In patients with advanced HF and severe systolic dysfunction: (1) a significant reduction of MSNA (at rest and during handgrip) occurred after CRT, and this behavior was significantly superior to HF patients receiving only medical therapy; (2) MSNA reduction after CRT had an inverse correlation with O2 consumption outcomes.

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Glossopharyngeal neuralgia is an uncommon condition that has rarely been described in association with syncope. We report here 2 cases of glossopharyngeal neuralgia in elderly patients. Both were male and underwent temporary pacemaker insertion to prevent syncopal episodes. We discuss the clinical and surgical treatment of glossopharyngeal neuralgia, the role of cardiac stimulation, and the possible physiopathological mechanism of the associated cardiac disturbances.

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We report the case of a 42-year-old female with fatigue on exertion and palpitation consequent to the existence of isolated noncompaction of the myocardium. We discuss clinical and familial findings, diagnostic possibilities, and prognostic and therapeutical implications of this rare disorder of endomyocardial morphogenesis.During the initial phase of embryonic development, the heart is a trabecular net with a spongy myocardium. The intertrabecular spaces communicate with the cardiac chambers. As the heart develops, the myocardium condenses and the intertrabecular recesses are reduced to capillaries. Trabecular compaction is usually more complete in the left ventricle than in the right ventricle. Noncompaction of the ventricular myocardium is defined as an anomaly of endomyocardial morphogenesis, and it is believed to be an arrest in the compaction of the myocardial fibers, which meet forming an interwoven loose net during intrauterine life. Persistence of the noncompaction of the myocardium is a rare entity, usually diagnosed in the pediatric population and associated with other structural congenital malformations of the heart. It predominates in patients with congenital obstruction of the right or left ventricle outflow tract [1][2][3][4] . Isolated noncompaction of the myocardium, defined by absence of any other associated structural cardiac alteration, is an even rarer form of the entity, with only a few reports in the literature [5][6][7][8] . Isolated noncompaction of the myocardium may be identified from childhood to adulthood. Its diagnosis may be delayed because of some findings resembling other clinical entities. Both sexes may be affected and familial recurrence may occur.We report the case of a 42-year-old female with isolated noncompaction of the myocardium, describing the clinical and familial history, diagnostic possibilities, and therapeutical approach. We also review the literature about this rare disorder of endomyocardial morphogenesis. Case reportA 42-year-old female complaining of fatigue on medium exertion, chest pain, and palpitation for 10 years was referred to our service to investigate arrhythmia. She reported loosing 2 children in the first year of life, one due to sudden death at the age of 5 months and the other due to refractory heart failure in the first week of life. The anatomicopathological study of the latter child performed in another service showed a dilated left ventricle with increased and abnormal trabeculation, whose final diagnosis, at the time, was cardiomyopathy of undetermined etiology. She also reported two siblings who had sudden death during childhood, and one uncle and one cousin, who died due to refractory congestive heart failure. The physical examination was normal. The 12-lead electrocardiogram showed sinus rhythm and deviation of the axis to the right in the frontal plane without meeting the criteria of left posteroinferior divisional heart block (figura 1A). Chest X-ray was normal. The exercise test showed depression of the ST segment associated with typical...

Introduction The muscular metaboreflex, whose activation regulates blood flow during isometric and aerobic exercise, is blunted in patients with heart failure (HF), and cardiac resynchronization therapy (CRT) may restore this regulatory reflex. Objective To evaluate metaboreflex responses after CRT. Methods Thirteen HF patients and 12 age‐matched healthy control subjects underwent the following evaluations (pre‐ and post‐CRT implantation in the patient group): (a) heart rate, blood pressure, and forearm blood flow measurements; (b) muscle sympathetic nerve activity (MSNA) evaluation; and (c) peak oxygen consumption (VO2peak). Examinations were performed at rest, during moderate isometric exercise (IE), and during forearm ischemia (metaboreflex activation). The primary outcome was the increment in MSNA during limb ischemia compared to the rest moment (ΔMSNA rest to metaboreflex activation). Results After CRT, rest MSNA decreased in the HF participants: 50.4 ± 9.2 bursts/min pre‐CRT vs 34.0 ± 14.4 bursts/min post‐CRT, P = .001, accompanied by an improvement in systolic blood pressure and in rate‐pressure product. MSNA during limb ischemia decreased: 56.6 ± 11.5 bursts/min pre‐CRT vs 43.6 ± 12.7 bursts/min post‐CRT, P = .001, and the ΔMSNA rest to metaboreflex activation increased: 0% (interquartile range [IQR)], −7 to 9) vs 13% (IQR, 5‐30), P = .03. An augmentation of mean blood pressure during limb ischemia post‐CRT was noticed: 94 mmHg (IQR, 81‐104) vs 110 mmHg (IQR, 100‐117), P = .04. CRT improved VO2peak, and this improvement was correlated with diminution in ΔMSNA pre‐ to post‐CRT at rest moment (rs = ‐0.74, P = .006). Conclusion CRT provides metaboreflex sensitization and MSNA enhancement. The restoration of sympathetic responsiveness correlates with the improvement in functional capacity.

and the * Cardiovascular Research and Teaching Institute Aalst, Aalst, Belgium LORGA, A., ET AL.: Electrocardiographic Identification of Mid-Septal Accessory Pathways in Close Prox-imity to the Atrioventricular Conduction System. In order to identify ECG characteristics of overt midseptal accessory pathways (APs) predictive of dose proximity to the AV conduction system we analyzed data from patients who underwent successful RF catheter ablation of a mid-septa! AP. Mean patient age was 31 ^ 16 years, and 13 were male. The 40° right anterior oblique view was used to divide the mid-septal area into 3 zones: 1 (anterior portion); 2 (intermediate): and 3 (posterior portion). The 12-lead ECG was analyzed with regard to delta wave polarity and R/S transition in the precordial leads. The findings from patients ablated at zone 3 were compared to those at zones 1 and 2. All patients had a positive delta wave in the leads I. II, aVL, and negative delta wave in the leads III and aVR. The R/S transition occurred in lead V-, in 80% of patients. The delta wave in lead aVF was the only ECG characteristic that correlated with the AP ablation zone. Six of 8 patients ablated at zone 3 had a negative delta wave in lead aVF while 6 out of 7 patients ablated at zone 1 or 2 had a positive or isoelectric delta wave in lead aVE (P = 0.03). A positive or isoelectric delta wave in lead aVF identifies mid-septal AP in close proximity to the AV conduction system.

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