Nov 29;2(6):652-662. Epub 2020 May 29.

Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Background: The Hearts in Rhythm Organization (HiRO) is a team of Canadian inherited heart rhythm and cardiomyopathy experts, genetic counsellors, nurses, researchers, patients, and families dedicated to the detection of inherited arrhythmias and cardiomyopathies, provision of best therapies, and protection from the tragedy of sudden cardiac arrest.

Methods: Recently, existing disease-specific registries were merged into the expanded National HiRO Registry, creating a single common data set for patients and families with inherited conditions that put them at risk for sudden death in Canada. Eligible patients are invited to participate in the registry and optional biobank from 20 specialized cardiogenetics clinics across Canada.

Results: Currently, there are 4700 participants enrolled in the National HiRO Registry, with an average of 593 participants enrolled annually over the past 5 years. The capacity to enable knowledge translation of research findings is built into HiRO's organizational infrastructure, with 3 additional working groups (HiRO Clinical Care Committee, HiRO Active Communities Committee, and HiRO Annual Symposium Committee), supporting the organization's current goals and priorities as set alongside patient partners.

Conclusion: The National HiRO Registry aims to be an integrated research platform to which researchers can pose novel research questions leading to a better understanding, detection, and clinical care of those living with inherited heart rhythm and cardiomyopathy conditions and ultimately to prevent sudden cardiac death.
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http://dx.doi.org/10.1016/j.cjco.2020.05.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710951PMC
November 2020

The Clinical Utility of Continuous QT Interval Monitoring in Patients Admitted With COVID-19 Compared With Standard of Care: A Prospective Cohort Study.

CJC Open 2020 Nov 22;2(6):592-598. Epub 2020 Jul 22.

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Background: QT interval monitoring has gained much interest during the COVID-19 pandemic because of the use of QT-prolonging medications and the concern about viral transmission with serial electrocardiograms (ECGs). We hypothesized that continuous telemetry-based QT monitoring is associated with better detection of prolonged QT episodes.

Methods: We introduced continuous cardiac telemetry (CCT) with an algorithm for automated QT interval monitoring to our designated COVID-19 units. The daily maximum automated heart rate-corrected QT (Auto-QTc) measurements were recorded. We compared the proportion of marked QTc prolongation (Long-QTc) episodes, defined as QTc ≥ 500 ms, in patients with suspected or confirmed COVID-19 who were admitted before and after CCT was implemented (control group vs CCT group, respectively). Manual QTc measurement by electrophysiologists was used to verify Auto-QTc. Charts were reviewed to describe the clinical response to Long-QTc episodes.

Results: We included 33 consecutive patients (total of 451 monitoring days). Long-QTc episodes were detected more frequently in the CCT group (69/206 [34%] vs 26/245 [11%]; < 0.0001) and ECGs were performed less frequently (32/206 [16%] vs 78/245 [32%]; < 0.0001). Auto-QTc correlated well with QTc measurement by electrophysiologists with an excellent agreement in detecting Long-QTc (κ = 0.8; < 0.008). Only 28% of patients with Long-QTc episodes were treated with recommended therapies. There was 1 episode of torsade de pointes in the control group and none in the CCT group.

Conclusions: Continuous QT interval monitoring is superior to standard of care in detecting episodes of Long-QTc with minimal need for ECGs. The clinical response to Long-QTc episodes is suboptimal.
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http://dx.doi.org/10.1016/j.cjco.2020.07.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374138PMC
November 2020

Atrial Arrhythmias in Clinically Manifest Cardiac Sarcoidosis: Incidence, Burden, Predictors, and Outcomes.

J Am Heart Assoc 2020 09 20;9(17):e017086. Epub 2020 Aug 20.

Division of Cardiology University of Ottawa Heart Institute Ottawa ON Canada.

Background Recent data have suggested a substantial incidence of atrial arrhythmias (AAs) in cardiac sarcoidosis (CS). Our study aims were to first assess how often AAs are the presenting feature of previously undiagnosed CS. Second, we used prospective follow-up data from implanted devices to investigate AA incidence, burden, predictors, and response to immunosuppression. Methods and Results This project is a substudy of the CHASM-CS (Cardiac Sarcoidosis Multicenter Prospective Cohort Study; NCT01477359). Inclusion criteria were presentation with clinically manifest cardiac sarcoidosis, treatment-naive status, and implanted with a device that reported accurate AA burden. Data were collected at each device interrogation visit for all patients and all potential episodes of AA were adjudicated. For each intervisit period, the total AA burden was obtained. A total of 33 patients met the inclusion criteria (aged 56.1±7.7 years, 45.5% women). Only 1 patient had important AAs as a part of the initial CS presentation. During a median follow-up of 49.1 months, 11 of 33 patients (33.3%) had device-detected AAs, and only 2 (6.1%) had a clinically significant AA burden. Both patients had reduced burden after CS was successfully treated and there was no residual fluorodeoxyglucose uptake on positron emission tomography scan. Conclusions First, we found that AAs are a rare presenting feature of clinically manifest cardiac sarcoidosis. Second, AAs occurred in a minority of patients at follow-up; the burden was very low in most patients. Only 2 patients had clinically significant AA burden, and both had a reduction after CS was treated. Registration URL: https://www.clini​caltr​ials.gov; unique identifier NCT01477359.
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http://dx.doi.org/10.1161/JAHA.120.017086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660760PMC
September 2020

Catheter Ablation of Low-Voltage Areas for Persistent Atrial Fibrillation: Procedural Outcomes Using High-Density Voltage Mapping.

Can J Cardiol 2020 12 5;36(12):1956-1964. Epub 2020 Apr 5.

Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Background: Several approaches have been proposed to address the challenge of catheter ablation of persistent atrial fibrillation (AF). However, the optimal ablation strategy is unknown. We sought to evaluate the efficacy of pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation using contemporary high-density mapping to identify LVA in patients with persistent AF.

Methods: Consecutive patients accepted for AF catheter ablation were studied. High-density bipolar voltage mapping data were acquired in sinus rhythm using multipolar catheters to detect LVA (defined as bipolar voltage < 0.5 mV). Semiautomated impedance-based software was used to ensure catheter contact during data collection. Patients underwent PVI + LVA ablation (if LVA present).

Results: A total of 145 patients were studied; 95 patients undergoing PVI + LVA ablation were compared with 50 controls treated with PVI only. Average age was 61 ± 10 years, and 80% were male. Baseline characteristics were comparable. Freedom from atrial tachycardia/AF at 18 months was 72% after PVI + LVA ablation vs 58% in controls (P = 0.022). Median procedure duration (273 [240, 342] vs 305 [262, 360] minutes; P = 0.019) and radiofrequency delivery (50 [43, 63] vs 55 [35, 68] minutes; P = 0.39) were longer in the PVI + LVA ablation group. Multivariable analysis showed that the ablation strategy (PVI + LVA) was the only independent predictor of freedom from atrial tachycardia/AF (hazard ratio, 0.53; 95% confidence interval, 0.29-0.96; P = 0.036). There were no adverse safety outcomes associated with LVA ablation.

Conclusions: An individualized strategy of high-density mapping to assess the atrial substrate followed by PVI combined with LVA ablation is associated with improved outcomes. Adequately powered randomized clinical trials are needed to determine the role of PVI + LVA ablation for persistent AF.
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http://dx.doi.org/10.1016/j.cjca.2020.03.040DOI Listing
December 2020

Guidance on Minimizing Risk of Drug-Induced Ventricular Arrhythmia During Treatment of COVID-19: A Statement from the Canadian Heart Rhythm Society.

Can J Cardiol 2020 06 8;36(6):948-951. Epub 2020 Apr 8.

University of British Columbia, Vancouver, British Columbia, Canada.

The COVID-19 pandemic has led to efforts at rapid investigation and application of drugs which may improve prognosis but for which safety and efficacy are not yet established. This document attempts to provide reasonable guidance for the use of antimicrobials which have uncertain benefit but may increase risk of QT interval prolongation and ventricular proarrhythmia, notably, chloroquine, hydroxychloroquine, azithromycin, and lopinavir/ritonavir. During the pandemic, efforts to reduce spread and minimize effects on health care resources mandate minimization of unnecessary medical procedures and testing. We recommend that the risk of drug proarrhythmia be minimized by 1) discontinuing unnecessary medications that may also increase the QT interval, 2) identifying outpatients who are likely to be at low risk and do not need further testing (no history of prolonged QT interval, unexplained syncope, or family history of premature sudden cardiac death, no medications that may prolong the QT interval, and/or a previous known normal corrected QT interval [QTc]), and 3) performing baseline testing in hospitalized patients or those who may be at higher risk. If baseline electrocardiographic testing reveals a moderately prolonged QTc, optimization of medications and electrolytes may permit therapy. If the QTc is markedly prolonged, drugs that further prolong it should be avoided, or expert consultation may permit administration with mitigating precautions. These recommendations are made while there are no known effective treatments for COVID-19 and should be revisited when further data on efficacy and safety become available.
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http://dx.doi.org/10.1016/j.cjca.2020.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195336PMC
June 2020

A new electrocardiographic definition of left bundle branch block (LBBB) in patients after transcatheter aortic valve replacement (TAVR).

J Electrocardiol 2020 Nov - Dec;63:167-172. Epub 2019 Oct 22.

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada. Electronic address:

Background: Current LBBB definitions cannot always distinguish LBBB from left ventricular conduction delay. Only patients with LBBB are expected to normalize with His bundle pacing. Patients who develop new LBBB immediately post transcatheter aortic valve replacement (TAVR) provide an excellent model to define electrocardiogram (ECG) features of LBBB. We sought to describe their ECG features and develop a new ECG definition of LBBB.

Methods: We screened ECGs from 264 consecutive patients who underwent TAVR at the University of Ottawa Heart Institute. Patients with a baseline QRS of ≤100 ms who developed QRS ≥120 ms immediately after TAVR were included. Two electrocardiologists reviewed all ECG independently. Baseline demographics and echocardiographic data were retrospectively collected.

Results: 36 patients were included in the analysis. The median age was 85.5 years (IQR, 81.8-89 years) and 52.8% were males. The minimum QRS duration was 126 ms. The median QRS axis was -18° (IQR, -40-4.5°), which is 18.5° leftward compared to the median QRS axis before TAVR. Fourteen patients (38.9%) had left axis deviation. All patients had a notched/slurred R wave in at least one lateral lead and an R wave duration of ≤20 ms in V1 when present.

Conclusion: We developed a new ECG definition of LBBB that includes 2 novel findings: notching/slurring of the R wave in at least one lateral lead and an R wave ≤20 ms in V1. Further larger studies are warranted to confirm these findings.
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http://dx.doi.org/10.1016/j.jelectrocard.2019.10.005DOI Listing
June 2021

A Strategy of Lead Abandonment in a Large Cohort of Patients With Sprint Fidelis Leads.

JACC Clin Electrophysiol 2019 09 28;5(9):1059-1067. Epub 2019 Aug 28.

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada. Electronic address:

Objectives: This study sought to examine outcomes of our approach to managing a large cohort of patients with Sprint Fidelis (Medtronic, Minneapolis, Minnesota) leads.

Background: The optimal management approach for patients with leads under advisory is unknown. Concerns regarding the risk of device infection and complications associated with delaying lead extraction have recently been suggested to argue against abandoning leads under advisory.

Methods: All patients with a Sprint Fidelis lead implanted at our institute were included. Lead management options were discussed with patients who presented for device surgery at the time of device upgrade, lead fracture, or elective replacement indicator. Implantation of a new lead with abandonment of the Sprint Fidelis lead was the recommended strategy. Patients were subsequently followed at the device clinic at 6-month intervals and were enrolled prospectively in a longitudinal registry.

Results: A total of 520 patients had Sprint Fidelis leads implanted between December 2003 and October 2007 at the study center; 217 patients underwent lead replacement (213 underwent a lead abandonment strategy and 4 underwent a lead extraction strategy). Mean follow-up after lead replacement was 55 ± 33 months. In patients undergoing lead abandonment, 10 of 213 (4.7%) had a procedural complication and 3 of 213 (1.4%) developed subsequent device infection requiring system extraction.

Conclusions: In patients with a Sprint Fidelis lead, implanting a new lead without prophylactic extraction may be a feasible and safe strategy but requires longer follow-up.
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http://dx.doi.org/10.1016/j.jacep.2019.07.006DOI Listing
September 2019

The echocardiographic assessment of the right ventricle in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia compared with athletes and matched controls.

Echocardiography 2019 04 18;36(4):666-670. Epub 2019 Mar 18.

Harry Perkins Institute of Medical Research and Fiona Stanley Hospital, The University of Western Australia, Perth, Western Australia, Australia.

Background: There are discrepancies in the quantitative echocardiographic criteria for the right ventricle (RV) between the revised task force criteria (TFC) for Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia (ARVC/D) and the guidelines for RV assessment endorsed by American Society of Echocardiography (ASE). Importantly, these criteria do not take into account potential adaptation of the RV to exercise. The goal of this study was to compare the revised TFC quantitative echocardiographic parameters in patients with ARVC/D, athletes and matched controls.

Methods: Echocardiographic parameters of the RV were retrospectively collected in patients who fulfilled the TFC for ARVC/D, an age- matched, sex-matched, and body surface area-matched control population, and athletes (defined as individuals who exercised for more than 7 hours per week). Patients with structural heart disease were excluded in the control and athlete groups.

Results: Twenty patients with ARVC/D, 11 athletes and 20 matched controls were included. There was no significant difference between ARVC/D patients and athletes with the exception of the parasternal long axis right ventricular outflow tract diameter. All parameters were significantly different between ARVC/D patients and the control group. Furthermore, when subjects were categorized into meeting 1 major revised TFC/abnormal ASE criteria or not, only ASE criteria were able to differentiate ARVC/D from control population. Both were unable to differentiate ARVC/D from athletes.

Conclusions: Right ventricle quantitative echocardiographic criteria in the revised TFC are not specific for ARVC/D. Care should be taken in applying these criteria in athletes.
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http://dx.doi.org/10.1111/echo.14308DOI Listing
April 2019

Disease modeling of cardiac arrhythmias using human induced pluripotent stem cells.

Expert Opin Biol Ther 2019 04 7;19(4):313-333. Epub 2019 Feb 7.

a Division of Cardiology, Department of Medicine , University of Ottawa Heart Institute , Ottawa , Canada.

Introduction: Inherited arrhythmias are an uncommon, but malignant family of cardiac diseases that result from genetic abnormalities in the ion channels and/or structural proteins within cardiomyocytes. Given the inherent differences between species and the limited reproducibility of in vitro heterologous cell models, progress in understanding the mechanisms underlying these malignant diseases has always languished far behind the clinical science and need. The ability to study human induced pluripotent stem cells (iPSCs) derived cardiomyocytes promises to change this paradigm as patient cells have the potential to become testing platforms for disease phenotyping or therapeutic discovery.

Areas Covered: This review will outline methods developed to genetically reprogram adult cells into iPSCs, differentiate iPSCs into ex vivo models of adult cardiac tissue and iPSCs-based progress in exploring the mechanisms underlying pro-arrhythmic disease phenotypes.

Expert Opinion: Despite being discovered less than 15 years ago, several studies have successfully leveraged iPSCs-derived cardiomyocytes to study malignant arrhythmogenic diseases. These models promise to increase our understanding of the pathophysiology underlying these complex diseases and may identify personalized approaches to treatment.
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http://dx.doi.org/10.1080/14712598.2019.1575359DOI Listing
April 2019

Mitral valve repair results in suppression of ventricular arrhythmias and normalization of repolarization abnormalities in mitral valve prolapse.

HeartRhythm Case Rep 2018 May 2;4(5):191-194. Epub 2018 Mar 2.

Echocardiography Laboratory, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada.

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http://dx.doi.org/10.1016/j.hrcr.2018.02.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003536PMC
May 2018

Prevalence of left atrial appendage thrombus detected by transoesophageal echocardiography before catheter ablation of atrial fibrillation in patients anticoagulated with non-vitamin K antagonist oral anticoagulants.

Europace 2019 Jan;21(1):48-53

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada.

Aims: There is ongoing controversy about the need for routine transoesophageal echocardiography (TOE) prior to atrial fibrillation (AF) ablation. Recently, the debate was reignited by the publication of a large series of patients showing a prevalence of left atrial appendage thrombus (LAAT) on TOE of 4.4%. We sought to assess the prevalence of LAAT on TOE before AF ablation at our institution.

Methods And Results: Consecutive patients scheduled for AF ablation at our institution between January 2009 and December 2016 were included. All patients were on oral anticoagulation for at least 4 weeks prior to TOE. Transoesophageal echocardiographies were performed 3-5 days prior to scheduled AF ablation. Data were collected utilizing a prospective database. In all, 668 patients and 943 AF ablation procedures were included. Mean age was 64 ± 11 years, 72% were male, average CHADS2 score was 1.0 ± 1.0, and 72% of the patients had paroxysmal AF. At the time of ablation, 496 (53%) were on non-vitamin K antagonist oral anticoagulants (NOACs) and 447 (47%) were on Warfarin. There were three cases with LAAT (3/943, 0.3%), all of whom had persistent AF and were on Warfarin. Two patients underwent surgical ablation and the third patient did not undergo ablation.

Conclusion: In our experience, the prevalence of LAAT in patients on anticoagulation therapy undergoing TOE before catheter ablation of AF is 0.3%, which was much lower than recently reported. None of the patients with paroxysmal AF or on NOACs were found to have LAAT. Rather than routine use of TOE prior to AF ablation, a risk-based approach should be considered.
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http://dx.doi.org/10.1093/europace/euy129DOI Listing
January 2019

Three-year outcomes and reconnection patterns after initial contact force guided pulmonary vein isolation for paroxysmal atrial fibrillation.

J Cardiovasc Electrophysiol 2017 Sep 1;28(9):984-993. Epub 2017 Sep 1.

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Canada.

Background And Objective: Contact force (CF) sensing is a novel technology used for catheter ablation of atrial fibrillation (AF). We compared the single procedure success of CF-guided pulmonary vein isolation (PVI) with that of non-CF guided PVI during a 3-year (1,095 days) follow up period and analyzed the pattern of pulmonary vein (PV) reconnection.

Methods: A cohort of 167 subjects (68 CF vs. 99 non-CF) with paroxysmal AF were included in the study. Atrial arrhythmia (AA) recurrence was defined as documented AF, atrial flutter, or atrial tachycardia lasting >30 seconds and occurring after 90 days.

Results: Subjects in the CF group showed a statistically nonsignificant improvement in AA free survival compared to those in the non-CF group (66.2% vs. 51.5%; P value: 0.06). A greater propensity for reconnection was noted around the right-sided PVs compared to left-sided PVs related in both catheter ablation groups. For example, in the CF group 36% of right-sided segments reconnected compared to 16% of left-sided segments (P value <0.01).

Conclusions: A greater propensity for reconnection was noted around the right sided PV segments in both the CF and non-CF groups. The explanation for this finding was related to greater catheter instability around the right sided veins. Further research is needed to explore the utility of a "real-time" composite indicator that includes RF energy, CF and catheter stability in predicting transmural lesion formation during catheter ablation.
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http://dx.doi.org/10.1111/jce.13280DOI Listing
September 2017

Identifying and Managing Premature Ventricular Contraction-Induced Cardiomyopathy: What, Why, and How?

Can J Cardiol 2017 02 1;33(2):287-290. Epub 2016 Jul 1.

Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Premature ventricular contraction (PVC)-induced cardiomyopathy is increasingly being recognized as a reversible cause of left ventricular (LV) systolic dysfunction (LVSD). The diagnosis of PVC-induced cardiomyopathy is considered in subjects with high PVC burdens (> 10,000 per 24 hours) after excluding other known causes of LVSD. PVC suppression is the mainstay of the management of PVC-induced cardiomyopathy, in addition to proven evidence-based medical therapy recommended for subjects with LVSD. Management strategies for PVC-induced cardiomyopathy include medical therapy and/or catheter ablation, with an increasing role for catheter ablation as a first-line therapy in view of the potential for permanent suppression of PVCs. Recovery of LVSD is typically a gradual process over months after effective suppression of PVCs. Last, asymptomatic patients with high PVC burdens and preserved LV systolic function appear to be at low risk over the intermediate term for developing LVSD. However, it is prudent to monitor LV function periodically because of the potential for deterioration of LV function observed during long-term follow-up in some subjects.
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http://dx.doi.org/10.1016/j.cjca.2016.06.010DOI Listing
February 2017

Weight loss · diarrhea · mild eosinophilia · Dx?

J Fam Pract 2015 Mar;64(3):174-6

Lawrence S. Bloomberg Faculty of Nursing, Department of Medicine, Department of Health Policy, Management and Evaluation, Public Health Sciences, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.

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March 2015

Prognostic implications of prominent R wave in electrocardiographic leads V1 or V2 in patients with acute coronary syndrome.

Am J Cardiol 2014 Jun 1;113(12):1962-7. Epub 2014 Apr 1.

Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael's Hospital, Toronto, Canada; University of Toronto, Toronto, Canada. Electronic address:

Although the adverse prognosis of Q-waves on electrocardiogram (ECG) has been demonstrated, the prognostic significance of prominent R wave (PRW) in V1 or V2 across a broad spectrum of acute coronary syndrome (ACS) has not been specifically studied. In the Global Registry of Acute Coronary Events (GRACE) and the Canadian ACS Registry I ECG substudies, admission ECGs were analyzed in an independent core ECG laboratory. PRW was defined as R wave >40 to 50 ms in V1 or V2, R/S ≥1 in V1, or R/S ≥1.5 in V2. Among 11,895 patients with ACS, 495 (4.2%) had PRW; they were less likely to have a history of hypertension or heart failure and had lower GRACE risk scores, but a higher incidence of ST-segment depression (all p ≤0.001). Patients with PRW had similar rates of in-hospital death (2.8% vs 4.1%, respectively, p = 0.15) but lower rates of in-hospital heart failure (8.5% vs 15.2%, respectively, p = 0.02) and 6-month mortality (4.6% vs 8.4%, respectively, p = 0.004). In multivariable analyses, PRW was not a significant independent predictor of in-hospital mortality (adjusted odds ratio = 0.99, 95% confidence interval 0.55 to 1.8) or 6-month mortality (adjusted odds ratio = 0.70, 95% confidence interval 0.43 to 1.15). Among 4,418 patients who underwent coronary angiography, those with PRW had a higher prevalence of left circumflex artery disease (62.5% vs 49.5%, respectively, p = 0.01). In conclusion, across the broad spectrum of patients with ACS, PRW provides no significant additional prognostic utility beyond comprehensive risk assessment using the GRACE risk score. PRW is more frequently associated with left circumflex artery disease.
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http://dx.doi.org/10.1016/j.amjcard.2014.03.035DOI Listing
June 2014