Computational intraprocedure methods can automatically identify the segment and site of left ventricular activation using novel algorithms, with accuracy within <10 mm.

Background Early and accurate risk assessment is an important clinical demand in patients with infective endocarditis (IE). The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are independent predictors of prognosis in many infectious and cardiovascular diseases. Very limited studies have been conducted to evaluate the prognostic role of these markers in IE. Results We analyzed clinical, laboratory, and echocardiographic data and outcomes throughout the whole period of hospitalization for a total of 142 consecutive patients with definitive IE. The overall in-hospital mortality was 21%. Major complications defined as central nervous system embolization, fulminant sepsis, acute heart failure, acute renal failure, and major artery embolization occurred in 38 (27%), 34 (24%), 32 (22.5%), 40 (28%), and 90 (63.4%) patients, respectively. The NLR, total leucocyte count (TLC), neutrophil percentage, creatinine, and C-reactive protein (CRP) level obtained upon admission were significantly higher in the mortality group [p ≤ 0.001, p = 0.008, p = 0.001, p = 0.004, and p = 0.036, respectively]. A higher NLR was significantly associated with fulminant sepsis and major arterial embolization [p = 0.001 and p = 0.028, respectively]. The receiver operating characteristic (ROC) curve of the NLR for predicting in-hospital mortality showed that an NLR > 8.085 had a 60% sensitivity and an 84.8% specificity for an association with in-hospital mortality [area under the curve = 0.729, 95% confidence interval (CI) 0.616–0.841; p = 0.001]. The ROC curve of the NLR for predicting severe sepsis showed that an NLR > 5.035 had a 71.8% sensitivity and a 68.5% specificity for predicting severe sepsis [area under the curve 0.685, 95% CI 0.582–0.733; p = 0.001]. The PLR showed no significant association with in-hospital mortality or in-hospital complications. Conclusion A higher NLR, TLC, neutrophil percentage, creatinine level, and CRP level upon admission were associated with increased in-hospital mortality and morbidity in IE patients. Furthermore, a lower lymphocyte count/percentage and platelet count were strong indicators of in-hospital mortality among IE patients. Calculation of the NLR directly from a CBC upon admission may assist in early risk stratification of patients with IE.

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proarrhythmia, PVC response, implantable cardiovertor defibrillator, atrial pace on PVC Case PresentationA 62-year-old man presented to the hospital following an episode of syncope and implantable cardiovertor defibrillator (ICD) shock. He was known to have ischemic cardiomyopathy, prior coronary artery bypass grafting in 2007, and a dual-chamber ICD, a Current Accel DR (St. Jude Medical, Inc., Minneapolis, MN, USA) implanted in 2009 following a ventricular fibrillation (VF) arrest.Device interrogation revealed a VF episode that was successfully terminated with a 36-J shock. Testing of the atrial and ventricular leads demonstrated adequate pace/sense function and normal lead impedances. Device parameters were as follows: DDD mode with a base rate of 40 beats per minute (rate response sensor was passive), postventricular atrial refractory period (PVARP) was 275 ms, ventricular intrinsic preference (VIP) was enabled and programmed to 100-ms extension (a setting to prolong the atrioventricular [AV] delay and permit intrinsic conduction), and premature ventricular contraction (PVC)/pacemakermediated tachycardia responses were enabled. Tachycardia detection was set to three zones, with the ventricular tachycardia 1 (VT1) zone starting at 375 ms, VT2 starting at 320 ms, and VF zone starting at 280 ms. Therapy was programmed with antitachycardia pacing followed by shocks in the first two zones and shocks only in the VF zone. The presenting episode is shown in Figure 1. What is the most likely mechanism of initiation of this VF episode; is it likely related to the underlying Conflict of interest:

Left atrial ablation has become more commonplace with the advent of catheter ablation for atrial fibrillation. A number of transseptal sheaths have been produced to enhance safe and efficient catheter manipulation in the left atrium (LA) for these procedures. Some of the sheaths have been subject to recall due to partial or complete detachment of its radiopaque tip. We report a case of a 46 year-old female diagnosed with idiopathic dilated cardiomyopathy that presented with atypical left atrial flutter. During electrophysiologic study, a Swartz braided SL1 (SL-1) transseptal sheath was used to introduce the ablation catheter to the left atrium. During left atrial mapping, the radiopaque tip of the sheath detached from the rest of the sheath and was seen floating in the LA. After exchanging the SL-1 sheath with a deflectable sheath, the detached segment was retrieved out of the LA and eventually out of the vascular system using an angioplasty balloon advanced over a wire and inflated distal to the lumen of the detached tip. The root cause of this malfunction was found to be lack of a secondary bonding process that these sheaths generally undergo during the manufacturing process. We describe the case of a left atrial ablation procedure where a novel percutaneous method was able to successfully retrieve the detached tip of a transseptal sheath from the vascular system, thereby avoiding a potential catastrophic complication or thoracotomy. This method may be useful in other cases where similar circumstances may present.