AimsPatients with repaired tetralogy of Fallot (rTOF) have an increased risk of ventricular tachycardia (VT), with slow conducting anatomical isthmus (SCAI) 3 as dominant VT substrate. In patients... Show moreAimsPatients with repaired tetralogy of Fallot (rTOF) have an increased risk of ventricular tachycardia (VT), with slow conducting anatomical isthmus (SCAI) 3 as dominant VT substrate. In patients with right bundle branch block (RBBB), SCAI 3 leads to local activation delay with a shift of terminal RV activation towards the lateral RV outflow tract which may be detected by terminal QRS vector changes on sinus rhythm electrocardiogram (ECG).Methods and resultsConsecutive rTOF patients aged ≥16 years with RBBB who underwent electroanatomical mapping at our institution between 2017–2022 and 2010–2016 comprised the derivation and validation cohort, respectively. Forty-six patients were included in the derivation cohort (aged 40±15 years, QRS duration 165±23 ms). Among patients with SCAI 3 (n = 31, 67%), 17 (55%) had an R″ in V1, 18 (58%) had a negative terminal QRS portion (NTP) ≥80 ms in aVF, and 12 (39%) had both ECG characteristics, compared to only 1 (7%), 1 (7%), and 0 patient without SCAI, respectively.Combining R″ in V1 and/or NTP ≥80 ms in aVF into a diagnostic algorithm resulted in a sensitivity of 74% and specificity of 87% in detecting SCAI 3. The inter-observer agreement for the diagnostic algorithm was 0.875. In the validation cohort [n = 33, 18 (55%) with SCAI 3], the diagnostic algorithm had a sensitivity of 83% and specificity of 80% for identifying SCAI 3.ConclusionA sinus rhythm ECG-based algorithm including R″ in V1 and/or NTP ≥80 ms in aVF can identify rTOF patients with a SCAI 3 and may contribute to non-invasive risk stratification for VT. Show less
First the VG-RVPO as a monitoring for PAH in SSc patients was evaluated, here serial measurements of the VG-RVPO, can be used as a follow-up instrument to detect early changes in RV pressure over... Show moreFirst the VG-RVPO as a monitoring for PAH in SSc patients was evaluated, here serial measurements of the VG-RVPO, can be used as a follow-up instrument to detect early changes in RV pressure over time. Then we investigated the role of the VG-RVPO in improving the efficiency of the YEARS algorithm. Neither as a stand-alone diagnostic test nor when combined with the YEARS algorithm, it had any diagnostic value. Then the role of VG-RVPO in estimating the presence of PH, and the prognostic value of an abnormal VG-RVPO in PE patients was evaluated. There was an association between VG-RVPO and RV overload as measured by CTPA. In Chapter 5, the outcome of AAOCA patients is described and linked to pre-and postoperative symptoms. Overall, surgical correction significantly reduces symptoms. The CTOA on pre-and post-operative CTAs of patients with AAOCA was compared and related to anatomy and post-operative outcome. It suggests that CTA can be used to look at the anatomy of AAOCA patients before and after surgery. The last study re-evaluates the late clinical outcome and hemodynamics in patients with TOF. The findings shows, after 17.1 years there was a stabilization of RV function and an impressive durability of the homograft. Show less
Aim Heart rate (HR) is the most important parameter to evaluate newborns' clinical condition and to guide intervention during resuscitation at birth. The present study aims to compare the accuracy... Show moreAim Heart rate (HR) is the most important parameter to evaluate newborns' clinical condition and to guide intervention during resuscitation at birth. The present study aims to compare the accuracy of NeoBeat dry-electrode ECG for HR measurement with conventional ECG and pulse oximetry (PO). Methods Newborns with a gestational age >= 32 weeks and/or birth weight >= 1.5 kg were included when HR evaluation was needed. HR was simultaneously measured for 10 min with NeoBeat, PO and conventional ECG. Results A total of 18 infants were included (median (IQR) gestational age 39 (36-39) weeks and birth weight 3 150 (2 288-3 859) grams). Mean (SD) duration until NeoBeat obtained a reliable signal was 2.5 (9.0) s versus 58.5 (171.0) s for PO. Mean difference between NeoBeat and ECG was 1.74 bpm (LoA -4.987-8.459 and correlation coefficient 0.98). Paired HR measurements over 30-s intervals revealed no significant difference between NeoBeat and ECG. The positive predictive value of a detected HR <100 bpm by NeoBeat compared with ECG was 54.84%, negative predictive value 99.99%, sensitivity 94.44%, specificity 99.99% and accuracy 99.85%. Conclusions HR measurement with NeoBeat dry-electrode ECG at birth is reliable and accurate. Show less
Introduction We investigated improvement of electrocardiographic LVH detection by adding measures of adiposity and/or novel electrocardiographic measures. Left ventricular hypertrophy (LVH) is an... Show moreIntroduction We investigated improvement of electrocardiographic LVH detection by adding measures of adiposity and/or novel electrocardiographic measures. Left ventricular hypertrophy (LVH) is an important risk factor for adverse cardiovascular outcomes. Improvement of electrocardiographic criteria for LVH is desirable, since electrocardiography is widely used. Methods We included 1091 participants of the Netherlands Epidemiology of Obesity Study (NEO) who underwent cardiac magnetic resonance imaging (MRI). Performance of Sokolow-Lyon and Cornell voltage and product criteria was assessed. Stepwise regression analysis was performed with each conventional electrocardiographic criterion and age, sex, body mass index (BMI), waist circumference, and waist:hip ratio (p-entry < 0.05, p-removal > 0.10). T-wave abnormalities or the spatial QRS-T angle (SA) were added to the improved models. Results The study population had a mean (SD) age of 56 (6) years, BMI of 26.1 (4.0) kg/m(2) and 46% were men. MRI-LVH was present in 10% of participants. The c-statistic for Sokolow-Lyon voltage was 0.58, R-2 was 0.02 and sensitivity at 90% specificity was 16%, for Sokolow-Lyon product this was 0.62, 0.02, and 21%, for Cornell voltage 0.65, 0.04, and 28% and for Cornell product 0.67, 0.04, and 25%. Best performing models were obtained by addition of both BMI and SA (Sokolow-Lyon voltage: c-statistic 0.74, R-2 0.11, sensitivity of 41% at 90% specificity; Sokolow-Lyon product: 0.75, 0.12, 42%; Cornell voltage: c-statistic 0.70, R-2 0.08, sensitivity of 38% at 90% specificity; Cornell product: c-statistic 0.72, R-2 0.08, sensitivity of 44% at 90% specificity). Conclusions Electrocardiographic detection of LVH improved by adding BMI and SA to a model with conventional electrocardiographic criteria. This approach would require little extra effort and application in clinical practice is feasible. However, results should first be replicated in high-risk populations. Show less
This thesis provides insight in the impact of congenital and acquired heart diseases on electrophysiology and hemodynamics in the heart, that could help understand the often complex... Show moreThis thesis provides insight in the impact of congenital and acquired heart diseases on electrophysiology and hemodynamics in the heart, that could help understand the often complex pathophysiological mechanisms involved in cardiovascular diseases and might aid in the early detection of patients prone to cardiovascular deterioration. The first part of this thesis shows the value of the electrocardiogram and vectorcardiogram in the assessment of patients with right-sided acquired and congenital heart defects. The 3D vectorcardiographic VG and SA could be valuable in the assessment of patients with right ventricular volume or pressure overload. The second part of this thesis shows significant steps towards clinical utility of 4D flow MRI. Valvular flow quantification with 4D flow MRI, especially in combination with automated valve tracking, has great potential as a future clinical standard. The third part of this thesis provides important insights in intraventricular hemodynamics in Fontan patients. In time to come, knowledge on intraventricular hemodynamics could aid in determining follow-up frequency and the ideal timing of initiation of heart failure management, perhaps even on an individual patient’s level. Moreover, these findings can create a platform for further research in the field of intraventricular hemodynamics in healthy subjects and different patient groups. Show less
In this thesis, the importance of visceral obesity in the relation of obesity with cardiometabolic risk factors (chapter 2) was confirmed and it was shown that in individuals free of known... Show moreIn this thesis, the importance of visceral obesity in the relation of obesity with cardiometabolic risk factors (chapter 2) was confirmed and it was shown that in individuals free of known cardiovascular disease clustering of cardiometabolic risk factors is associated with changes in electrocardiographic parameters indicative of subclinical cardiovascular disease (chapter 3). The findings from chapter 3 also point to the importance of the prevention of these metabolic syndrome components, not only in obese, but also in non-obese individuals. Furthermore, both overall and abdominal adiposity were found to be associated with these deleterious changes in electrocardiographic parameters (chapter 4). Borderline Q-waves were associated with a negative cardiovascular risk profile and increased pulse wave velocity and intima-media thickness (chapter 5). Chapter 6 shows that several cardiovascular risk factors were associated with a wider spatial QRS-T angle, which reflects ventricular electrophysiological heterogeneity. Both carotid intima-media thickness, as measure of subclinical atherosclerosis, and pulse wave velocity, as measure of arterial stiffness, were associated with a wider spatial QRS-T angle. In chapter 7, improvement of electrocardiographic detection of left ventricular hypertrophy with conventional electrocardiographic criteria by taking into account body mass index and the spatial QRS-T angle is shown. Show less
Background: In western societies, atrial fibrillation is an increasingly common finding among the elderly. Established risk factors of atrial fibrillation include obesity, diabetes, hypertension,... Show moreBackground: In western societies, atrial fibrillation is an increasingly common finding among the elderly. Established risk factors of atrial fibrillation include obesity, diabetes, hypertension, and cardiovascular disease. Atrial fibrillation has almost exclusively been studied in western populations where these risk factors are widely present. Therefore, we studied the epidemiology of atrial fibrillation in a traditional African community. Methods: In rural Ghana, among 924 individuals aged 50 years and older, we recorded electrocardiograms to detect atrial fibrillation. As established risk factors, we documented waist circumference, body mass index (BMI), capillary glucose level, blood pressure, and electrocardiographic myocardial infarction. In addition, we determined circulating levels of interleukin-6 (IL6), a proinflammatory cytokine, and C-reactive protein (CRP), a marker of systemic inflammation. We compared the risk factors with reference data from the USA. Results: Atrial fibrillation was detected in only three cases, equalling 0.3% (95% CI 0.1–1.0%). Waist circumference, BMI, and capillary glucose levels were very low. Hypertension and myocardial infarction were uncommon. Circulating levels of IL6 were similar, but those of CRP were lower compared with the USA. Conclusion: Atrial fibrillation is very scarce in this traditional African community. Its low prevalence compared with western societies can be explained by the rareness of its established risk factors, which are closely related to lifestyle, and by possible unmeasured differences in other risk factors or genetic factors. Show less
The aim of this thesis was to further characterize the right ventricle within three different fields of cardiovascular research: 1. Embryonic development, 2: Non-invasive right ventricular imaging,... Show moreThe aim of this thesis was to further characterize the right ventricle within three different fields of cardiovascular research: 1. Embryonic development, 2: Non-invasive right ventricular imaging, 3: Right ventricular electrocardiography. In part I, several aspects of embryonic development, relevant for normal right ventricular morphology and function are investigated. In chapter 2, a novel concept for normal development of the right ventricular outflow tract is introduced. In chapter 3, the potential relevance of epicardium-derived cells for the difference between left and right ventricular morphology is discussed. Non-invasive imaging techniques are evaluated in part II. In chapter 4, the use of conventional semi-quantitative measurement of right ventricular function in patients with transposition of the great arteries is analyzed. The relevance of abnormal response to stress, measured with cardiovascular magnetic resonance imaging, is investigated in chapter 5. Chapters 6-8 demonstrate how strain measurement can be used in various types of (suspected) right ventricular disease. In part III, both conventional electrocardiography as well as computerized vectorcardiography is described in patients with right v entricular disease. A case-study of conventional electrocardiographic assessment of right ventricular pressure overload is provided in chapter 9. The prognostic value of QRS duration in patients with tetralogy of Fallot who undergo pulmonary valve replacement, is demonstrated in chapter 10. Chapter 11 and 12 discuss the application of ECG-derived vectorcardiography in normal subjects and suspected pulmonary arterial hypertension patients Show less
Hoogendijk, M.G.; Potse, M.; Linnenbank, A.C.; Verkerk, A.O.; Ruijter, H.M. den; Amersfoorth, S.C.M. van; ... ; Coronel, R. 2010
Right ventricular overload covers a spectrum ranging from volume overload to pressure overload, and often is a combination of these, compromising cardiac function. Part I focuses on right... Show moreRight ventricular overload covers a spectrum ranging from volume overload to pressure overload, and often is a combination of these, compromising cardiac function. Part I focuses on right ventricular volume overload in adults with Fallot__s tetralogy corrected in early childhood. We determined which patient characteristics are associated with a more prompt recovery time after surgical pulmonary valve replacement. Furthermore, we analyzed what may be expected from pulmonary valve replacement with respect to right ventricular reverse remodeling. We also determined that pulmonary valve replacement has a positive effect on myocardial repolarization characteristics in adult Fallot patients. Part II addresses right ventricular pressure overload due to pulmonary arterial hypertension. Development of pulmonary arterial hypertension in rats induced characteristic evolutionary changes in right ventricular morphology and function, as monitored with electrocardiography, echocardiography, and heart catheterization. The documented evolutionary electrocardiographic changes in evolving right ventricular pressure overload in rats were similar to the abnormalities found in patients with varying degrees of pulmonary arterial hypertension. Electrocardiographic cut-off points can be useful for monitoring treatment response in pulmonary arterial hypertension patients. Finally, resting heart rate, reflecting hemodynamics and neurohumoral activation, is an important prognosticator in pulmonary arterial hypertension, and should be addressed at frequent intervals. Show less
Repolarization heterogeneity refers to differences in repolarization instants in the heart. Normally, repolarization in the human heart is a relatively smooth, continuous process, during which... Show moreRepolarization heterogeneity refers to differences in repolarization instants in the heart. Normally, repolarization in the human heart is a relatively smooth, continuous process, during which adjacent areas repolarize almost simultaneously. Several drugs or cardiac diseases may disturb the repolarization and thus increase the repolarization heterogeneity, which predisposes to arrhythmias. A non-invasive index able to assess this repolarization heterogeneity would have great clinical value. The standard 12-lead electrocardiogram (ECG) is attractive for this purpose as it is widely used and reflects repolarization heterogeneity. We used mathematical simulations to demonstrate that increased repolarization heterogeneity caused by increased APD heterogeneity in normally excited hearts is reflected in the T-wave amplitude, T-wave area, T-wave symmetry, and, with restrictions, in T-wave complexity and the Tapex-Tend interval. Our measurements in normal subjects suggest that hypertensive stress and recovery from exercise are conditions in normal hearts during which repolarization heterogeneity is increased. Immediately after vigorous exercise repolarization heterogeneity is largest. Pulmonary valve replacement in Fallot patients decreases QRS duration and electrocardiographic indices of repolarization heterogeneity. Left ventricular pacing in heart failure patients leads to similar effects on the repolarization heterogeneity as traditional right ventricular pacing. Transmural repolarization heterogeneity cannot be assessed from the electrocardiogram during pacing, as T wave morphology in paced hearts is predominated by the global repolarization pattern induced by pacing. Show less
