Podcast appearances and mentions of paul wong

Sprott's Paul Wong and Jake White join host Ed Coyne to discuss key themes for 2025. Topics include uranium, silver, copper and how central bank buying has become a dominant theme in the universe of gold.This podcast is provided for information purposes only from sources believed to be reliable. However, Sprott does not warrant its completeness or accuracy. Any opinions and estimates constitute our judgment as of the date of this material and are subject to change without notice. Past performance is not indicative of future results. This communication is not intended as an offer or solicitation for the purchase or sale of any financial instrument. Any opinions and recommendations herein do not take into account individual client circumstances, objectives, or needs and are not intended as recommendations of particular securities, financial instruments, or strategies. You must make your own independent decisions regarding any securities, financial instruments or strategies mentioned or related to the information herein. This communication may not be redistributed or retransmitted, in whole or in part, or in any form or manner, without the express written consent of Sprott. Any unauthorized use or disclosure is prohibited. Receipt and review of this information constitute your agreement not to redistribute or retransmit the contents and information contained in this communication without first obtaining express permission from an authorized officer of Sprott.

Paul Wong is a media-maestro making art for site-specific spaces and screens of all sizes. He is an award winning artist and curator known for pioneering early visual and media art in Canada, founding several artist-run groups, and organizing events, festivals, conferences and public interventions since the 1970s. Wong has produced projects throughout North America, Europe and Asia.

Release any ancestral beliefs that may be causing your physical, emotional, or mental pains with the FREE Chinese Energetics healing teachings by Paul Wong. Learn more at http://chineseenergetics.com Chinese Energetic LLC City: Park Ridge Address: PO Box 211 Website: https://www.chineseenergetics.com Email: paul@chineseenergetics.com

Kelly Ingraham shares the psychological theories of meaning and purpose are such powerful healers and guides, including Viktor Frankls' logotherapy, positive psychology and Martin Seligman's PERMA theory, Dr. Paul Wong's meaning theory, ending with studies on the power of purpose. Follow us @ancientfutureheart @kellyjoyceingraham

We find ourselves living in a time of great complexity and flux, where the very fabric of our societies is being rewoven by the rise of artificial intelligence and the interplay of complex systems. How do we make sense of a world that is undeniably interconnected, with increasingly porous boundaries between nature and culture, human and machine, science and art? Paul Wong is reshaping that conversation, drawing on science, philosophy, and art. Origins Podcast WebsiteFlourishing Commons NewsletterShow Notes:Buckminster Fuller (07:40)Principia Mathematica by Russell and Whitehead (09:00)Peter Kropotkin and Mikhail Bakunin (11:00)Commonwealth Grants Commission (13:10)Range by David Epstein (15:00)David Krakauer (15:20)Claude Shannon and information theory (17:10)Chaos by James Gleick (20:00)Duncan Watts, Barabási Albert-László , and network analysis (24:20)Networks the lingua franca of complex systems (25:20)Stephen Wolfram (25:30)Open Science (28:20)Australian National University School of Cybernetics (28:50)Australian Research Data Commons (29:50)Genevieve Bell (31:20)Ross Ashby's Law of Requisite Variety (32:30)Sara Hendren on Origins and Sketch Model (36:30)What he tells his students (38:00)Alex McDowell on Origins (41:00)The Patterning Instinct by Jeremy Lent and Fritjof Capra (47:30)Tao Te Ching (48:20)Morning routine (49:30)Lightning round (53:40)Book: Special relativity and Dr. SeussPassion: MusicHeart sing: Stitching together cybernetics, complexity, and improvisation Screwed up: Many thingsFind Paul online: https://cybernetics.anu.edu.au/people/paul-wong/'Five-Cut Fridays' five-song music playlist series  Paul's playlistLogo artwork by Cristina GonzalezMusic by swelo on all streaming platforms or @swelomusic on social media

Inflation is at 40 year highs and the Fed has increased interest rates 9x in the past year. What does this mean for financial markets and the gold price? To answer these questions we have brought together some of the best thought leaders and gold companies in the world. John Hathaway, Senior Portfolio Manager at Sprott Asset Management USA, will provide his views on the economy and how gold will benefit from the current economic environment. Paul Wong, Market Strategist at Sprott Asset Management, will do a deep dive on interest rates, inflation, and the U.S. dollar and what they mean to the gold price. John Reade, Chief Market Strategist at the World Gold Council will provide an overview of what Central Banks around the world have been doing with their gold holdings. Alissa Corcoran, Deputy CIO at Kopernik Global will provide her views on gold equities. Daniella Dimitrov, Mining Executive and Director, will provide her insights on gold valuations. Gold Producers Presenting David Smith, CFO of Agnico Eagle. Agnico is the 3rd largest gold producer and will produce over 3 million ozs of gold in 2023. Agnico owns Canada's 2 largest gold mines, Malartic and Detour, and 80% of Agnico's production comes from Canada. Andrea Freeborough, CFO at Kinross Gold. Kinross produces over 2 million ozs of gold annually from 4 mines. Kinross also owns a development project in Ontario, Canada called Great Bear Project. Great Bear is a world-class gold project and has the potential to be a top tier gold producer. George Burns, CEO of Eldorado Gold. Eldorado has 4 producing mines and produces over 450k ozs of gold annually. Eldorado has and extensive growth pipeling which will see its production go from 500k ozs to 700k ozs by 2027. Eldorado recently announced the closing of a financing package for its Skouries Mine in Greece. Tyron Bretenbach, SVP at Aris Mining. Aris has 2 producing gold mines in Colombia and produces 250k ozs of gold annually. The BOD of Aris Mining is comprised of many successful mine builders including Ian Telfer, Neil Woodyer, and Peter Marrone. Waiver & Disclaimer If you register for this webinar/podcast you agree to the following; This podcast is provided for information purposes only. Presenters will not be providing legal or financial advice to any webinar participants or any person watching a recorded version of the webinar. All webinar/podcast participants or any person watching or listening to a recorded version of this webinar should obtain independent legal and financial advice. All webinar/podcast participants accept and grant permission to Bloor Street Capital Inc. and its representatives in connection with such recording. The information contained in this webinar/podcast is current as of April the 14th, 2023, the date of this webinar/podcast, unless otherwise indicated, and is provided for information purposes on. Bloor Street Capital was paid a fee for this conference.

Yaakov Breaks Spiritual Ice, Nature with OAT, Strickland Authors, Heart Wisom Process with Paul Wong and Author Sevinc Chelebi, Bob Proctor, Evan Carmichael, Yaakov Healing Art and Olivia Tatara Healing Art coming together in Spirit. Much love to all making this world grow in vibration and consciousness. Support this podcast by getting a piece of healing art by the creators of Spirituality Decoded for Everyone and Poetry and Inspiration TIME. OAT Healing Art: artcestral.redbubble.com Yaakov Healing Art: earthyaakov.redbubble.com .... Yaakov Breaks Spiritual Ice and OAT Talks Nature - Spiritual Healing and Spiritual Authors for All - THIS CONTENT DOES NOT COPY ANYONE OR USE ANYONE IN A UNETHICAL WAY NOR DO WE RECIEVE ROYALTIES OFF MENTIONING THIS INFORMATION. WE ARE HERE TO SPREAD THE LOVE AND INFO. WE ARE NEVER HERE TO STEAL ANYONES IDENTITY OR INFO. If you are experiencing cyber harassment, join our group Spiritual Lawyers Defending Mankind and you can find insigh and support on your situation and raise your vibration to transform. If someone is talking negative about you, continue to do you. --- Support this podcast: https://podcasters.spotify.com/pod/show/frequency-life-change/support

'Assisted dying' involves patients with incurable illnesses, whose condition is not amenable to meaningful relief, such that their lives are - in their opinion - not worth living, and from which they seek an end. One of the arguments against legalising assisted dying in South Africa was that patients had access to palliative care. On this week's episode we explore the specialised field of Palliative Medicine, and the psychological approach of seeking meaning in assistance with dying. Joining us to discuss this topic are Dr Julia Riley and Prof. Paul Wong. Adcock Ingram

'Assisted dying' involves patients with incurable illnesses, whose condition is not amenable to meaningful relief, such that their lives are - in their opinion - not worth living, and from which they seek an end. One of the arguments against legalising assisted dying in South Africa was that patients had access to palliative care. On this week's episode we explore the specialised field of Palliative Medicine, and the psychological approach of seeking meaning in assistance with dying. Joining us to discuss this topic are Dr Julia Riley and Prof. Paul Wong.

Show love and support: FPS/轉數快 ID: 164023863 Payme QRcode: http://bit.ly/247TalkPaymeQRcode Payme: http://bit.ly/247TalkPayme Paypal: http://bit.ly/247TalkPayPal 24/7TALK: Episode 29 ft. Jimmy 老占 Special guest: Jimmy 老占 Hosts: 24Herbs Filmed and edited: Pak Khei, Marco Mak, and Leo Chan Produced: 24HERBS and Studio8ight ---------------------------------------------------------------------------------------------------------- 24/7TALK Episode 29 featuring Jimmy aka Lo Jim, one of the most OGs when it comes to musician in Hong Kong. Check out his stories from meeting Wong Ka Kui from Beyond to becoming his roadie, working with Paul Wong, joining LMF, how he promotes BMX scene in HK and more. Stoked to have Jimmy in the show. 今集24/7Talk有請人稱香港地下搖滾人肉百科全書，BMX界老祖宗，Beatles狂熱份子，砌模型高高手，專欄作家，慈父，好老公.......兼LMF創始成員 - 老占！ ------------------------------------------------------------------------------------------------------- 留咗言而又被揀中嘅朋友請聯絡 247talkhk@gmail.com 領取獎品 ------------------------------------------------------------------------------------------------------- Pls support and buy our music: https://itunes.apple.com/us/album/go-hard-single/id1260822753 https://itunes.apple.com/ca/artist/24herbs/id486419646 Instagrams: https://www.instagram.com/24Herbs_Official/ https://www.instagram.com/djkeepintouch https://www.instagram.com/phat24herbs https://www.instagram.com/eddie24herbs https://www.instagram.com/dudemakesbeats https://www.instagram.com/jbs8five2 https://www.instagram.com/djspyzitrix Facebook: http://www.facebook.com/24Herbs https://www.facebook.com/kittttt.leung https://www.facebook.com/phatchan https://www.facebook.com/GhostStyle https://www.facebook.com/jbrian.siswojo https://www.facebook.com/eddiechung https://www.facebook.com/deejayspyzi.trix Please subscribe here - https://www.youtube.com/c/24HERBS?sub_confirmation=1

Welcome back to Million Dollar Relationship Podcast with Kevin Thompson. Today we are joined by Tim Templeton.  Tim Templeton is a self-directed and driven former franchisor CEO/President with comprehensive executive accomplishments leading corporate franchise restructuring, 3-year rolling plans / 90-day budgets, board development, C-level recruiting, franchise sales development, private equity relationship development, and negotiation through the sale of the business.  Templeton is also a best-selling business author, his last book, The Referral of a Lifetime was published by Berrett-Koehler Publishing and translated into 14 languages.  Since the successful sale of Authority Franchise Systems LLC., the parent company of Mosquito Authority, Pest Authority, and Authority Systems International, Tim offers contract Entrepreneur in Residence (EIR) services to private equity companies and best practice management consulting and executive coaching services to corporate management teams and company founders. Let's join him as he honors Paul Wong and Ken Blanchard   Key Highlights:    [00:00 - 09:34] Tim Templeton: The Man Behind the One Minute Manager Tim Templeton is an entrepreneur and author who has a collective background of successes. He started out as a young man and was an entrepreneur his entire career. In May of 2016, Tim and Kevin had a conversation that changed his life trajectory. Since that conversation, Tim has run a community for high-level entrepreneurs, written a book, and spoken extensively on relationships. [09:34 - 17:10] How Tim Built a Relationship That Changed His Life How Tim met Ken Blanchard and how Ken introduced him to the world of business Ken's promise to help Tim publish his book and get wider distribution, as well as coaching on the principles of referral, Tim's experience with failure and rebuilding his business with the help of a mentor, Paul Wong [17:11 - 24:59] Tim Templeton Shares How Paul Wong Taught Him How to Be a Great Businessman Tim met Paul Wong in the early 1990s and was soon partners with him. Paul Wong taught Tim how to be a successful businessman and partner. Paul Won's influence continues to impact Tim's life today. Tim dedicates his book to Paul. [25:00 - 31:31] Closing Segment Final Words Follow Tim Templeton on Facebook or LinkedIn You may also reach him via email: timt789@gmail.com Check out his books on Amazon Resources Mentioned The Referral of a Lifetime: The Networking System that Produces Bottom-Line Results The Referral of a Lifetime: Never Make a Cold Call Again! Thanks for tuning in!   If you liked my show, please LEAVE A 5-STAR REVIEW, like, and subscribe!     Find me on the following streaming platforms: Apple Spotify Google Podcasts IHeart Radio Stitcher  Tweetable Quotes "I always had the attitude. When I see a business model, when I see an opportunity, I always live in the future. I've always had this gift where I see things completed. I see it, richly done in rich detail."  Tim Templeton    

In this episode, we join Managing Broker, Justine Loo, Senior Analyst, Ryan Wyse, along with rennie advisor, Paul Wong, to review the latest residential data for the Vancouver Region and discuss three key insights gleaned in June 2022:Market activity slowed in June, much more than the typical seasonal declineThe single-family segment is detached from the multi-family marketPrices have started to decline, but affordability isn't improvingFeatured guestsJustine Loo, Managing BrokerRyan Wyse, Senior Analyst, Intelligence  Paul Wong, rennie advisor Additional readingthe rennie review - July 2022the rennie advance - July 2022

Kaj Rozga, Counsel, Davis Wright Tremaine LLP, speaks with Michelle Yost Hale, Partner, Wilson Sonsini Goodrich & Rosati, and Paul Wong, Director, NERA Economic Consulting, about the key takeaways from the Sidibe v. Sutter case, which was a class-action lawsuit filed by consumers in Northern California alleging that Sutter Health engaged in anti-competitive contracting practices; the case ended in Sutter Health's favor. They discuss the two main theories the plaintiffs used to allege Sutter Health's monopolization of medical services, how those theories may have played with the jury, and practical advice for lawyers and economists who are advising health care providers on these issues. From AHLA's Antitrust Practice Group.Watch the conversation here. Watch Kaj Rozga's first video, where he provides more background on the case, here.

You can help support the show by donating today! CLICK HEREPaul Wong The Las Vegas native joins the show to discuss his ability to find hidden gem combos and some ideas to grow the sport. We also discuss some of the recent AHFS changes. Class Racing Today classracingtoday.com Facebook, Instagram, YouTube, AppleT-shirts and Stickers for sale!SPONSOR:Kenwood Welding & Metalizing | Baltimore, MD | 410-686-3760 grncpe@comcast.net Kenwood Welding and Metalizing has been offering quality welding services for all processes and all materials since 1932.DragInsights Sportsman App app.draginsights.com Register FREE to track yourself and your competition!

Show love and support: FPS/轉數快 ID: 164023863 Payme QRcode: http://bit.ly/247TalkPaymeQRcode Payme: http://bit.ly/247TalkPayme Paypal: http://bit.ly/247TalkPayPal 記得留低聯絡方法! 24/7TALK: Episode 81 ft. Paul Wong 黃貫中 Special guest: Paul Wong 黃貫中 Hosts: 24Herbs Filmed and edited: Pak Khei, Marco Mak, and Leo Chan Produced: 24HERBS and Studio8ight ---------------------------------------------------------------------------------------------------------- 唔講喇直接去片啦！ 記得癡嗱曬線comment like share subscribe. Thank you The man that doesn't need any introduction, PAUL WONG, yes, the Paul Wong from Beyond is in our 247Talk episode 81. We are extremely honoured to be catching up with Paul and talked about his childhood, love for music, Beyond stuff and more. MUST CHECK! --------------------------------------------------------------------------------------------------------- 24/7Talk is now on Spotify, Apple Podcast, Google Podcast: Spotify Podcast: http://bit.ly/247Talk_SpotifyPodcast Apple Podcast: http://bit.ly/247Talk_ApplePodcast Google Podcast: http://bit.ly/247Talk_GooglePodcast Pls support and buy our music: https://itunes.apple.com/us/album/go-hard-single/id1260822753 https://itunes.apple.com/ca/artist/24herbs/id486419646 Instagrams: https://www.instagram.com/24Herbs_Official/ https://www.instagram.com/djkeepintouch https://www.instagram.com/phat24herbs https://www.instagram.com/eddie24herbs https://www.instagram.com/dudemakesbeats https://www.instagram.com/jbs8five2 https://www.instagram.com/djspyzitrix Facebook: http://www.facebook.com/24Herbs https://www.facebook.com/kittttt.leung https://www.facebook.com/phatchan https://www.facebook.com/GhostStyle https://www.facebook.com/jbrian.siswojo https://www.facebook.com/eddiechung https://www.facebook.com/deejayspyzi.trix Please subscribe here - https://www.youtube.com/c/24HERBS?sub_confirmation=1 ------------------------------------------------------------------------------------------------------- 留咗言而又被揀中嘅朋友請聯絡 247talkhk@gmail.com 領取獎品 -------------------------------------------------------------------------------------------------------

Show love and support: FPS/轉數快 ID: 164023863 Payme QRcode: http://bit.ly/247TalkPaymeQRcode Payme: http://bit.ly/247TalkPayme Paypal: http://bit.ly/247TalkPayPal 記得留低聯絡方法! 24/7TALK: Episode 81 ft. Paul Wong 黃貫中 Special guest: Paul Wong 黃貫中 Hosts: 24Herbs Filmed and edited: Pak Khei, Marco Mak, and Leo Chan Produced: 24HERBS and Studio8ight ---------------------------------------------------------------------------------------------------------- 唔講喇直接去片啦！ 記得癡嗱曬線comment like share subscribe. Thank you The man that doesn't need any introduction, PAUL WONG, yes, the Paul Wong from Beyond is in our 247Talk episode 81. We are extremely honoured to be catching up with Paul and talked about his childhood, love for music, Beyond stuff and more. MUST CHECK! --------------------------------------------------------------------------------------------------------- 24/7Talk is now on Spotify, Apple Podcast, Google Podcast: Spotify Podcast: http://bit.ly/247Talk_SpotifyPodcast Apple Podcast: http://bit.ly/247Talk_ApplePodcast Google Podcast: http://bit.ly/247Talk_GooglePodcast Pls support and buy our music: https://itunes.apple.com/us/album/go-hard-single/id1260822753 https://itunes.apple.com/ca/artist/24herbs/id486419646 Instagrams: https://www.instagram.com/24Herbs_Official/ https://www.instagram.com/djkeepintouch https://www.instagram.com/phat24herbs https://www.instagram.com/eddie24herbs https://www.instagram.com/dudemakesbeats https://www.instagram.com/jbs8five2 https://www.instagram.com/djspyzitrix Facebook: http://www.facebook.com/24Herbs https://www.facebook.com/kittttt.leung https://www.facebook.com/phatchan https://www.facebook.com/GhostStyle https://www.facebook.com/jbrian.siswojo https://www.facebook.com/eddiechung https://www.facebook.com/deejayspyzi.trix Please subscribe here - https://www.youtube.com/c/24HERBS?sub_confirmation=1 ------------------------------------------------------------------------------------------------------- 留咗言而又被揀中嘅朋友請聯絡 247talkhk@gmail.com 領取獎品 -------------------------------------------------------------------------------------------------------

Today it's a great honor to chat with the legendary Paul Wong on the podcast. Dr. Wong is Professor Emeritus of Trent University. He's a fellow of APA and CPA and president of the International Network on Personal Meaning and the Meaning-Centered Counselling Institute Inc. Editor of the International Journal of Existential Positive Psychology, he's also edited two influential volumes on The Human Quest for Meaning. A prolific writer, he is one of the most cited existential and positive psychologists. The originator of Meaning Therapy and International Meaning Conferences, he has been invited to give keynotes and meaning therapy workshops worldwide. Dr. Wong is the recipient of the Carl Rogers Award from the Society for Humanistic Psychology. Topics: · Dr. Wong's childhood and upbringing · Animal learning research: optimism vs. helplessness · Locus of control is not a dichotomy · The unheard cry of a successful Asian psychologist · Positive Psychology 2.0 · Embracing the dark side to enhance well-being · Dual-systems model of what makes life worth living · Agency, spirituality, and community contribute meaning · How to find meaning in life --- Support this podcast: https://anchor.fm/the-psychology-podcast/support

今集主題：夫妻分享 (May & Paul Wong)

The guest this week is Dr. Paul Wong, who is a Professor Emeritus of Trent University and President of the International Network on Personal Meaning. Paul has published across topics relating to meaning related therapies and we touch on his journey getting to the work of Viktor Frankl and logotherapy as a starting point. We spent some time talking about how dealing with depression is not an indicator that a person is ‘broken' or ‘flawed' and we got into how we can best repurpose that energy and experience to something positive in the end. We also got to talk about the PURE model that Dr. Wong created and talked about Meaning Therapy and how it differs from Existential and other meaning-oriented therapies more broadly. Here are some links to learn more about Paul and his work: http://www.drpaulwong.com/http://www.meaningtherapy.com/ Be well!

Our guest this week is Paul Wong, market strategist at Sprott, Inc. In this podcast, Paul discusses "transitory" inflation, commodities and what he expects from the FOMC next week. You can submit your questions to submissions@sprottmoney.com Visit our website https://www.sprottmoney.com​​​​​ for more news.

Who else knows the phrase, "no pain, no gain? Dr. Paul Wong, registered psychologist  adds to that phrase with "no suffering, no healing." The Founding President of the International Network on Personal Meaning (INPM), Fellow of both the American Psychological Association and the Canadian Psychological Association, and author of more than 120 scholarly journal articles, 60 invited chapters, and 7 books, Dr. Wong continues his quest for contemplation, connection, and shared humanity and community. In a world untouched by suffering, Dr. Wong joins the PTSD and Beyond podcast to talk about the importance of embracing our shadow self as well as the pain, suffering, and grieving of life. "Have you ever talked to your 'evil twin?' Your 'evil twin' gives you the guts to be rejected," states Dr. Wong. Through the delicate balance of the soul and the shadow, that balance and harmony leads to wisdom and freedom. Deep wisdom and freedom lies on the the other side of darkness.  "It takes courage, determination, promise, and consistency to see the light through the lens of darkness," Dr. Paul Wong. To learn more about Dr. Wong or to attend the 11th Biennial International Meaning Conference, connect at: Web: DrPaulWong.com Web: Meaning.ca Twitter: @PaulTPWong Instagram: @INPMeaning    

By its name, a non-compete agreement restricts competition. But can non-competes be procompetitive or otherwise designed to minimize the competition concerns? Dr. Paul Wong, Economist and Director at National Economic Research Associates, Inc. (NERA), speaks with Anora Wang and Christina Ma about the interests and tradeoffs involved in a non-compete agreement and relevant enforcement and legal developments in this space, especially at the state level. Listen to this episode to get the economic story behind non-competes. Related Links: Paul Wong, Yun Ling, Emily Walden, Non-Compete Agreements: Might They be Procompetitive in Healthcare?, CPI (May 11, 2020) Comments of the Antitrust Law Section of the ABA in connection with the FTC workshop on "Non-competes in the workplace: Examining antitrust and consumer protection issues" (April 24, 2020) Hosted by: Anora Wang, Davis Wright Tremaine LLP and Christina Ma, Wachtell, Lipton, Rosen & Katz

Paul Wong offers breakthrough methodology for Yuen Method practitioners and clients to remove generational trauma using the Heart Wisdom Process. Learn more at https://heartwisdomprocess.com (https://heartwisdomprocess.com)

Paul Wong of Sprott Inc joins us this week to discuss the long-term price and seasonality trends in both gold and silver.

Even before the pandemic threw the labour market into disarray, mature workers faced daunting challenges finding employment. In Career 360, Howie Lim speaks to Shawn Moi who’s a Workforce Singapore career coach and Paul Wong, who’s now Group HR Manager, Richland Logistics about the importance of career coaching for mature workers.  See omnystudio.com/listener for privacy information.

Paul Wong with Coldwell Banker - Oakland/Eastbay California. Paul gives us his monthly update on real estate in the greater Oakland Area Paul is part of the most advanced real estate coaching program, Tom Ferry. Paul Wong on Facebook: https://www.facebook.com/paul.wong.7370 Paul Wong on Facebook Business Page https://www.facebook.com/Paul-Wong-Group-102460348279001 Paul Wong on YouTube Paul Wong on the Web http://www.dubagent.com/ Paul Wong on LinkedIn https://www.linkedin.com/in/paul-wong-1b11b3133/ Tom Ferry - http://www.TomFerry.com Coach Bob McCranie - https://www.facebook.com/BrokerCoachBob

Show love and support: FPS/轉數快 ID: 164023863 Payme QRcode: http://bit.ly/247TalkPaymeQRcode Payme: http://bit.ly/247TalkPayme Paypal: http://bit.ly/247TalkPayPal 記得留低聯絡方法! 24/7TALK: Episode 81 ft. Paul Wong 黃貫中 Special guest: Paul Wong 黃貫中 Hosts: 24Herbs Filmed and edited: Pak Khei, Marco Mak, and Leo Chan Produced: 24HERBS and Studio8ight ---------------------------------------------------------------------------------------------------------- 唔講喇直接去片啦！ 記得癡嗱曬線comment like share subscribe. Thank you The man that doesn't need any introduction, PAUL WONG, yes, the Paul Wong from Beyond is in our 247Talk episode 81. We are extremely honoured to be catching up with Paul and talked about his childhood, love for music, Beyond stuff and more. MUST CHECK! --------------------------------------------------------------------------------------------------------- 24/7Talk is now on Spotify, Apple Podcast, Google Podcast: Spotify Podcast: http://bit.ly/247Talk_SpotifyPodcast Apple Podcast: http://bit.ly/247Talk_ApplePodcast Google Podcast: http://bit.ly/247Talk_GooglePodcast Pls support and buy our music: https://itunes.apple.com/us/album/go-hard-single/id1260822753 https://itunes.apple.com/ca/artist/24herbs/id486419646 Instagrams: https://www.instagram.com/24Herbs_Official/ https://www.instagram.com/djkeepintouch https://www.instagram.com/phat24herbs https://www.instagram.com/eddie24herbs https://www.instagram.com/dudemakesbeats https://www.instagram.com/jbs8five2 https://www.instagram.com/djspyzitrix Facebook: http://www.facebook.com/24Herbs https://www.facebook.com/kittttt.leung https://www.facebook.com/phatchan https://www.facebook.com/GhostStyle https://www.facebook.com/jbrian.siswojo https://www.facebook.com/eddiechung https://www.facebook.com/deejayspyzi.trix Please subscribe here - https://www.youtube.com/c/24HERBS?sub_confirmation=1 ------------------------------------------------------------------------------------------------------- 留咗言而又被揀中嘅朋友請聯絡 247talkhk@gmail.com 領取獎品 -------------------------------------------------------------------------------------------------------

Paul Wong with Coldwell Banker - Oakland/Eastbay California. Paul gives us his monthly update on real estate in the greater Oakland Area Paul is part of the most advanced real estate coaching program, Tom Ferry Paul Wong on Facebook: https://www.facebook.com/paul.wong.7370 Paul Wong on Facebook Business Page https://www.facebook.com/Paul-Wong-Group-102460348279001 Paul Wong on the Web http://www.dubagent.com/ Paul Wong on LinkedIn https://www.linkedin.com/in/paul-wong-1b11b3133/ Tom Ferry - http://www.TomFerry.com Coach Bob McCranie - https://www.facebook.com/BrokerCoachBob

美國郵政局（英語：United States Postal Service，縮寫：USPS），又稱美國郵局、美國郵政服務，是美國聯邦政府的一个獨立機構，是少數在美國憲法中提及設立的機構。根據維基百科，美國郵政局擁有596,000名僱員，以及218,684輛汽車，是全球最龐大的民用車隊。每年處理1770億信件，佔全球數量的四成。郵政局投遞覆蓋美國國土的每一個角落，設置專用信箱，并採取統一資費。 由於新冠肺炎疫情在美國蔓延，給美國郵政局帶來「毀滅性的」業務下滑，現金流嚴重緊缺，破產危機就在眼前。 同樣是由於新冠疫情，以郵寄方式投票的美國選民可能在2020大選中達到歷史新高，美國郵政局的投遞效率因而意外成為了兩黨選前交鋒的爭議焦點。 美國郵政局正推行一系列削減開支的舉措，由於大選日逐漸臨近，引發郵寄選票延誤的疑慮。由於新冠疫情在美國持續蔓延，專家估計本屆美國大選可能會有半數選民透過郵寄方式投票，呈現「得郵政者得天下」的態勢。 節目訪問了Paul Wong，一位剛退休不久的美國郵政局郵差，從事了將近15年的“跑腿遞送”，跟大家說說郵局裡面的真實情況。 #美國郵政局 #Go潮生活 #美國郵差 YouTube: Go潮生活 Twitter:Go潮生活 跪謝「四有」善心人：有訂閱，有按讚，有分享，有在聽。 --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/gofreshfashion/support

In this episode of COVID Convos, we chat with Dr. Paul Wong, a clinical psychologist, pastor, and researcher residing in Toronto, Canada. We explore the need for integrating the east and the west, suffering as the foundation for happiness, and the opportunity presented to go deeper and explore our inner world.

In this episode of COVID Convos, we chat with Anna Glynn, a positive psychology teacher for organisations in Melbourne, Australia. We explore the hardships facing small businesses, tips for working from home and online, and the outpouring of positive resources helping organisations take care of their most important asset, humans. Find more from Anna here: annaglynn.com.au Instagram: annamglynn Sign Up for Paul Wong's study and get a free book here: https://docs.google.com/forms/d/e/1FA... Get your free Strengths Profile here: https://lnkd.in/dH4--fv Access Michelle Mcquaid's research on Organisational Wellbeing here: https://www.michellemcquaid.com/ Follow Michael Steger's meaning and purpose work here: https://www.linkedin.com/posts/michae...

@poormanscommish of @LetsGoWarriors welcomes the legendary Paul Wong, who in 2007 brought in a placard to Oracle Arena. On it read, "We Believe Playoff" -- and the rest is history. Are we in We Believe 2.0 season? Let Wong help you cope with the recent growing pains of the new squad. We're also joined by aspiring journalism student and super-fan Kellen Reid, whose little brother was actually born on that night of Game 6 vs the Dallas Mavericks! Learn more about your ad choices. Visit megaphone.fm/adchoices --- Support this podcast: https://anchor.fm/letsgowarriors/support

Episode 2 - Season 1 Introducing Paul Wong, a fellow dreamer and aspirer of great things, AND dear friend of Liza and Haley's.   Well It Takes a Village to turn around some bad moods, mindsets or mental health challenges!  And Haley, Liza, and Paul show you one tip up their sleeves.  They have all had a hard week for various reasons: biology, politics, cruddy jobs, bills teetering out of control, cat fur, and feeling as if they are not living their best alife (whatever that is), the same ol" crap.  They share how the alchemical power of Gratitude and Community of Friendly Fools can make all the difference in their worlds. As a final flourish they separately pull out Energy Cards from the deck created by Sandra Taylor.  What will the cards say?  Will LIza find love?  Will Haley find her Sugar Daddy?  And will Paul be a lunar architect?   This episode points to the truth that whether you have dreams or not, you gotta find a way to enjoy the journey along the way - never mind the  bumps in the road, dust in your eyes,  skin frying heat or throat parching air - there is an amazing view - especially if you are falling off a cliff. If you enjoy a giggle or two, sandwiching life wisdoms on how to JUST BE whether you are a fan of yourself or not, please find us on on your favorite Podcast platform and SUBSCRIBE, dernit SUBSCRIBE.  You help give this podcast for a reason for opening it's eyes and greeting the day with hope and promise!  And even BETTER if you give us a Fabulous rating - we will digitally kiss your feet!  We will give shout OUTS  to the most deserving of REVIEWS!   And if you want even MORE than this podcast you can  INTRO Song - Accordion Wail-along sung by Liza Davis.  Accordion stylings by Liza.  ( FYI - This is the first song she has ever written after years of struggling with performance anxiety, so she is feeling happy with the result in spite of some flaws)   EMAIL US ---   widtmtpodcast@gmail.com    Instagram us ---- @WhatIDidntTellMyTherapist      https://www.instagram.com/whatididnttellmytherapist/  Tweet us @WhatTherapist   https://twitter.com/WhatTherapist  (Yeah, we know what it looks like...retroactive oops) Sending out LOVE and PRISHeeation for reading the shownotes!  --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/widtmtpodcast/message Support this podcast: https://anchor.fm/widtmtpodcast/support

Dr. Wang:            Welcome to the monthly podcast, On the Beat, for Circulation: Arrhythmia and Electrophysiology. I'm Dr. Paul Wong, editor-in-chief, with some of the key highlights from this month's issue.                                 In our first paper, Jeremy Wasserlauf and associates compare the accuracy of an atrial fibrillation sensing smartwatch with simultaneous recordings from an insertable cardiac monitor.                                 The authors use smart rhythm 2.0, a convolutional neuro-network, trained on anonymized data of heart rate, activity level and EKGs from 7500 AliveCor users.                                 The network was validated on data collected in 24 patients with insertable cardiac monitor, and a history of paroxysmal atrial fibrillation who simultaneously wore the atrial fibrillation sensing smart watch with smart rhythm 0.1 software.                                 The primary outcome was sensitivity of the atrial fibrillation sensing smart watch for atrial fibrillation episodes of greater than equal to one hour. Secondary end points include sensitivity of atrial fibrillation sensing smart watch for detection of atrial fibrillation by subject and sensitivity for total duration across all subjects.                                 Subjects with greater than 50% false positive atrial fibrillation episodes on insertable cardiac monitor were excluded.                                 The authors analyzed 31,349 hours meaning 11.3 hours per day of simultaneous atrial fibrillation sensing smart watch and insertable cardiac monitor recordings in 24 patients. Insertable cardiac monitor detected 82 episodes of atrial fibrillation of one hour duration or greater while the atrial fibrillation sensing smartwatch was worn. With a total duration of 1,127 hours.                                 Of these, the smart rhythm 2.0 neural network detected 80 episodes. Episode sensitivity 97.5% with total duration 1,101 hours. Duration sensitivity 97.7%.                                 Three of the 18 subjects with atrial fibrillation of one hour or greater had atrial fibrillation only when the watch was not being worn. Patient sensitivity 83.3% or 100% during the time worn. Positive predictive value for atrial fibrillation episodes was 39.9%.                                 The authors concluded that an atrial fibrillation sensing smartwatch is highly sensitive to detection of atrial fibrillation and assessment of atrial fibrillation duration in an ambulatory population when compared to insertable cardiac monitor.                                 In our next paper, Liliana Tavares and associates examine the autonomic nervous system response to apnea in its mechanistic connection to atrial fibrillation. They study the effects of ablation of cardiac sensory neurons with resiniferatoxin, a neurotoxic transient receptor potential vanilloid one agonist.                                 In a canine model, apnea was induced by stopping ventilation until oxygen saturation decreased in 90%. Nerve recordings from bilateral vagal nerves left stellate ganglion and anterior right ganglion plexi were obtained before and during apnea, before and after resiniferatoxin injection in the anterior white ganglion plexi in seven animals.                                 Each refractory period and atrial fibrillation inducibility upon single extra stimulation was assessed before and during apnea, before and after intrapericardial resiniferatoxin administration in nine animals.                                 The authors found that apnea increased anterior wide ganglion plexi activity followed by cluster crescendo vagal bursts synchronized with heart rate and blood pressure oscillation.                                 Upon further oxygen desaturation, a tonic increase in left stellate ganglion activity in blood pressure oscillations ensued. Apnea induced atrial effective refractory shortening from 110 to 90 milliseconds, P less than 0.001 and atrial fibrillation induction in nine animals vs. zero out of nine at baseline.                                 After resiniferatoxin administration increases in ganglion plexi and left stellate ganglion activity, and blood pressure during apnea were abolished, in addition, the atrial effector refractory period increased to 127 milliseconds, P=0.0001 and atrial fibrillation was not induced.                                 Vagal bursts remain unchanged. Ganglion plexi cells showed cytoplasmic microvacuolation and apoptosis. The authors concluded that apnea increased ganglion plexi activity followed by vagal bursts and tonic left stellate ganglion firing. Resiniferatoxin decreases sympathetic and ganglion plexi nerve activity, abolishes apnea's electrophysiotic response and atrial fibrillation inducibility indicating that sensory neurons play a role in apnea induced atrial fibrillation.                                 In our next paper, Thomas Pambrun and associates examined whether using unipolar signal modification as a local end point would improve the safety and efficacy of high-power ablation during pulmonary vein isolation. They studied four swine and 100 consecutive patients referred for pulmonary vein isolation with the first 50 patients in a control group using 25 to 30 watts and the last 50 patients in a study group with 40 to 50 watts.                                 Atrial radiofrequency applications were stopped two seconds in the study group and swine or five seconds in the control group after unipolar signal modification. Ventricular radiofrequency applications of 500 joules were performed at the swine epicardium.                                 The authors found that swine did not show any extracardiac damage related to atrial lesions. At equal energy of 500 joules, 50 watt lesions were deeper, three vs. 2.6 millimeters, P=0.3 and wider, 6.2 vs. five millimeters, P=0.006 and 25 watt lesions.                                 In a clinical study, there were no complications occurring at either power output. The study group displayed higher first pass pulmonary vein isolation, 92% vs. 73%, P less than 0.001. In addition, the study group had a lower acute pulmonary vein reconnection, 2% vs. 17%, P less than 0.001 as well as reduced procedure time, 73.1 vs. 107.4 minutes and ablation team, 13 vs. 30.3 minutes. Sinus rhythm maintenance at 12 months was similar, 90% and 88%.                                 The authors concluded that high power pulmonary vein isolation guided by unipolar signal modification safely decreases procedural burden while achieving similar 12-month outcomes.                                 In our next paper, Toshiaki Sato and associates attempted to identify predictors of low his-bundle pacing threshold. They studied 51 patients, 53% with atrial ventricular block undergoing his-bundle pacing for bradycardia with an intrinsic QRS duration of less than 120 milliseconds.                                 His-bundle pacing lead positioning was guided by unipolar his-bundle electrograms recorded with an electrophysiology recording system. In total, 153 attempts at anchoring the his-bundle pacing lead were made, of which 45 achieved acceptable his-bundle pacing thresholds, less than or equal to 2.5 volts at one millisecond.                                 The amplitude of negative deflection in unipolar his-bundle electrograms and the selective his-bundle pacing at fixation where independently associated with achieving a acceptable threshold. A negative amplitude of greater than or equal to 0.06 millivolts in the his-bundle electrograms was determined as the optimal value for identifying acceptable threshold. This deep negative his-bundle electrogram was recorded with a his-bundle pacing threshold of 1.4 volts in 34 attempts, significantly lower than the positive his-bundle electrogram without deep negative deflection, 2.8 volts in 31 trials or greater than five volts in 38 trials.                                 The permanent his-bundle pacing lead remained with a deep negative, greater than or equal to 0.06 millivolts or positive his-bundle electrogram in 28 or 14 patients respectively and with a positive or negative his-bundle pacing injury current in 19 and 23 patients respectively.                                 During follow-up, increased his-bundle pacing threshold of greater than one volt was significantly more prevalent in the positive his-bundle electrogram group. The his-bundle pacing threshold of deep negative his-bundle electrogram and his-bundle injury current but not of selective his-bundle pacing group were significantly lower than other sub-groups during follow-up.                                 In the next paper, Claire Martin and associates examined whether altering activation wavefront affects activation timing and local abnormal ventricular activity characterization in patients with ischemic cardiomyopathy. They use the ultra-high density arrhythmia to generate maps for all stable ventricular tachycardias and with pacing from the atrium, right ventricular apex and left ventricular branch of the coronary sinus.                                 56 pace maps and 23 ventricular tachycardia circuits were mapped in 22 patients. In 79% of activation maps, there was one or greater lines of block in the pace conduction wavefront with 93% having fixed block and 32% showing functional partial block. Bipolar scar was larger with atrial than right ventricular, 31.7 centimeters squared vs. 27.6 centimeters squared, P = 0.003 or left ventricular pacing, 31.7 centimeters squared vs. 27.0 centimeters squared, P = 0.009.                                 Local abnormal ventricular activities areas were smaller with atrial than right ventricular pacing, 12.3 centimeters squared vs. 18.4 centimeters squared or left ventricular pacing, 12.3 centimeters squared vs. 17.1 centimeters squared. Local abnormal ventricular activities were larger with wavefront propagation perpendicular vs. parallel to the line of block along isthmus boundaries, 9.3 vs. 13.6 centimeters squared P = 0.01.                                 All patients had successful tachycardia isthmus ablation in 11 months follow-up, two patients had a recurrence.                                 In our next paper, Andrew Tseng and Katie Kunze and associates conducted a systematic review and network meta-analysis on the effect of medication device therapies and reduced ejection fraction on all-cause mortality. Randomized control trials published between January 1980 and July 2017 were identified.                                 The authors found that combination therapy of angiotensin converting enzyme inhibitors or angiotensin receptor blockers with beta blockers alone or in addition to implantable cardioverter defibrillator or cardiac resynchronization therapy with defibrillators demonstrated significant reduction in all cause of mortality when compared to placebo.                                 By probability rank, implantable cardio defibrillator plus angiotensin receptor blockers plus beta blockers plus mineralocorticoid receptor blockers, implantable cardioverter defibrillators plus angiotensin receptor blockers plus beta blockers and angiotensin receptor-neprilysin inhibitor plus beta blockers and mineralocorticoid receptor antag as combination therapies have the highest probability of being ranked the best treatment. There was no significant difference in the rate of mortality when comparing angiotensin receptor-neprilysin inhibitors plus beta blockers plus mineralocorticoid receptor antagonist to ICD plus optimal pharmacologic combination therapy.                                 In our next paper, Karl-Heinz Kuck and associates examined repeat ablation in the fire and ice trial, which examined efficacy and safety of pulmonary vein isolation using cryoballoon vs. radio-frequency current ablation in patients with drug refractory symptomatic paroxysmal atrial fibrillation.                                 Patients with re-ablation procedures during fire and ice were retrospectively consented and rolled at 13 trial centers. 89, 36 cryo-balloon and 53 radio-frequency patients were studied. Paroxysmal atrial fibrillation was the predominant recurring arrhythmia, 69% prior to re-ablation. Re-ablations occurred at the median of 173 and 182 days in the cryoballoon and radio frequency cohorts.                                 The number of reconnected pulmonary veins was significantly higher in the radio frequency than the cryo-balloon, 2.1 vs. 1.4 P = 0.01, which was significantly driven by more connected left superior pulmonary veins and markedly more reconnected right superior pulmonary veins.                                 The number of predominantly radio frequency lesions applied during re-ablation was significantly greater in patients originally treated with radio frequency, 3.3 vs. 2.5, P=0.015 with no difference in overall acute success.                                 After re-ablation, no differences in procedure related rehospitalization or antiarrhythmic drug utilization was observed between cohorts.                                 In the next paper, Ayelet Shapira-Daniels and Michael Barkagan and associates examined the ability of reducing baseline impedance to improve ventricular ablation success. In 16 patients with ventricular tachycardia or frequent ventricular premature complexes with failed rate of frequency ablation with irrigated catheters, the impedance was modulated by adding or repositioning return patches.                                 Ablation was repeated at similar location and power settings. The authors studied six patients with idiopathic ventricular premature complexes originated from the left ventricular summit, N=4 or papillary muscles, N=2. Six patients with non-infarct related ventricular tachycardia and four patients with infarc related ventricular tachycardia. Prior unsuccessful radio frequency ablation at critical sites had a number of 10.4 applications, power of 43.3 watts, duration 55.3 seconds and impedance reduction, 14.6 Ohms in low ionic solution was used in 81%.                                 Modulating the return patches resulted in reduced baseline impedance, 111.7 vs. 34.7 ohms, P less than 0.0001. Increased current output 0.6 vs. 0.56 amps, P also less than 0.0001. And impedance dropped 16.8 ohms.                                 Repeat ablation at similar locations had successful effect in 12 out of 16 or 75% patients. During a follow-up duration of 13 months, 10 out of 12 or 83% patients remained free of arrhythmia occurrence. The frequency of steam pops was similar between higher and lower baseline impedance settings.                                 The authors concluded that in patients with deep ventricular substrate, reducing the baseline impedance is a simple, safe and effective technique for increasing the effect of radio frequency ablation.                                 However, the combination with low ionic solutions may increase the risk for steam pops and neurological events.                                 Our last paper is a review by Robert Anderson and associates. The authors summarize all of the published 12 lead ECD algorithms used to localize ventricular arrhythmias from the right ventricular and left ventricular outflow tracks.                                 That's it for this month. We hope that you'll find the journal to be the go-to place for everyone interested in the field. See you next time!                                 This program is copyright American Heart Association 2019.

Dr Paul Wong:                   Welcome to the monthly podcast on the beat for Circulation: Arrhythmia and Electrophysiology. I'm Dr Paul Wong, Editor-in Chief with some of the key highlights from this month's issue.                                                 This month's issue is dedicated to a new exciting topic, His bundle pacing. His bundle pacing is designed to achieve a more physiological human dynamic response than right ventricular pacing alone, which may be needed in patients with AV conduction abnormalities. In our first paper, Marek Jastrzebski and associates examined whether program stimulation may be used to distinguish nonselective His bundle capture from right ventricular myocardial capture. Premature beats were introduced at 10 millisecond steps during intrinsic rhythm, and also after a drive train of 600 milli seconds. The longest coupling interval that resulted in an abrupt change in the QRS morphology was considered equal to the effective refractory period of the His bundle or right ventricular myocardium.                                                 Program His bundle pacing was performed from 50 different sites in 32 patients. In 34 out of 36 cases of nonselective His bundle pacing, the right ventricular myocardial effective refractory period was shorter than the His bundle effective a refractory period. 271 milliseconds versus 353 milliseconds, P less than 0.0001. Program His bundle pacing using a drive train typically resulted in an abrupt change of the QRS morphology. From nonselective His bundle to right ventricular myocardial QRS 34 out of 36 cases, or to selective His bundle QRS in two out of 36 cases. Program His bundle pacing deliver during native conduction resulted in obtaining selective His bundle QRS in 20 out of 34 patients, and right ventricular myocardial QRS in 14 out of 34 of the nonselective His bundle cases.                                                 In right ventricular myocardial only pacing cases, so-called false nonselective His bundle pacing, and equals 14. Such responses were not observed. The QRS morphology remained stable. Therefore His bundle pacing correctly diagnosed, using programs stimulation, all nonselective His bundle cases in all right ventricular myocardial pacing cases.                                                 In our next paper Aditya Saini and associates sought to determine whether the device electric cam can be used to differentiate between selective, nonselective His bundle pacing, and right ventricular septal capture. In 148 consecutive patients, His bundle pacing was performed. The near field ventricular electrogram morphology, the near field ventricular electrogram time to peak and the far field ventricular electrogram QRS duration were recorded while pacing the His bundle was simultaneous 12 lead ECG rhythm strips. The mean baseline QRS duration was 108 milliseconds, with QRS duration greater than 120 milliseconds in 57 or 39% of patients, including 27 with right bundle branch block, 18 with left bundle branch block, and 12 with an IVCD.                                                 Selective His bundle pacing was noted in 54 or 36% of patients. A positive near field ventricular electrogram time to peak, and a near field ventricular electrogram time to peak of greater than 40 milliseconds were highly sensitive, 94% and 93% respectively, and specific 90% and 94% for selective His bundle pacing, irrespective of baseline QRS duration. All three parameters including positive near field ventricular electrogram time to peak, the near field ventricular electrogram time to peak greater than 40 milliseconds, and far field ventricular electrogram QRS duration less than 120 milliseconds had high predictive negative predictive value, 97%, 95%, and 92%. Therefore, a novel device-based algorithm for a selective His bundle pacing was proposed.                                                 Electrogram transitions correlated with ECG transitions during threshold testing, and can accurately predict and differentiate between selective His bundle pacing, nonselective His bundle pacing, and right ventricular septal pacing with a cumulative positive predictive value of 91% and 100% in patients with a baseline QRS duration of less than 120 milliseconds.                                                 In the next paper, Pugazhendhi Vijayaraman and associates examined whether Cardiac Resynchronization Therapy could be optimized by sequential His bundle pacing followed by left ventricular pacing, which the authors called His optimize CRT or hot CRT. Hot CRT was successfully achieved in 25 of 27 patients. The QRS duration and baseline was 183 milliseconds, and significantly narrowed to 162 milliseconds with biventricular pacing, to 151 milli seconds during His bundle pacing, and further to 120 milliseconds during hot CRT pacing, P less than 0.0001. During a mean follow-up of 14 months, left ventricular ejection fraction improved from 24 to 38%, P less than 0.0001, and New York Heart Association Functional Class changed from 3.3 to 2.04. 21 out of the 25 patients, or 84% were clinical responders, while 23 of 25, 92% showed echocardiographic response.                                                 In our next paper, Parikshit Sharma and associates compared permanent His bundle pacing using three-dimensional electro anatomic mapping in low fluoroscopy in 10 patients, and compared the outcomes with conventional fluoroscopy guided His bundle pacing implants in 20 patients. His bundle pacing was successful in nine out of 10 patients using electro anatomic mapping, and 100% successful in the conventional patients. The mean His bundled fluoroscopy time was lower in electro anatomic mapping group, 0.2 minutes compared to eight minutes in the conventional group, P equals 0.002. The His bundle capture threshold was lower in the electro anatomic mapping group, 0.7 at one millisecond compared to the conventional group, 1.15 at one millisecond, P equals 0.04. There were no procedure related complications or lead dislodgements in either group.                                                 In our next paper, Michael Orlov and associates describe a new technique in which pacing leads for permanent His bundle pacing were connected to electro anatomical mapping in 28 patients. The selective and nonselective His bundle capture sites were tagged. The His bundle cloud was 360 millimeters squared, and the lead was successfully deployed in 25 patients in the threshold of the His bundle pacing, and implant was 1.5 volts at 1.5 milli seconds.                                                 In our final paper, Haran Burri and associates provide practical recommendations for programming pacemakers with His bundle pacing in order to deliver optimal therapy and ensure patient's safety. The authors discuss the important role of electrocardiographic analysis of His bundle capture. They also advise that ventricular capture management should be programmed inactive because of the absence of an evoked potential. The authors discuss the option of placing the His bundle electrode in the left and trigger a report of a cardiac resynchronization therapy pacemaker.                                                 The readers will find this overview of programming His bundle pacing very informative. In this issue, we also have a very special year-end review, which highlights many of the top discoveries in our field. You will not want to miss it.                                                 Okay. That's it for this month. We hope that you'll find the journal to be the go to place for everyone interested in the field. See you next time.                                                 This program is copyright American Heart Association, 2019.  

Show love and support: FPS/轉數快 ID: 164023863 Payme QRcode: http://bit.ly/247TalkPaymeQRcode Payme: http://bit.ly/247TalkPayme Paypal: http://bit.ly/247TalkPayPal 24/7TALK: Episode 29 ft. Jimmy 老占 Special guest: Jimmy 老占 Hosts: 24Herbs Filmed and edited: Pak Khei, Marco Mak, and Leo Chan Produced: 24HERBS and Studio8ight ---------------------------------------------------------------------------------------------------------- 24/7TALK Episode 29 featuring Jimmy aka Lo Jim, one of the most OGs when it comes to musician in Hong Kong. Check out his stories from meeting Wong Ka Kui from Beyond to becoming his roadie, working with Paul Wong, joining LMF, how he promotes BMX scene in HK and more. Stoked to have Jimmy in the show. 今集24/7Talk有請人稱香港地下搖滾人肉百科全書，BMX界老祖宗，Beatles狂熱份子，砌模型高高手，專欄作家，慈父，好老公.......兼LMF創始成員 - 老占！ ------------------------------------------------------------------------------------------------------- 留咗言而又被揀中嘅朋友請聯絡 247talkhk@gmail.com 領取獎品 ------------------------------------------------------------------------------------------------------- Pls support and buy our music: https://itunes.apple.com/us/album/go-hard-single/id1260822753 https://itunes.apple.com/ca/artist/24herbs/id486419646 Instagrams: https://www.instagram.com/24Herbs_Official/ https://www.instagram.com/djkeepintouch https://www.instagram.com/phat24herbs https://www.instagram.com/eddie24herbs https://www.instagram.com/dudemakesbeats https://www.instagram.com/jbs8five2 https://www.instagram.com/djspyzitrix Facebook: http://www.facebook.com/24Herbs https://www.facebook.com/kittttt.leung https://www.facebook.com/phatchan https://www.facebook.com/GhostStyle https://www.facebook.com/jbrian.siswojo https://www.facebook.com/eddiechung https://www.facebook.com/deejayspyzi.trix Please subscribe here - https://www.youtube.com/c/24HERBS?sub_confirmation=1

24/7TALK: Episode 29 ft. Jimmy 老占 Special guest: Jimmy 老占 Hosts: 24Herbs Filmed and edited: Pak Khei, Marco Mak, and Leo Chan Produced: 24HERBS and Studio8ight ---------------------------------------------------------------------------------------------------------- 24/7TALK Episode 29 featuring Jimmy aka Lo Jim, one of the most OGs when it comes to musician in Hong Kong. Check out his stories from meeting Wong Ka Kui from Beyond to becoming his roadie, working with Paul Wong, joining LMF, how he promotes BMX scene in HK and more. Stoked to have Jimmy in the show. 今集24/7Talk有請人稱香港地下搖滾人肉百科全書，BMX界老祖宗，Beatles狂熱份子，砌模型高高手，專欄作家，慈父，好老公.......兼LMF創始成員 - 老占！ ------------------------------------------------------------------------------------------------------- 留咗言而又被揀中嘅朋友請聯絡 247talkhk@gmail.com 領取獎品 ------------------------------------------------------------------------------------------------------- Pls support and buy our music: https://itunes.apple.com/us/album/go-hard-single/id1260822753 https://itunes.apple.com/ca/artist/24herbs/id486419646 Instagrams: https://www.instagram.com/24Herbs_Official/ https://www.instagram.com/djkeepintouch https://www.instagram.com/phat24herbs https://www.instagram.com/eddie24herbs https://www.instagram.com/dudemakesbeats https://www.instagram.com/jbs8five2 https://www.instagram.com/djspyzitrix Facebook: http://www.facebook.com/24Herbs https://www.facebook.com/kittttt.leung https://www.facebook.com/phatchan https://www.facebook.com/GhostStyle https://www.facebook.com/jbrian.siswojo https://www.facebook.com/eddiechung https://www.facebook.com/deejayspyzi.trix Please subscribe here - https://www.youtube.com/c/24HERBS?sub_confirmation=1

Show love and support: FPS/轉數快 ID: 164023863 Payme QRcode: http://bit.ly/247TalkPaymeQRcode Payme: http://bit.ly/247TalkPayme Paypal: http://bit.ly/247TalkPayPal 24/7TALK: Episode 133 ft. 黃貫中, Jimmy 老占, Prodip Special guest: 黃貫中 Hosts: 24Herbs Filmed and edited: Pak Khei, Marco Mak, and Wesley Ng Produced: 24HERBS and Studio8ight ---------------------------------------------------------------------------------------------------------- Wow, look at the guests on this episode; Paul Wong, Prodip and Jimmy, the OGs of all OGs. All because we all have something in common, that we fucking love Davy. This episode is dedicated to Davy Chan, rest in peace brother. Now, go to Years Sham Shui Po on the 16th and 17th Mar to buy the latest single for a good caused. 今集247talk主要係由Paul哥，老占同大佬庭講吓一夥呢隻為紀念飛哥嘅作品。大家記住要癡嗱曬線CLSS comment like share subscribe呀！Thank you and enjoy the show😊 --------------------------------------------------------------------------------------------------------- 24/7Talk is now on Spotify, Apple Podcast, Google Podcast and Google Play Music Podcast. Podcast Links: https://open.spotify.com/show/6YtrxuEogjz0xEMtitVeNz https://podcasts.apple.com/hk/podcast/24-7talk/id1513852953 Pls support and buy our music: https://itunes.apple.com/us/album/go-hard-single/id1260822753 https://itunes.apple.com/ca/artist/24herbs/id486419646 Instagrams: https://www.instagram.com/24Herbs_Official/ https://www.instagram.com/djkeepintouch https://www.instagram.com/phat24herbs https://www.instagram.com/eddie24herbs https://www.instagram.com/dudemakesbeats https://www.instagram.com/jbs8five2 https://www.instagram.com/djspyzitrix Facebook: http://www.facebook.com/24Herbs https://www.facebook.com/kittttt.leung https://www.facebook.com/phatchan https://www.facebook.com/GhostStyle https://www.facebook.com/jbrian.siswojo https://www.facebook.com/eddiechung https://www.facebook.com/deejayspyzi.trix Please subscribe here - https://www.youtube.com/c/24HERBS?sub_confirmation=1 ------------------------------------------------------------------------------------------------------- 留咗言而又被揀中嘅朋友請聯絡 247talkhk@gmail.com 領取獎品 ------------------------------------------------------------------------------------------------------- Davy Chan 生前有一個心願是想LMF舉辦一場慈善演唱會，將所有收益撥捐拯救貓狗的慈善組織，所以(一夥)歌曲將會印製成CD 延續Davy 的心願，我們會把CD的所有收益作慈善用途(不扣除任何成本), CD 售價$100 (只收現金) 這次會有3個受惠機構包括: 香港拯救貓狗協會 @hkscda SAA保護遺棄動物協會 @saa_hk 毛孩救援 @paws_grs 義賣日時間: 12:00pm-8:00pm 義賣日地址: 九龍深水埗汝州街126號 @shopatyears

Dr Wong:             Welcome to the monthly podcast, "On The Beat, for Circulation: Arrhythmia, and Electrophysiology." I'm doctor Paul Wong, editor in chief, with some of the key highlights from this month's issue. We'll also here from Dr. Suraj Kapa reporting on new research from the latest journal articles in the field.                                 In our first article, Mathew Daly and associates examine whether a high-resolution, 9 French, infrared thermography catheter can continuously image esophageal temperatures during atrial fibrillation catheter ablation. The infrared temperature catheter was inserted nasally or orally into the esophagus, adjacent to the left atrium. Endoscopy was performed within 24 hours to document esophageal injury. Thermal imaging showed that 10 out of 16 patients experienced one or more events where the peak esophageal temperature was greater than 40 degrees centigrade. Three patients experienced temperatures greater than 50 degrees centigrade and one experienced greater than 60 degrees centigrade. Analysis of temperature data from each subject's maximal thermal event revealed high radius, 2.3 degrees centigrade per millimeter and rates of change 1.5 degrees centigrade per second, with an average length of esophageal involvement of 11.0 millimeters.                                 Endoscopy identified three distinct thermal lesions, all in patients with temperatures greater than 50 degrees centigrade, all resolving within two weeks. The authors concluded that infrared thermography, high-resolution mapping of esophageal temperatures during catheter ablation may be performed. Esophageal thermal injury occurs with temperatures greater than 50 degrees centigrade, and was associated with large spacial-temporal gradients.                                 In our next article, Nitesh Sood and associates reported on the real-world incidence and predictors of perioperative complications in transvenous lead extractions involving ICD leads in the NCDR ICD registry. Lead extraction was defined as removal of leads implanted for greater than one year. Predictors of major perioperative complication for all extraction procedures, 11,304, and for high voltage leads, 8,362, or 74% across 762 centers were analyzed, using univariate and multivariate logistic regression. Major complications occurred in 258, or 2.3% of the extraction procedures. Of these, 258 procedures with a complication, 41 or 16% required urgent cardiac surgery. Of these, 14 or 34% died during surgery. Among the total 98, or 0.9% deaths reported, 18 or 0.16% of the total occurred during extraction.                                 In multivariate, logistic regression analysis of all extractions, female sex, admission other than electively for the procedure, three or more leads extracted, longer implant duration, dislodgement of other leads, patients' clinical status, requiring lead extraction, such as infection or perforation, were associated with increased risk of complications. For high voltage leads, smaller lead diameter, a flat versus round coil shape, in greater proximal surface coil area, were multivariate predictors of major perioperative complications.                                 The rate of major complications and mortality with transvenous lead extraction is similar in the real world compared to single center studies from high volume centers. There remains a significant risk of urgent cardiac surgery with a very high mortality, and planning for appropriate cardiothoracic surgical backup is imperative.                                 In our next paper, Bence Hegyi and associates, have reported on the repolarization reserve in failing rabbit ventricular myocytes, and the role of calcium and beta-adrenergic effects on delayed and inward rectifier potassium currents. The authors measured the major potassium currents, IKr, IKs, IK1, and their calcium and beta-adrenergic dependence in rabbit ventricular myocytes, in chronic pressure, in volume overload, induced heart failure, and compared them to age-matched controls.                                 The authors made a number of observations. One, action potential duration was significantly prolonged only at lower pacing rates, 0.2 to 1 Hertz, in heart failure under physiological ionic conditions and temperature. Two, beat to beat variability of action potential duration was also significantly increased in heart failure. Three, both IKr and IKs were significantly regulated in heart failure under action potential clamp but only when cytosolic calcium was not buffered. Four, CaMKII inhibition abolished IKs upregulation in heart failure, but did not affect IKr. Five, IKs response to beta-adrenergic stimulation was also significantly diminished in heart failure, and, six, IK1 was also decreased in heart failure regardless of calcium buffering, CaMKII inhibition or beta-adrenergic stimulation.                                 These observations changed when cytosolic calcium was buffered. The action potential prolongation in heart failure was also significant in higher pacing rates. The authors concluded that in heart failure, calcium dependent up regulation of IKr and IKs counter-balances the reduced IK1, maintaining the repolarization reserve, especially at higher heart rates. In physiologic conditions, unlike conditions of strong cytosolic calcium buffering. Under beta-adrenergic stimulation, reduced IKs responsiveness, severely limits the integrated repolarizing potassium current in repolarization reserve in heart failure, increasing the arrhythmia propensity.                                 In the next paper, Christopher Piorkowski and associates report on the feasibility of a combined endo-epicardial catheter approach for mapping the ablation of atrial fibrillation. The authors studied 59 patients with permanents pulmonary veins isolation and had further symptomatic recurrences of paroxysmal atrial fibrillation, persistent atrial fibrillation, or atrial tachycardia. These patients underwent repeat ablation using bi-atrial endo- and epicardial mapping and ablation. Identification of arrhythmia substrates and selection of ablation strategy were based on sinus rhythm voltage mapping. In all patients, endo-epicardial mapping ablation were feasible using standard technologies of catheter access, three dimensional mapping, and radiofrequency ablation.                                 Epicardial mapping and ablation did not add procedural risk. Exclusively, epicardial low voltage substrate were found in 14% of patients. For the first time, novel epicardial conduction abnormalities located in the epicardial fiber network were described in human patients, 19% of the cohort. Epicardial ablation was needed in 80% of the patients. Over 23 months of follow up, freedom from arrhythmia recurrence was 73%. The authors used continuous monitoring and three months blanking period. Freedom from ATR of greater than two minutes was defined as the primary end-point.                                 The authors concluded that endo-epicardial mapping ablation was feasible and safe. Epicardial ablation increases transient mortality of ablation lesions. Further studies will be needed to demonstrate reproducibility and long-term outcomes, and how the technique compares to other methods.                                 In the next article, Michael Wolf and associates examined the long-term results of substrate modification for ablation of ventricular tachycardia using substrate elimination, targeting local, abnormal ventricular activities, or LAVA, post-myocardial infarction. They reported on 159 consecutive patients undergoing first ablation, age 65, 92% with ICDs, 54% with storms, and 73% with appropriate shocks. LAVA were identified in 92% and VT was inducible in 73%. Complete LAVA elimination after ablation was achieved in 64% and non-inducibility was achieved in 85%. During a median follow-up of 47 months, single procedure, ventricular free survival was 55%, 10% storms, and 19% shocks. The ventricular arrhythmia free survival was 73% after one year and 49% after five years.                                 Complete LAVA elimination was associated with improved outcomes, ventricular arrhythmia free survival of 82% at one year and 61% at five years. The subgroup treated with multi-electrode mapping and real-time image integration had improved ventricular arrhythmia free survival, 86% at one year and 65% at four years. Repeat procedures were also performed in 18% of patients. The outcomes improved, 69% ventricular arrhythmia free survival during a median follow-up of 46 months.                                 In a single center study, substrate modification, targeting LAVA for post myocardial infarction ventricular tachycardia resulted in a substantial reduction in ventricular tachycardia storm and ICDs shocks with up to 49% of patients free of arrhythmias at five years after a single procedure. Complete LAVA elimination, multi-electrode mapping, and real-time integration were associated with improved ventricular arrhythmia free survival.                                 In the next paper, Jean-Baptiste Gourraud and associates examined the safety and feasibility of transvenous lead extraction in adults with congenital heart disease over a 20 year period at a single center. The authors reported on 71 transvenous lead extraction procedures in 49 patients with adult congenital heart disease, mean age 38 years in which a total of 121 leads were extracted. The primary indication for extraction were infection in 48%, lead failure in 31%. A laser sheath was required in 46% and a femoral approach in 8%. Complete transvenous lead extraction was achieved in 92% of the leads. 49% of the patients had transposition of the great arteries. In multivariate analysis, lead duration was predictive of transvenous lead extraction failure. No perioperative death or pericardial effusion was observed. Subpulmonary, atrioventricular valve regurgitation increased in eight patients, five of whom had TGA and were independently associated with ICD leak or valvular vegetation.                                 After a median of 54 months of follow up after the first lead extraction, three deaths occurred independently from lead management. The authors concluded that despite complex anatomical issues, transvenous lead extraction can be achieved successfully in most adult congenital heart disease patients using advanced extraction techniques. Subpulmonary AV valve regurgitation is a prevalent complication, particularly in patients with transposition of the great arteries.                                 In the next paper, Gabriela Orgeron and associates examined the incidence of ventricular arrhythmias and follow-up in ARVC patients grouped by the level of indication for ICD placement, based on the 2015 International Task Force Consensus Statement Risk Stratification Algorithms for ICD Placement in arrhythmogenic right ventricular dysplasia/cardiomyopathy. In 365 of arrhythmogenic right ventricular dysplasia/cardiomyopathy patients, the authors found that the algorithm accurately differentiates survival from any sustained VT/VF among the four risk groups, p < 0.001. Patients with a Class I indication had significantly worst survival from VT/VF than patients with a Class IIa indication or a Class IIb. However, the algorithm did not differentiate survival free from VF or V flutter between patients with Class I and Class II indications. Adding Colter results, less than 100 PVCs per 24 hours to the classification, helps differentiate the risk.                                 Patients with a high PVCs burden, greater than 1000 PCVs per 24 hours had a poor survival from both VT/VF and VF and V flutter.                                 In the next paper, Takeshi Kitamura and associates studied eight patients that had bi-atrial tachycardia, a rare form of atrial macroreentrant tachycardia, in which both atria form a critical part of the circuit and were mapped using an automatic, high resolution, mapping system. 708 patients had a history of persistent atrial fibrillation, including septal or anterior left atrial ablation before developing bi-atrial tachycardia. One of the patients had a history of atrial septal path closure with a massively enlarged right atrium. The authors found that 9 atrial tachycardias, with a median cycle length of 334 milliseconds had three different types. Three were peri-mitral and peri-tricuspid reentrant circuit, three utilized the right atrial septum in a peri-mitral circuit, and three utilized only the left atrium and the left right atrial septum.                                 Catheter ablation successfully terminated eight of the nine bi-atrial tachycardias. The authors found that all patients who developed bi-atrial tachycardia had an electrical obstacle on the intraseptal left atrium, primarily from prior ablation lesions.                                 In our next paper, Kwang-No Lee and associates randomized 500 patients with paroxysmal atrial fibrillation to one of two strategies after pulmonary vein isolation. One, elimination of non-PV triggers in 250 patients, group A, or, two, step-wise substrate modification using complex fractionated atrial electrogram or linear ablation until non-inducibility of atrial tachyarrhythmias was achieved, 250 patients in group B. Recurrence of atrial tachyarrhythmias was higher in group B compared to group A. 32% of patients in group A experienced at least one episode of recurrent atrial tachyarrhythmia after the single procedure, compared to 43.8% in group B. P-value of 0.012 after a median follow-up of 26 months. Competing risk analysis showed that the cumulative incidence of atrial tachycardia was significantly higher in group B compared to group A (p= 0.007).                                 The authors concluded that elimination triggers as the end-point of ablation in paroxysmal atrial fibrillation patients decreased long-term recurrence of atrial tachyarrhythmias compare to non-inducibility approach achieved by additional empiric ablation.                                 In our final paper of the month, Roland Tilz and associates reported on 10 year outcome after circumferential pulmonary vein isolation using a double lasso and three dimensional electro anatomic mapping technique. From 2003 to 2004, 161 patients with symptomatic drug refractory paroxysmal atrial fibrillation underwent electro-anatomical mapping guided circumferential pulmonary vein isolation. The procedure end-point was absence of pulmonary vein spikes thirty minutes after isolation, after a single procedure and a median follow up of 129 months, stable sinus rhythm was present in 32.9% of patients based on Holter-ECGs and telephonic interviews. After multiple procedures, mean 1.73 and median follow up of 123.4 months, stable sinus rhythm was seen in 62.7% of patients. Progression towards persistent atrial fibrillation was observed in 6.2%.                                 The authors concluded that although the 10-year single procedure outcome in patients with paroxysmal atrial fibrillation was low, 32.9%, it increased to 62.7% after multiple procedures and the progression rate to persistent atrial fibrillation was remarkably low.                                 That's it for this month but keep listening. Suraj Kapa will be surveying all journals for the latest topics of interest in our field. Remember to download the podcast, "On the beat." Take it away Suraj. Dr Kapa:               Thank you Paul, and welcome back everybody to Circulation’s “On the Beat”, where we'll be discussing hard hitting articles across the electrophysiology literature.                                 Today, we'll be reviewing 22 separate articles of particular interest, published in January 2018. The new year saw plenty of articles that are of particular interest either for the future of our field of for present management of our patients. First, within the realm of atrial fibrillation, we'll review several articles within the realm of anticoagulation and left atrial appendage occlusion.                                 The first article we'll review is by Yong et al in the American Heart Journal, volume 195, entitled "Association of insurance type with receipt of oral anticoagulation in insured patients with atrial fibrillation: A report from the American College of Cardiology NCDR PINNACLE registry." In this publication, the author sought to evaluate the effect of insurance type on the appropriate receipt of anticoagulant therapy, specifically looking at warfarin versus NOACs. They reviewed retrospectively over 360,000 patients and found significant differences in appropriate prescription of anticoagulants, irrespective of which anticoagulant was considered. Medicaid patients received less appropriate anticoagulant prescription than those who were privately insured on Medicare or military insured. Furthermore, those on military or private insurances had a higher rate of NOAC prescription than those with Medicare.                                 Furthermore, there was an even wider disparity in NOAC use than warfarin use amongst differently insured patients. These data are important in that they highlight potential variability in appropriate management of patients based on insurance type. Of course, there are many issues that might impact this, such as health care access or available pharmacy coverage of specific medications. Furthermore, the authors do not dive into the impact on outcomes based on the therapy availability.                                 The next article we'll review is by Jazayeri et al, entitled "Safety profiles of percutaneous left atrial appendage closure and lysis: An analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database from 2009 to 2016" published in the Journal of Cardiovascular Electrophysiology in volume 29 issue 1. Here, the authors sought to evaluate the overall safety profiles of procedures performed with different percutaneous left atrial appendage occlusion devices, including LARIAT and WATCHMAN. They review 356 unique reports and compared outcomes pre- and post- approval of the WATCHMAN device. The look at the specific composite outcome of stroke, TIA, pericardiocentesis, cardiac surgery, and death. They noted that this composite outcome occurred more frequently with WATCHMAN than with LARIATs, and this is irrespective of pre- or post- approval status.                                 These findings highlight the importance of postoperative monitoring in evaluation of overall outcomes. The reason by which there was more frequent negative outcomes in the WATCHMAN than LARIATs need to be considered. Obviously there's several limitations in the MAUDE database, similar with all large databases. However, it does highlight the importance of considering the mechanisms or sure decision making necessary, not just amongst patients and their providers but amongst operators of the staff or amongst physicians and industry executives. To determine how to optimize devices going forward.                                 Speak of left atrial appendage occlusion devices and the potential future of these, we next review an article by Robinson et al, entitled "Patient-specific design of a soft occluder for the left atrial appendage" published in nature biomedical engineering, in volume two in the year 2018. Robinson et al used 3D printing to create a soft, immunocompatible, biocompatible, endocardial implant to occlude the left atrial appendage. They use the individual CT of an in vivo pig to three D print using a specialized material, a left atrial appendage occlusion device, and demonstrated feasibility of achieving adequate occlusion. This paper is important and is one of the initial [inaudible 00:22:03] to how three D printing may be used to optimize patient care. In fact, three D printing has the potential to overturn medical manufacturing and device development.                                 Anatomy tends to be more often patient-specific than not. That's one size fits all implant designs may not be optimal, and resulting exclusion or inadequate occlusion amongst many patients. Decide of three D printable patient specific rapidly prototype soft devices that are biocompatible and hemocompatible, holds the potential to revolutionize the occlusion.                                 Staying in the field of left atrial appendage occlusion, we next review an article by Lakkireddy et al entitled "left atrial appendage closure and systemic homeostasis: The LAA homeostasis study" published in JACC. The authors sought to evaluate the effect of epicardial-versus endocardial left atrial appendage occlusion on systemic homeostasis, including effects on neuro-hormonal profiles of patients. They performed a prospective, single center, observational study, including 77 patients, about half of whom received endocardial versus epicardial device. Interestingly, they noted that the epicardial left atrial appendage occlusion cohort exhibited significant decrease in blood adrenaline, noradrenaline and aldosterone levels. Those are not seen with endocardial devices. Internal epicardial devices are associated with increases in adiponectin and insulin levels as well as a decrease in free fatty acids and consistently lower systemic blood pressure.                                 These data suggest a significant difference in the effect of epicardial versus endocardial closure left atrial appendage on neurohormonal profile. The authors propose several mechanisms for these findings but not the exact mechanisms as yet unclear. Several factors potentially could lead to these findings. One is that epicardial ligation may result in more total ischemia of the left atrial appendage than endocardial closure. Another potential mechanism maybe that the presence for material in the pericardial space versus in the bloodstream may have different effects on neuro-hormonal profile. However, these significant differences in outcomes highlight the importance of considering whether all approaches of left atrial appendage occlusion are considered equal. Many flaws of this study is that it's observational and not randomized. Does it possible those receiving epicardial closure may have been perceived to be lower risk for epicardial puncture, in this, as result, had better long-term outcomes.                                 Changing gears now but staying within the realm of atrial fibrillation, we next review elements for cardiac mapping and ablation. The first article we review is one that has received significant press, published by Marrouche et al entitled "Catheter ablation for atrial fibrillation with heart failure" in the New England Journal of Medicine, volume 378. It is well recognized that morbidity and mortality are higher in heart failure patients who also have atrial fibrillation. Marrouche et al published the results of the CASTLE-AF trial, which attempted to determine if catheter ablation [inaudible 00:24:46] better outcomes among patients with heart failure and atrial fibrillation. They randomized 179 patients to ablation and 184 to medical therapy, which consisted of either rate or rhythm control. Inclusion criteria were those with NYHA class II to IV heart failure, LVEF of 35% or less, and an ICD.                                 The primary endpoint was a composite where the death from many causes or hospitalizations for worsening heart failure. They noted over a median of three as a follow up, the end-point was reached in 28.5% of the ablation group and 44.6% of the medical therapy group, accounting for a significant hazard ratio of 0.62. Furthermore, fewer patients that in the ablation group died from any cause, were hospitalized for worsening heart failure, or died from cardiac causes. These data made a big splash because they're highly supportive of the premise that catheter ablation may be beneficial in some patients with atrial fibrillation and heart failure, often beyond that of medical therapy alone.                                 One major strength of this paper is that the actual AF burden was tracked by the ICD, so we know for sure whether or not the procedure was successful and how controlled the atrial fibrillation was. One thing to note however, is that subgroup analysis suggest that those with more symptomatic heart failure, namely NYHA class III to IV, not benefit as much from ablation. Furthermore, it's also important to note that the five years expected mortality in patients was higher than predicted in the CASTLE-AF trial, however overall these trials highly suggest that the potential benefit that ablation may hold over conventional medical therapy. Extrapolation to comparison with the utility of interventions such as biventricular pace with AV node ablation, however, remains to be considered.                                 Next, we review an article by Chugh et al entitled "Spectrum of atrial arrhythmias using ligament of Marshall in patients with atrial fibrillation" published in Heart Rhythm volume 15, issue 1. They reviewed the spectrum of presentations associated with arrhythmogenesis attributed to the ligament of Marshall, amongst patients with atrial fibrillation. They demonstrate that nearly a third of those patients, ligament of Marshall associated arrhythmias had a pulmonary vein ligament connection, that variously required ablation, the left lateral ridge, the mitral annulus, or alcohol ablation. In addition, they noted about a quarter of patients had atrial tachycardia attributable to the ligament, and the remaining had periatrial reentry requiring either ablation or alcohol injection of the ligament to attain a conduction block.                                 The relevance of this publication, albeit it is of a small number of patients and a small center, lies in highlighting on the right mechanisms by which the ligament of Marshall may contribute to arrhythmogenesis. Namely, can include direct venous connections, inhibition to inaudibility to attain mitral block, and directly attributed atrial arrhythmias. Recognition of the various ways and situations under which the ligament of Marshall may play a role in arrhythmogenesis in atrial fibrillation patients, may optimize physician decisions to look for identify and target the ligaments. What is not as well understood however is the frequency with which ligament of Marshall plays a significant role in arrhythmogenesis in atrial fibrillation.                                 Moving gears, we next review an article by Pathik et al entitled "Transient rotor activity during prolonged three-dimensional phase mapping in human persistent atrial fibrillation" published in a special issue of JACC Clinical Electrophysiology, that focus on atrial fibrillation specifically, in volume 4 issue 1. Pathik et al sought to validate three-dimensional phase mapping system for persistent atrial fibrillation. Commercially available rotor mapping systems project the heart into two dimensions based on a three-dimensional catheter. Instead, Pathik et al used a combination of basket catheters along with the non-left atrial surface geometry to construct three D representations of phase progression. Amongst 9 out of 14 patients, they identified 34 rotors, with all these rotors being transients. Of particular interest, the rotors were only seen in areas of high electric density, where internal electric distances were shorter. They also noted the single wave front is also the most common propagation pattern. The importance of this publication lies in considering two things. First is the three dimensional representation of rotor position and the feasibility of this, and the second is really the high electro-density necessary to observe for others.                                 This has been one of the main problems in rotor analysis, namely what the spacial and temporal density is, that is required to identify rotors, especially given how transient they often are. The presence of rotors does not necessarily mean they're ablation targets in all patients. However, the question still remains regarding the optimal approach to mapping rotors, it needs to be remembered that rotors actually are meant to represent three dimensional scrollway phenomena, that cannot necessarily always be reflected in traditional two D mapping schema. Furthermore, to be remembered that when we claim three-dimensional mapping, this just reflects a two-dimensional surface being wrapped in three dimensions to reflect overall internal surface geometry but it does not take into account transmural activation.                                 Thus, taking into account all these elements it should be remembered as sometimes, it is possible that a rotor might exist but it's just not evident based on the two-dimensional representation or a two-dimensional representation that looks like a rotor may in fact not be a rotor when you consider it in a three-dimensional media.                                 Our last article within the realm of cardiac mapping and ablation we will consider is by Zghaib et al, entitled "Multimodal examination of atrial fibrillation substrate: Correlation of left atrial bipolar voltage using multielectrode fast automated mapping, point by point mapping, and magnetic resonance imaging intensity ratio", published in JACC Clinical Electrophysiology, in the same volume as the previous article. The authors sought to compare fast automated mapping with multiple electrodes versus point by point mapping and correlate with weighed gadolinium enhancement as seen by MRI, termed the image intensity ratio.                                 We all recognize that bipolar voltage is critical to recognizing and evaluating substrate. It's traditionally used in decay regions of substrate in both the atrium and ventricles. However, whether a newer automated approach used to characterize substrate perform equally well in comparison with traditional point to point mapping is still unknown. Thus, the authors in 26 patients perform cardiac MRI and mapping endocardial using both voltage mapping techniques. They noted that for each unit increase in image intensity ratio on MRI, in other words, increasing late enhancement, there was 57% reduction of bipolar voltage. They also noted that the bipolar voltage using other fast elevating mapping or point by point was significantly related with actual differences in calculated voltage, becoming more dissimilar in the extreme of high and low voltage areas.                                 The relevance of this publication is highlight in the potential utility of fast automated mapping in creating accurate voltage maps. The correlation of voltage values with image-intensity ratios suggest the utility of either approach. In turn, correlation with MRI suggest a pathologic correlate for all of these findings. However, whether substrate characterization guide ablation carries incremental benefit remains to be seen.                                 Changing gears but staying in the realm of atrial fibrillation, we next review elements of risk stratification and management. The first article we review is by Friedman et al, entitled "Association of left atrial appendage occlusion and readmission for thromboembolism amongst patients with atrial fibrillation undergoing concomitant cardiac surgery", published in JAMA, volume 319, issue four. Friedman et al sought to evaluate whether surgical left atrial appendage occlusion let to a reduction in long-term thromboembolic risk in a large database of Medicare recipients. They included the primary outcome as readmission for thromboembolism, including stroke, TIA, or systemic embolism, in up to three years of follow-up. With secondary end-points including hemorrhagic stroke, all-cause mortality, and a composite end-point of all outcomes.                                 Amongst more than 10,000 patients, there were almost 4,000 patients receiving surgical occlusion of left atrial appendage. Surgical occlusion was associated with a reduction in thromboembolic risk, OR of 6%, all cause mortality, 17 versus 24%, and the composite end-point, 21 versus 29%. However, interestingly, surgical occlusion was only associated with reduction in thromboembolic risk compared with no occlusion amongst those discharged without anticoagulation and those discharge with it. Namely, the thromboembolic risk reduction was primarily seen in those where the surgical occlusion, those who were sent home without any sort of anticoagulation. These data suggest that surgical occlusion leads to reduction of thromboembolic risk overall. As any large database based study, there are massive flaws in the database itself. Namely, we're relying on the coding of hospitals and operators. To know exactly what was done and what happens latter.                                 However, these data are hypothesis generating. One key element is the fact that surgical left atrial appendage occlusion was only superior in reducing thromboembolic risk amongst those discharged without anticoagulation. This raises the question as why. Was left atrial appendage completely closed in these patients? In which case, they may be at further increased risk or that the operators felt that there is a high risk for other reasons that cannot be cleaned from an administrative datasets? While the data support consideration of the benefit of left atrial appendage occlusion in a surgical manner, a kin to what has been seen in papers on WATCHMEN and other approaches, and how is the critical nature of randomized trials in this regard.                                 We next review an article published in JAMA Cardiology, volume three issue one by Inohara et al, entitled "Association of atrial fibrillation clinical phenotypes with treatment patterns and outcomes: A multicenter registry study." Traditionally classification of AF has depended largely on factors such as the nature of AF, paroxysmal versus persistent, LA size, and other factors such as extend of the late enhancement. Inohara et al sought to evaluate whether cluster analysis could better define heterogeneity of AF in the population. They included an observational cohort of almost 10,000 patients admitted to 124 sites in the United States in the ORBIT-AF registry.                                 Outcome was a composite major address cardiovascular and neurological events or major bleeding. Amongst these patients, they identified four clusters, including one those with lower rates of risk factors and comorbidities than other clusters, two, those with AF at younger ages and with comorbid behavior disorders. Three, those with AF with tachycardia-bradycardia type syndromes and had devices for sinus node dysfunction, and four, those with AF with other risk factors such as a coronary disease. Those in the first cluster had significantly lower risks of major events. All clusters were noted to have symptom dissociation to specific clinical outcomes.                                 These data are interesting and highlight the highly heterogeneous nature of classifying risk attributable to atrial fibrillation. When broad datasets associated atrial fibrillation with specific outcomes. Maybe suggest an attribution to all patients with atrial fibrillation. However, this single relationship was specific to the outcomes suggest the limitation of applying outcome as approach to understand atrial fibrillation impacts and outcomes, namely depending on clusters that may take into account patient age or comorbidities, it may be irrelevant in discriminating patient outcomes than the traditional paradigm in the same paroxysmal versus persistent or depending on the left atrial size.                                 These data also highlight the importance of considering the inclusion criteria in randomized trials of atrial fibrillation before stripling real world outcomes to patients who don't fit within that trial.                                 Next, we will be reviewing an article by Chou et al entitled "Relationship of aging and incident comorbidities to stroke risk in patients with atrial fibrillation," published in JACC, volume 71 issue two. Chou et al sought to evaluate the effect of aging and evolving instant comorbidities to stroke risk in patients with atrial fibrillation. Many large database studies or trials where added baseline CHADSVASC score and the then ensuing follow up period to define risk over time of ischemic stroke.                                 The authors hypothesized that as patients age, develop new comorbidities that would change the score, may be more predictable of long-term outcomes than the score itself. They included over 31,000 patients who do not have comorbidities to CHADSVASC aside from age and sex but had atrial fibrillation. They didn't calculate a delta score defined as the difference between the baseline and follow up scores. The mean baseline score was 1.29 with an increase in 2.3 during follow up, with an average delta of one. The score may not change over follow up in 41% of patients. Interestingly, significantly more patients had a delta CHADSVASC of one or more and develop ischemic stroke than non-ischemic stroke. The delta CHADSVASC was shown to better predictor of ischemic stroke than either baseline or follow up CHADSVASC score. This data suggest that additive shifts in the CHADSVASC score over time may be more predictive of stroke risk than the actual score itself.                                 These findings are thoughtful and logical. They indicate the potential impact of continued aging or acquisition identification of new comorbidities. In some patients, potential discovery or new comorbidities or follow-up; for example, hypertension and coronary artery disease may lead to reclassification of stroke risk. That is important to maintain close follow up of atrial fibrillation patients, and not to show a continued need or lack of need of anticoagulation on the basis of a baseline evaluation. This also holds relevance single center long-term outcomes in patients specific scores. Whether is acquisition of new comorbidities or presence of baseline comorbidities or predict a long-term score, should we consider when assessing the need for anticoagulation, particularly in perceived initially low risk cohorts who go on to develop ischemic stroke.                                 Lastly, within the realm of atrial fibrillation, we review an article by Hussain et al, entitled "Impact of cardiorespiratory fitness on frequency of atrial fibrillation, stroke, and all-cause mortality" published in the American Journal of Cardiology, volume 121 issue one. Hussain et al review the effect of cardiorespiratory fitness on overall outcomes and incidence of atrial fibrillation and outcomes amongst patients with atrial fibrillation. Amongst over 12,000 individuals prospectively followed up after treadmill exercise test, they noted 1,222 had a incidence of AF, 1,128 developed stroke, and 1,580 died. For every 10% increase in functional layover capacity, there was a 7% decrease in risk of incident AF, stroke, or death.                                 Similarly, in those who developed AF, stroke was lower in those with higher functional aerobic capacity. These findings support the notion known to other areas of cardiovascular disease that better cardiorespiratory fitness is associated with better outcomes, in this case to stroke, incident AF, or mortality. Furthermore, even on the presence of AF, those with better functional capacity had a lower risk of stroke. These data highlight the continued importance of counseling patients on the benefits of physical fitness even in the setting of already present AF.                                 Moving on to a different area of electrophysiology, we review the realm of ICD pacemakers and the CRT.                                 The first article review is by Sze et al entitled "Impaired recovery of left ventricular function in patients with cardiomyopathy and left bundle branch block" published in JACC volume 71 issue 3. Patients with left bundle branch block and cardiomyopathy are known to respond to CRT therapy. Thus the investigators sought to evaluate whether guideline medical therapy in patients with reduced LVEF and left bundle branch block, afford a beneficial first line approach therapy. The reason for this currently guidelines suggest waiting at least three months before consideration of CRT has had as some patients may recover on guideline directed medical therapy without the need for device implantation.                                 They review patients with a LVEF of less or equal than 35% and baseline ECG showing left bundle branch block. In evaluating left ventricular ejection fraction at follow up of three to six months. They excluded patients with severe valvular disease, and already present cardiac device, an LVAD, or heart transplant. Among 659 patients meeting criteria, they notice 74% had a narrow QRS duration of less than 120 whereas 17% had QRS duration greater than 120, and the remainder had a QRS duration greater 120 but was not left bundle branch block. The mean increase in the left ventricular ejection fraction on guideline directed medical therapy was in those with a narrow QRS duration and least in those with left bundle branch block, 8.2%.                                 Furthermore, when comparing mean LVEF improvement, those with on versus non-on guideline directed medical therapy, there was virtually no difference in rates of recovery. Furthermore, composite end-point of heart failure hospitalization mortality was highest in those with left bundle branch block. These data suggest that those with bundle branch block and cardiomyopathy received less overall benefit from guideline directed medical therapy over the three to six months follow up period. Whether this is due to already more severe myopathic process to start with or due to the CRT is unclear. However, it may suggest that in some patients, left bundle branch block may benefit from inclusion of CRT early in their disease course as known the significant number of patients up to three to six months guideline directed medical therapy with insufficient DF recovery may then benefit from CRT. As well as intervening earlier may result in better outcomes, especially knowing the high and term raise mortality in heart failure hospitalization remains to be seen.                                 A trial studying early implantation of CRT on these patients may be relevant.                                 The next article review is by Gierula et al entitle "Rate-response programming tailored to the force-frequency relationship improves exercise tolerance in chronic heart failure" published in JACC Heart Failure, in volume six, issue two. The authors sought to evaluate whether tailored rate-response programming improved exercise tolerance in chronic heart failure. The double blinded, randomized, control, crossover study, they compared the effects of tailored programming on the basis of calculated force-frequency relationship, defined as including critical heart rate, peak contractility, and the slope, multidimensional programming and exercise time and maximal oxygen consumption. They demonstrate amongst 98 enrolled patients that rate-response settings limiting heart rate raise to below the critical heart rate led to create exercise timing and higher peak oxygen consumption.                                 These data suggest that personalizing rate-response therapies may improve exercise time and oxygen consumption values in patients with heart failure and pacing devices. The main limitation of the study is that the number of patients was small, 90, and then the number of patients crossing over was even smaller, 52. However, highlights the potential of working closely between device programmers and consideration of individual's characteristics and their exercise needs in determining optimal programming strategy.                                 Finally, within the realm of devices, we review an article by Hawkins et al, entitled "Long-term complications, reoperations, and survival following cardioverter defibrillator implant" published in Heart, volume 104 issue three. Hawkins et al sought to evaluate the long-term complications and risk of reoperation associated with defibrillator implantations in a large [inaudible 00:41:56] population of 300,410 patients, they noted over a 30-month follow up period there was a 12% reoperation rate within the year of implant. This is most prominent for CRT devices, with a risk of 18% in one year post-implant. Furthermore, CRT had the highest rate of early complications, with device complexity, age, or the presence of atrial fibrillation being significantly associated with complication risk.                                 Mortality also increased over time from 5% within the first year to nearly a third after five years. However, younger patients exhibited five years survival similar to the general population with a progressive decline of this as older patients were considered. These findings highlight several critical issues. First, they report a high one year reoperation rate for a variety of reasons. This finding highlights the importance of considering protocols to minimize the need for reoperation. Furthermore, they note the higher rate amongst CRT patients, with seems logical given the likely longer associated procedural risk and need for more leads. Finally, the impact of age on expectant survival are to be taken into consideration with the device and the life-saving potential of the defibrillator.                                 Moving on to cellular electrophysiology, review one article by Zhang et al, entitled "Reduced N-type calcium channels in atrioventricular ganglion neuron are involved in ventricular arrhythmogenesis" published at the journal of the American Heart Association, in volume seven issue two. Zhang et al reported a rat model of ventricular arrhythmogenesis and characterized the role of atrioventricular ganglion neurons in risk of arrhythmogenesis as well as the mechanism for this risk this model relates in humans to the attenuated cardiac vagal activity in heart failure patients, which is known to relate to their arrhythmic risk. The demonstrated reduced N-type calcium channel in these AV ganglion neurons, which project innervating systems to the myocardium, resulting in increased risk of PVCs, and increased susceptibility to induction of ventricular arrhythmias with programmed stimulation.                                 The relevance of the intrinsic cardiac nervous system arrhythmogenesis has become increasingly prominent as methods to study it have improved. Understanding the direct and most relevant inputs may facilitate better understanding of risk of arrhythmias in patients. In the case of this study by Zhang et al, the critical finding is that disorder of the atrioventricular ganglion neurons may lead to increased susceptibility for ventricular arrhythmogenesis. Clinical relevance includes consideration of effects on this specific ganglion when performing ablation on for other conditions, and potential long-term effect on arrhythmogenic risk, as well as potentially relevant functional explanations for arrhythmogenesis.                                 Moving on to the genetic channelop, these are considered two separate articles. The first one by Bilmayer et al, entitled "ExomeChip-Wide analysis of 95,626 individuals identified ten novel loci associated QT and JT intervals" published in Circulation: Genomic and Precision Medicine, in volume 11 issue 1. This whole exome study reviewed several novel loci that modified the QT and JT intervals. They include over 100,000 individuals and identified ten novel loci not previously reported in the literature. This increases the number of known loci that impact from ventricular portal adjacent by nearly one third. These loci appear to be responsible for myocyte and channel structure and interconnections that internally impact the ventricular repolarization.                                 While long QT syndrome be characterized amongst the known genes in 75% of affected individuals, that also means one fourth long QT syndrome cannot be characterized based on known genes impacting ventricular repolarization. The identification of novel loci or novel that may be affect repolarization kinetics to unique means are critical to define novel therapies as well as in genetic counseling the patients in potential effects on family members when screening them for potential disease risk. These findings should assess an opportunity for further studying the mechanisms by which these loci modulate QT and JT intervals and the potential contribution to phenotypic risk.                                 The second paper within this realm we review is by Zumhagen et al, entitled "Impact of presynaptic sympathetic imbalance on long QT syndrome by positron emission tomography" published in Heart, volume 104. The authors sought to evaluate by a PET scan the impact of sympathetic heterogeneity on long-QT syndrome risk. Amongst 25 patients with long-QT syndrome, including long-QT type I and II, and 20 ostensibly healthy controls, they noted that regional retention in disease were similar between affected patients and controls. However, regional washout rates were higher in the lateral left ventricles in patients with long-QT syndrome. Internal global washout rates were associated with greater frequency of clinical symptoms. That's there seem to be some relationship between regional and global sympathetic heterogeneity, particularly during washout, with overall risk in long-QT syndrome patients.                                 These findings report the notion for sympathetic imbalance, partly mediating the risk attributable to long-QT syndrome. The findings on PET suggest regional imbalance of presynaptic cathecholamine and reuptake and release, being one mechanisms. This was most prominent in long-QT I patients who also often drive most benefit from left sided sympathectomy. The novelty of these findings is in the potential role of imaging to determine basic contributors to congenital long-QT syndrome in given patients. The larger prospect of size would really need to be evaluated this further.                                 Moving on to the realm of ventricular arrhythmias, we review three different articles. The first one, by Hamon et al, entitled "Circadian variability patterns predict and guide premature ventricular contraction ablation, procedural disability, and outcomes" published in Heart Rhythm, volume 15 issue one. Hamon et al sought to evaluate whether circadian variability of PVC frequency can predict optimal drug response intraprocedurally during PVC ablation. One of the main problems of PVC ablation is when PVC are infrequent and tend to disappear during the procedure, achieving procedural success or attaining sufficient frequencies of PVCs to map becomes very difficult. Next, they use Holter monitoring in the ambulatory stripe to define three groups. Those of higher PVC burden during faster heart rates, those with higher PVC burden during slower heart rates, and those with no correlation between their PVCs burden and their heart rate.                                 More than half the one hundred and one patients included a high burden of PVCs at fast rate while 40% had no correlation between the two and 10% had higher burden in slower heart rates. Almost one third of patients taken for ablation have infrequent PVCs during a procedure, while the best predictor of this being a low ambulatory PVC burden of less than 120 per hour. Isoproterenol infusion was only useful in lessening PVCs in those with PVCs associated with fast heart rates. The isoproterenol washout or phenylephrine where used with those associated with slower heart rates.                                 Interestingly, not a single drug was effective in inducing PVCs in those with infrequent PVCs that have not heart rate correlation in the ambulatory stages. They noted that outcomes ablates were similar amongst those with higher heart rate associated PVCs and non-heart rate correlated PVCs previously responded to a drug. But, [inaudible 00:48:08] noted only a 15% success rate from ablation in infrequent PVCs in patients who lacked correlation between PVC burden and heart rate and who were unresponsive to drug previously. These data are important highlighting the potential for further defining idiopathic PVC ablation needs and likelihood of success based on ambulatory data, by correlating PVC burden with heart rate and their circadian variability, it's possible to predict likelihood specific intraoperative drugs working when dealing with infrequent intraprocedural PVCs.                                 Furthermore, the finding of lack of correlation with slower or fast heart rate in terms of PVC burden is associated with the poor success rate unless those PVCs are drug responsive. Highlights the potential benefit of performing preoperative antiarrhythmic drug testing to get likelihood of ablation success in this patients.                                 The next article we review is by Lee et al, entitled "Incidence and significance of the lesions encountered during epicardial mapping and ablation of ventricular tachycardia in patients with no history of prior cardiac surgery or pericarditis" published in Heart Rhythm, volume 15 issue one. Lee et al sought to determine the frequency of pericardial lesions, impeding mapping in patients without prior surgery, operative procedure, or pericarditis, in other words virgin hearts. Amongst 155 first time attempts of access, 8% had pericardial lesions. The only clinical predictor was the presence of severe renal impairment.                                 In addition, no patients with supposedly normal hearts had a lesions. Notably, those with a lesion had more frequent impairment in mapping and lower overall success rates; there were similar complication rates as those without the lesions. These data are relevant in highlighting the ease of mapping of pericardial access may not always be present, even when dealing with inversion of pericardial space. A lesion may be present in patients, particularly with severe renal disease. Advising patients of this possibility prior to the procedure and considering that epicardial access may be impaired in a fair number of patients, even the absence of prior history of surgery, epicardial access or pericarditis isn't important.                                 The final article we'll review within the realm of ventricular arrhythmias is by Kumar et al, published in Journal of Cardiovascular Electrophysiology, volume 29 issue one, entitled "Right ventricular scar-related ventricular tachycardia in nonischemic cardiomyopathy: Electrophysiological characteristics, mapping, and ablation underlying heart disease." Kumar et al sought to evaluate the substrate and outcomes associated with right ventricle scar related ventricular tachycardia ablation in nonischemic patients at large, but particularly in those with neither stroke or coronary artery disease as potential explanations for this scar. They reviewed 100 patients consecutively over half of whom had ARVC and the remainder was sarcoid or RV scar of unclear origin. Those with RV scar of unknown origin tend to be older compared to the ARVC patients, and had more severe LV dysfunction compared with saroid patients.                                 However, the scar distribution extend was similar within all these groups. Furthermore VT/VF survival was higher in those with RV scar of unknown origin. The velocity of survival free or death or cardiac transplant and VT/VF survival seen in sarcoid patients. These data suggest that close to one third of patients, RV scar related VT may have VT of unknown cause. Total outcome was superior overall to those with defined myopathic processes. What's most interesting is, over follow up, none of those with RV scar of unknown origin develop any further findings to reclassify them as sarcoid or ARVC. It is possible this group reflects some mild form of either disease however. Again, the exact pathophysiologic process remains unclear. These findings may help in counseling patients who are in long-term expected outcomes from ablation intervention.                                 The final article we'll review this month is within the realm of other EP concepts that may be broadly applicable, published by van Es et al, entitled "Novel methods for electrotissue contact measurement with multielectrode catheters", published in Europace, volume 20 issue one. In this publication, the authors sought to evaluate the potential utility of a novel measure on evaluating electro tissue contact. With multielectrode catheters it is known that one of the problems with assessing contact is a contact force that cannot be used. Electro with coupling index is often used but even this has fragile problems, especially when you get into high impedance areas, that can be affected by surrounding ion impedance structures. Due to the fact that measuring contacts forces challenging in such multielectrode catheters, the authors measure electric interface resistance by applying a low level electrical field, pushing neighboring electrodes. They compared the effectiveness of assessing contact by this approach without using contact force in a poor side model.                                 They know that this measure was directly correlated with contact force in measuring tissue contacts. These findings support a role for aversion of an active electrode location and determining tissue proximity and contact-based on the coupling between the electrodes on multipolar catheters in the tissue. These findings may be highly useful when there is a variety of catheters where contact force cannot be implemented. Further studies on the methods and cutoff to establish tissue proximity on the end of contact will be also needed.                                 To summarize, however, as a term was brilliant here that was not well explained, active electrical location is actually a phenomenon that occurs in nature. This is seen in deep sea fish, which actually have multiple electrodes oriented around its body. They emit a small electrical field that results in a general impedance field surrounding the fish. This essentially is the way of visualizing the world around them. Perturbations based on proximity to different structures, whether they are live or death, and based on whether they are live or death, results in changes in the perturbations of this resistive fields, resulting in proximity determination by the fish. Several individuals are looking into potential applications of this to understanding tissue proximity when using catheters in the body. This consideration of impedance is fundamentally different than the traditional measure impedance were used by traditional generator.                                 I appreciate everyone's attention to this key and hardening articles that we've just focus on or this past month of cardiac electrophysiology across literature. Thanks for listening. Now back to Paul. Dr Wong:             Thanks Suraj, you did a terrific job surveying all journals for the latest articles on topics of interesting in our field. There's not an easier way of staying in touch with the latest advances. These summaries and the list of all major articles in our field for month can be downloaded from the Circulation: Arrhythmia and Electrophysiology website. We hope that you find the journal to be the go to place for everyone interested in the field.                                 See you next month.  

Dr. Paul Wong:                  Welcome to the monthly podcast, On The Beat, for Circulation: Arrhythmia and Electrophysiology. I'm Dr. Paul Wong, editor in chief, with some of the key highlights from this month's issue. We'll also hear from Dr. Suraj Kapa, reporting on new research from the latest journal articles in the field. In our first article, Ratika Parkash and associates examined whether the outcomes following escalated antiarrhythmic drug therapy, or catheter ablation, depended on whether ventricular tachycardia with amiodarone refractory or sotalol refractory in patients with prior myocardial infarction in the VANISH study. At baseline, 169, or 65%, were amiodarone refractory, while the remaining were sotalol refractory. Amiodarone refractory patients had more renal insufficiency; 23.7% versus 10%. Worse, new ARC Heart Association class, 82.3% versus 65.5% class II or III; and lower ejection fraction, 29% versus 35%. Within the amiodarone refractory group, ablation resulted in a reduction of any ventricular arrhythmias compared to escalated drug therapy, with a hazard ratio of 0.53, P = 0.02. Sotalol refractory patients had trends towards higher mortality in VT storm with ablation, with no effect on ICD shocks. Within the escalated drug arm, amiodarone refractory patients had a higher rate of composite endpoint, with a hazard ratio of 1.94 and a P value of 0.01. In a trend toward higher mortality, hazard ratio 2.4, P = 0.07. While mortality was not different between amiodarone and sotalol refractory patients within the ablation treatment group. In our next study, Junaid Zaman and associates examined 57 cases in which local ablation of persistent atrial fibrillation terminated to sinus rhythm or organized tachycardia. The authors analyze unipolar electrograms collected during atrial fibrillation from multi-polar basket catheters to reconstruct isochronal activation maps for multiple cycles, and computational modeling and phase analysis were used to study mechanisms of map variability. At all signs of atrial fibrillation termination, localized, repetitive activation patterns were observed, 21% with complete rotational activity, 46% with partial rotational circuits, and 33% with focal patterns. In computer simulations incomplete segments of partial rotations coincided with areas of slow conduction, characterized by complex, multi-component electrograms. In our next article, Matthew Kalscheur and associates sought to use a novel machine-learning approach to predict outcomes following resynchronization therapy in the companion trial. The random forest algorithm resulted in the best performing model. In 595 CRTD patients in the companion trial, 105 deaths occurred, with a median follow-up of 15.7 months. The survival difference across subgroups differentiated by bundle branch block morphology and cure restoration did not reach significance, P = 0.08. The random forest model, however, produced quartiles of patients with an eight-fold difference in survival between those with the highest and lowest predictive probability for events, hazard ratio 7.96 with a P value of less than 0.0001. The model also discriminated the risk of composite endpoint of all cause mortality, or heart failure hospitalization, better than subgroups based on bundle branch block morphology and cure restoration. Future studies are needed to validate this model in other populations. In our next paper, Amr Barakat and associates examined the clinical outcomes of trans-venous lead extraction for CIED infection based on renal function. The authors examined 1,420 consecutive patients undergoing trans-venous lead extraction of infected CIEDs over a 14 year period. Groups with normal renal function, Group 1, consisting of 1,159 patients, Group 2, 163 patients with renal dysfunction not requiring dialysis, and Group 3, 98 patients on dialysis. Complete procedural success rates were comparable in the three groups: 94%, 96%, and 94% in Groups 1, 2 and 3, respectively. This was not statistically significant. The mortality rates were significantly higher in dialysis patients at one month. The procedure-related complication was 12.2% in dialysis patients versus 6.5% in Group 1 and 6.1% in Group 2. Other factors associated with mortality were lead material retention, functional New York Heart Association Class, and occurrence of procedural complications. In our next paper, Eric Johnson and associates studied the contribution of the current ITO, two left ventricular re-polarization in the human heart, since the current has been shown to have an important role in animal models. The authors found that using whole-cell voltage clamp recordings from myocytes, isolated from the left ventricle, non-failing human hearts, that there were two, distinct transient currents, ITO fast and ITO slow. The two currents have significantly different rates of recovery from inactivation and pharmacological sensitivities. ITO fast recovers in about 10 milliseconds, 100 times faster than ITO slow, and it's selectively blocked by KV4 channel toxin SNX 482. Using current clamp experiments, they found that regional differences in action potential wave forms, with a notch in phase one in the left ventricular subepicardial myocytes. In failing, left ventricular subepicardial myocytes, ITO fast was reduced, while ITO slow was increased. In addition, the notch and plateau potentials were depolarized, and action potential durations were prolonged, both statistically significantly. Slowing ITO fast inactivation results in a dramatic action potential shortening. The authors concluded that remodeling of ITO fast in failing, human left ventricular subepicardial myocytes, attenuates transmural differences in action potential wave forms. In our next paper, Ravi Vaidyanathan and associates examine the interaction between Caveolin 3 domain in the inward rectifier potassium channels. Although the IK1 current is mainly composed of Kir2.1, there are Kir2.2 and Kir2.3 heterotetromerisoforms that occur and modulate the IK1 current, but these have not been studied. Kir2.x isoforms have unique, subcellular co-localization in human cardiomyoctyes and co-immunoprecipitate with Cav3. Using induced pluripotential stem-cell-derived cardiomyocytes, the LQT9 Cav3 mutation, F97CCav3 resulted in actual potential prolongation. Based on the technique FRET, which is Fluorescent Resonance Energy Transfer, the authors calculated the distance between KR2.2 and cath ray proteins to be 6.61 nanometers. LQT9 is caused by Cav3 mutations. Prior work has shown that F97CCav3 mutation increases the late sodium current, and decreases KR2.1 current density by distinctive mechanisms. This study extends the authors' previous observations on the impact of LQT9 Cav3 mutation on Kir2.1 current, by demonstrating that mutation affects the Kir2.2 current. LQT9 causing Cav3 mutation differentially regulates current density and cell surface expression of Kir2.x homomeric and heteromeric channels. The authors show that the mutation does not affect Kir2.3 current, but the heterotetromer Kir2.2-2.3 demonstrated loss of function. Using the Li-Rudy [inaudible 00:09:45] model and myocyte mathematical model, the authors' data suggest that both loss of IK1 and increased sodium L are required for arrhythmia generation in LQT9. In our next study, Christophe Teuwen and associates use high resolution epicardial mapping electrodes, 128 or 192, with an inter-electrode distance of 2.0mm of the entire atrial surface in 164 patients. These patients were undergoing open-chest cardiac surgery. This study was designed to examine the conduction of atrial extrasystoles. The authors found that a higher degree of aberrancy was associated with a higher instance of conduction disorders. Most conduction disorders were provoked by atrial systoles emerging as epicardial breakthroughs. Atrial extrasystoles cause most conduction disorders in patients with left atrial dilatation or diabetes mellitus. In our next paper, Yuki Komatsu and associates examine 31 patients with idiopathic ventricular arryhthmias, using a two french microcatheter placed in a communicating vein between the great cardiac vein and small cardiac venous system, which passes between the aortic and pulmonary annulae, and is located in close associated with the left ventricular summit. They found that 14 patients had summit ventricular arryhthmias. The remaining 17 patients control group had ventricular arryhthmias originate from the right ventricular outflow track in the aortic cusps.  In patients with summit ventricular arryhthmias, the earliest activation during ventricular arryhthmias in the summit, preceded to cure as onset by 34 milliseconds. The summit ventricular arryhthmias exhibited inferior axes, negative polarity in lead one, deeper Q wave in AVL than AVR, nonspecific bundle branch morphology with an RS ratio in lead V1 of 0.67, distinguishing them from arryhthmias originating from the right ventricular outflow track or right ventricular cusp. Overall, ablation success was achieved in 10, or 71% of patients with summit ventricular arryhthmias, and 88% in the control group, P = 0.24. In our final paper, Deepak Padmanabhan and associates examine differences in mortality in patients with non-MRI conditional CID undergoing brain MRI compared to controls. Patients with CIDs undergoing brain MRI were compared with three control groups matched for age, sex, imaging year, and type of CID. These groups included 1) no CID and brain MRI, 2) CID in brain-computed CT, and 3) no CID in brain CT. They estimated all cause mortality at five years for CID MRI group, was not significantly different from patients who underwent CT, with or without a device. There was a significant increase in the mortality between CIED versus no CID MRI groups, hazard ratio 1.46 with a P value of 0.04. That's it for this month, but keep listening. Saraj Kapa will be surveying all journals for the latest topics of interest in our field. Remember to download the podcasts On the Beat. Take it away Saraj. Saraj Kapa:                          Thank you Paul, and welcome back to On the Beats where this month we'll be focusing on articles that are particularly hard-hitting, published across the literature in December of 2017. It's my pleasure to introduce 20 different articles that seem to have either particular interest or might change the field in the future. First, within the area of atrial fibrillation, we'll focus within the area of anticoagulation and stroke prevention. In the Journal of the American College of Cardiology, Vivek Reddy et al published on the five-year outcomes after left atrial appendage closure, from the Prevail and Protect AF trials. They included a total of 1,114 patients, with a total of 4,343 patient years of follow-up, randomized two to one to closure versus Warfarin. While ischemic stroke and systemic embolism of [inaudible 00:14:32] were numerically higher with closure, this did not reach statistical significance in terms of hemorrhagic stroke, unexplained death, and post-procedure bleeding favor left atrial appendage closure. These findings further support a role for left atrial appendage closure in the specific groups of patients enrolled in the Protect and Prevail Studies. Of course, we always need to understand, that extrapolation to patients who may not have met inclusion criteria will be difficult. In particular, given both trials had their own fundamental limitations in the Prevail study. There was a relatively low rate of [inaudible 00:15:09] in the Warfarin arm. And in turn, there was a relatively high complication rate in Protect AF with left atrial appendage closure. Part of the differences might be due to the fact that, with more experience, complication rates might decrease. Furthermore, a comparison with more novel agents, such as the new oral anticoagulants, remains to be seen. Next, within the realm of cardiac mapping and ablation for atrial fibrillation, we review an article by Vlachos et al published in the Journal of Cardiovascular Electrophysiology entitled Low-Voltage Areas Detected by High-Density Electroanatomical Mapping for Recurrence of Ablation after a Paroxysmal Atrial Fibrillation. They presented the results from a series of 80 patients undergoing ablation for paroxysmal atrial fibrillation, performing high-density voltage mapping to characterize the total area involved by low voltage. They demonstrated, when low voltage areas, defined as less than 0.4 millivolts, were seen in greater than 10% of the left atrial surface area, this served as an independent predictor of atrial fibrillation recurrence. These data support prior research, including that of MRIs, suggesting the characterization of the atrial substrate may correlate with likelihood of ablation success. Identifying methods however, to accurately and reproduce will identify these patients with more atrial substrate prior to ablation, remains to be seen. The importance of this, however, is our ability to better counsel patients on the likelihood of treatment success. Next within the realm of atrial fibrillation, we review elements of risk stratification managements. First, in the December issue of the Journal of American College of Cardiology, Takimoto et al published on how Eplerenone may reduce atrial fibrillation burden without preventing atrial electrical remodeling. In a randomized controlled ovine atrial tachy pacing model of atrial fibrillation. The authors provided daily, oral Eplerenone and compared this with a placebo. They showed that Eplerenone significantly reduced the rate of left atrial dilatation, with less smooth muscle actin protein, atrial fibril [inaudible 00:17:17]. Furthermore, Eplerenone further prolonged the time to persist in atrial fibrillation in 26% of animals. However, interestingly, Eplerenone did not prevent AF-induced electrical remodeling.  These data suggest that Eplerenone, or other medications that can be used to prevent or reverse structural remodeling, may offer an upstream therapy to reduce atrial fibrillation burden, and decrease likely the persistent atrial fibrillation. Giving the ever-growing population of patients suffering from atrial fibrillation, identifying upstream approaches to prevent it will be critical. Of course, these need to be taken with due consideration, however. Specifically, the model used here, namely that of an atrial tachy pacing model, might not be applicable to all human atrial fibrillation. Thus, whether or not such therapies actually offer benefit in clinical models, is as of yet unclear. Finally, from the realm of atrial fibrillation, we review the article by Rowin et al published in circulation entitled Clinical Profile of Consequences of Atrial Fibrillation Hypertrophic Cardiomyopathy. In patients presenting with hypertrophic cardiomyopathy, atrial fibrillation is known to be a significant co-morbidity. However, the implications of atrial fibrillation in terms of worsening of heart failure status, or long-term morbidity mortality are less clear. Rowin et al reviewed the natural history of atrial fibrillation amongst 1,558 patients, prospectively followed at a single center. Nearly 20% of the population developed atrial fibrillation with the majority having symptomatic paroxysmal atrial fibrillation. However, atrial fibrillation was not associated with any increase in cardiovascular mortality or worsening of heart failure status. Furthermore, mortality that was directly related to atrial fibrillation was nearly exclusively related to thrombolic stroke. Anticoagulation [inaudible 00:19:13] reduced this risk. The traditional scoring systems fared poorly in assessing the stroke risk of this population. About 121 patients underwent invasive rhythm control approaches, including 72 patients undergoing maze and 49 catheter ablation. The success rate of maze was significantly greater at around 75%. These data are important when counseling hypertrophic cardiomyopathy patients presenting with new-onset atrial fibrillation. While it is clear that paroxysmal atrial fibrillation has a significant impact on symptoms and quality of life, it does not cause worsened, overall, long-term outcomes. However, it does highlight the importance of anticoagulation in this population, nearly irrespective of the underlying risk score. In terms of rhythm control options, it appears that rhythm control options can be successful in these patients. Finding that catheter ablation is associated with a 40 to 50% success rate is in keeping with prior published data. Thus, consideration of when a patient needs to be referred to maze, needs to be considered in the clinical inpatient context. Changing gears, we will next review articles within the realm of ICDs, pacemakers, and CRT. In the New England Journal of Medicine this past month, Nazarian et al published on their experience regarding the safety of magnetic resonance imaging in patients with cardiac devices. They performed a prospective non-randomized study of the safety of, specifically, 1.5 tesla-strength MRI scans on legacy. In other words, not MRI conditionally-safe pacemakers and defibrillators. A total of 2,103 scans were done among 1,580 patients. They demonstrated no long term clinically significant adverse events. Nine patients did experience a reset to a backup mode, though eight of which were transients. The most common change seen acutely was a decrease in PVA amplitude in one percent of patients, and in a long term follow-up, 4% of patients experiencing a decrease in PVA amplitude, increase in atrial catheter sheer threshold, or increase in right or left ventricular capture threshold. However, none of these events were considered clinically significant. Furthermore, there was not a good [inaudible 00:21:23] group to know if this long term change in amplitudes or thresholds might have been seen in patients who had devices that were not exposed to MRI. These findings are complimentary to multiple, prior, published reports, indicating the safety of performing MRIs under clinical protocol in legacy pacemakers and defibrillators. It calls into question whether MRI conditional devices truly offer an additional safety factor furthermore, over legacy devices. Next we review an article by Lakkireddy et al published in Heart Rhythm entitled A Worldwide Experience, the Management of Battery Failures and Chronic Device Retrieval of the Nanostim Leadless Pacemaker. Lakkireddy et al reported their large multi-center experience on the overall risk of battery failure. Amongst 1,423 implanted devices there were 34 battery failures occurring, on the average, three years after implants. Furthermore, about 73 patients underwent attempted device retrieval, and this was successful in 90%, with the seven failures of retrieval being due to either inaccessibility of the docking button, or dislodgement of the docking button in one patient, in whom it embolized to the pulmonary artery. An additional 115 patients interestingly received an additional pacemaker after release of the device advisory. These data suggest that there may be as high as an overall 2% risk of battery failure with the Nanostim device, even late after implants. This highlights the need for close follow-up, even if the battery appears relatively stable up to two year after implants. Furthermore, almost 10% of devices cannot be successfully retrieved. However, in those patients, even with re-implantation of a separate device, there was no device-device interaction seen. Further innovation will be needed to optimize device longevity, and close follow-up of all patients undergoing implantation will be critical to understand the overall long term efficacy and safety when compared to other traditional devices. Finally, within the realm of device care, we focus on an article by Kiehl et al, again published in Heart Rhythm this past month entitled Incidence and Predictors of Late Atrial Ventricular Conduction Recovery Among Patients Requiring Permanent Pacemaker for complete heart block after cardiac surgery. They reviewed the likelihood of recovery of conduction in their retrospective cohort of 301 patients. Interestingly, 12% of patients had recovery of AV conduction on average six months after surgery. Those who did not recover tended to more likely have preoperative conduction abnormalities. Saraj Kapa:                          Findings that suggested a higher likelihood of long term conduction recovery included female sex and the existence of transient periods of AV conduction postoperatively. These data highlight that recovery of AV conduction is possible in a significant number of patients undergoing cardiac surgery. However, being able to predict long term recovery may assist in device selection, to avoid more costly device implantations that may not be needed over chronic follow-up. Prospective studies amongst larger numbers of patients are needed to better understand mechanisms of block, mechanisms of recovery, an optimal device in patient selection. Changing focus, we will next review two articles within the realm of supraventricular tachycardias. First we read an article by Han et al published in JACC Clinical Electrophysiology, entitled Clinical Features in Sites of Ablation for Patients With Incessant Supraventricular Tachycardia From Concealed Nodofascicular and Nodoventricular Tachycardias. Han and group describe three cases of concealed nodovascicular, nodoventricular re-entrant tachycardias, and focus on the different mechanisms of proving their participation in tachycardia. In all cases, atrial ventricular re-entering tachycardia was excluded. Successful ablation for these tachycardias occurred either at the slow pathway region, the right bundle branch, or the proximal coronary sinus. This is the first described case of incessant, concealed tachycardias related to these pathways. The importance of this article highlights an understanding the mechanisms proving the contribution to tachycardia, and the importance of recognition when performing electrophysiology studies, and being unable to reveal traditional mechanisms, which exist in most patients, such as atrial tachycardia, AVNRT or AVRT. Next we review an article by Guo et al published in Europace entitled Mapping and Ablation of Anteroseptal Atrial Tachycardia in Patients With Congenitally Corrected Transposition of the Great Arteries: Implications of Pulmonary Sinus Cusps. They reviewed three separate cases of anteroseptal atrial tachycardias in the setting of congenitally corrected transposition. They demonstrated that in these cases, there was successful ablation performed with the pulmonary sinus cusps. The result is successful and durable suppression. The reason this article is important lies in the fact that it's critical to understand both cardiac anatomy and cardiac nomenclature. The pulmonary valve in CCTJ is affectively the systemic ventricular arterial valve, given that the right ventricle is the systemic ventricle. Thus, mapping in this region of CCTJ abides the same principles as mapping the aortic valve in structurally normal hearts for similar tachycardias. However, understanding the nomenclature and that despite the variant anatomy, the utility of similar approaches to mapping of the systemic outflow are important when matching these complex, congenital anatomy or arrhythmia patients. Changing gears yet again, we review an article within the realm of sudden death and cardiac arrest. Baudhuin et al published in Circulation and Genetics entitled Technical Advances for the Clinical Genomic Evaluation of Sudden Cardiac Death. Baudhuin et al reviewed the utility of formal and fixed paraffin-embedded tissue, which is routinely obtained in an autopsy, to perform post-mortem, genetic testing. One of the main limitations to advising family members who have had prior family history of sudden death in closely related relatives, is that blood is often not available to perform DNA screening late after death. DNA however is often degraded in the tissues that are commonly available at autopsy, namely the formal and fixed paraffin-embedded tissues. The authors sought to evaluate if your next generation techniques could make these types of tissue adequate for diagnosis. They demonstrated amongst 19 samples, that performance characteristics were similar between whole blood and these tissue samples, which could be as old as 15 years. It can be critical to identify disease-causing mutations in family members, as individuals who might not yet be affected, but at risk, need to know about that overall risk. Given that decision to sequence might also not be universally applied at all centers, or in all situations, oftentimes these paraffin-embedded tissues might be the only available option, sometimes over a decade after death. This represents the first report of using next-generation sequencing approaches to successfully and accurately sequence for specific mutations using paraffin-embedded tissue. This may offer additional options to help family members achieve diagnoses for sudden death-inducing conditions. Within the realm of cellular electrophysiology, we review an article by Lang et al published in Circulation Research entitled Calcium-Dependent Arrhythmogenic Foci Created by Weakly Coupled Myocytes in the Failing Heart. Lang et al reviewed the effect of cell-cell coupling on the likelihood of triggered arryhthmias. In a [inaudible 00:28:45] model, they demonstrated the myocytes that are poorly synchronized with adjacent myocytes were more prone to triggered activity due to abnormal calcium handling when compared to myocytes with normal connection to adjacent cells. Thus, adequate coupling leads to voltage clamping during calcium waves, thus preventing triggering arrhythmias. While poorly coupled myocytes aren't able to to this due to a weakened currency, making them more prone arrhythmogenesis. These data highlight another critical cellular basis for arrhythmogenesis. In heart failure, while the focus for clinical management is typically areas of scar, there's clearly a role at the cellular level where cell-cell coupling abnormalities can lead to dynamic changes that can increase tendencies to arrhythmogenesis. The role in understanding the varying, arrhythmogenic risk based on varying factors, is important, and might have importance in the future advances in mapping technologies. Changing gears, we review an article published in the Journal of the American College of Cardiology by Mazzanti et al within the realm of genetic channelopathies entitled Hydroxyquinoline Prevents Life-Threatening Arrhythmic Events in Patients With Short QT Syndrome. They reviewed a cohort of 17 patients and demonstrated that hydroxyquinoline resulted in a reduction of arrhythmic events from 40% to 0% of patients. QTc prolongation was seen in all patients. These data clearly demonstrate that hydroxyquinoline plays a role in lowering the incidence of arrhythmic events in patients suffering from short QT syndrome. However, it's important to note that in many markets, quinoline has been difficult to access. In the specific case of QT syndrome thus, there's clearly a role for hydroxyquinoline. However, it also must be noted, the comparative efficacy with more commonly available drugs still needs to be evaluated. This past month has been of particular interest in the realm of ventricular arrhythmias, with multiple, potentially ground-breaking articles. One of the well-recited articles published this past month already is by Cuculich et al entitled Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia published in the New England Journal of Medicine. Cuculich et al reported the first in-human data on the use of stereotactic body radiation therapy to perform noninvasive ablation of ventricular arryhthmias. Using a combination of noninvasive electrocardiographic imaging curing ventricular tachycardia, and stereotactic radiation, patients were treated with a single fraction of 25 [inaudible 00:31:15] while awake. A total of five patients were included with a mean ablation time of only 14 minutes. During the three months prior to treatment, there was a total of 6,577 VT episodes seen, and during a six week post-ablation period, considered a blanking period, there were 680 episodes. After this blanking episodes, there were only four episodes of VT seen over the ensuing 46 patient months. This study is important because it reflects the first in-human proof of concept that noninvasive ablation using radiation therapy traditionally as for treatment of solid tumors, may be affective in targeting cardiac tissue. Furthermore, modern techniques such as noninvasive electrocardiographic imaging might allow for a fully noninvasive experience for the patients. This is a vast advance seen within the realm of cardiac electrophysiology. In the early days, all we could do was map invasively and then have to go to much more invasive, open-heart surgery to treat arryhthmogenic substrates. Since the advent of catheter and radiofrequency ablation, surgical ablation is relatively fallen by the wayside, to a less invasive approaches. A completely noninvasive approach to successfully targeting tissue is potentially ground-breaking. However, there are several limitations in this study that can only be ascertained by reading the actual article. When we actually review the patients included, the long term follow-up was limited to only four patients, as one patient actually died within the blanking period, and in fact, this patient suffered from the largest burden overall of VT. Furthermore, amongst the remaining four patients, one required a redo ablation within the blanking period, and one had to be restarted on amioderone after the blanking period was over. Thus further data is really needed to clarify efficacy, given the overall success rate appears to be less than 50% on a per patient basis. Though on an overall episode basis, there was significant reduction. The exact type of radiation to be used also needs to be considered, within the realm of solid oncology. Stereotactic radiation is considered an older modality, with proton beam, and more recently, carbon beams offer more directed therapy. Thus, a lot more data is required to identify the promise of radiation therapy. Though again, this is a significant advance. Next, within the realm of invasive electrophysiology, we review an article by Turagam et al published in the JACC Clinical Electrophysiology entitled Hemodynamic Support in Ventricular Tachycardia Ablation: An International VT Ablation Center Collaborative Group Study. The utility of hemodynamic support during VT ablation is relatively unclear. Studies have been variable and limited. This group included 1,655 patients who underwent 105 VT ablations using hemodynamic support with a percutaneous ventricular assist device. Those undergoing support overall tend to be sicker, including lower ejection fractions and [inaudible 00:34:07] classes, and more VT events, including ICD shocks and VT storm. Hemodynamic support use interestingly, was an independent predictor of mortality with a hazard ratio of 5, though there was no significant difference in VT recurrence rates irrespective of the subgroup considered. These data indicate that, while patients are receiving hemodynamic support were overall sicker, there was no clear incremental benefit in use of hemodynamic support in terms of long term outcomes. In the area of substrate ablation, whether use of hemodynamic support to facilitate mapping during VT, actually alters outcomes remains to be seen. This study highlights the potential importance of randomized clinical approaches to better evaluate whether hemodynamic support truly alters the long term outcomes of the VT ablation. Next, we review an article by Munoz et al that focuses more on prediction of those patients who might be at risk for ventricular arrhythmias, again published in the last edition of JACC Clinical Electrophysiology and entitled Prolonged Ventricular Conduction and Repolarization During Right Ventricular Stimulation Predicts Ventricular Arrhythmias and Death in Patients With Cardiomyopathy. Munoz et al reviewed the relationship between paced QRS and pace Qtc and long term risk. A total of 501 patients with mean ejection fractions of 33% were included. Longer paced ventricular QRS and Qtc was associated with a higher risk of ventricular arrhythmia, and all caused death or arrhythmia, irrespective or ejection fraction. A paced QRS duration of 190 milliseconds was associated with 3.6 fault higher risk of arrhythmia, and a 2.1 fault higher risk of death or arrhythmia. These data suggest that findings during [inaudible 00:35:47] pacing and otherwise normal rhythm, including paced QRS and QTc may independently result in elevation of overall risk of ventricular arrhythmia and death. Physiologically these data make sense. In light of the fact that longer cure restorations are probably related to a greater degree of myopathy. While these data offer a prognostic indication, whether they alter outcomes or decision making regarding ICM implantation, remains to be seen. Next, also published in JACC Clinical Electrophysiology, Vandersickel et al reviewed a more cellular basis for toursades in an article entitled Short-Lasting Episodes of Toursades de Pointes in the Chronic Atrial Ventricular Model Have Focal Mechanism While Longer-Lasting Episodes are Maintained by Reentry. Vandersickel et al reviewed the mechanisms underlying toursades, and demonstrated that both focal and reentry mechanisms may exist. In five canines they used broadly distributed neuro electrodes to simultaneously map across the heart. They demonstrated that initiation and termination was always focal, but longer and non-terminal episodes always had reentry mechanisms. These data suggest that the mechanisms underlying toursades actually reflect a spectrum of potentially dynamic, electrophysiologic phenomenon the heart, including both focal and reentry activity. Understanding these mechanisms, and the fact that focal mechanisms almost universally underlie initiation may bring into consideration the optimal treatments whether in the form of pacing and defibrillation techniques or medication techniques for toursades. Finally, in the realm of ventricular arrhythmia, we review an article published in the last month's edition of Heart Rhythm by Penela et al entitled Clinical Recognition of Pure Premature Ventricular Complex-Induced Cardiomyopathy at Presentation. As we know, it's sometimes difficult to recognize patients when they present with frequent PVCs and a depressed injection fraction in terms of, whose injection fractions are purely caused by the presence of PVCs, and whose PVCs are only exacerbated by the presence of an underlying myopathy. The group included 155 patients and excluded all patients who did not normalize their elevated ejection fraction, or who had previously diagnosed structural heart disease, leaving a total cohort under consideration, of 81 patients. About 50% were diagnosed as having a PVC-induced cardiomyopathy on the basis of normalization of elevated function after PVC suppression. While the remainder was considered to have PVC exacerbated cardiomyopathy on the basis that things did not entirely resolve, and thus had an independent mechanism for nonischemic myopathy. Characteristics that suggested patients with a lower likelihood of EF normalization included those with longer intrinsic QRSs, above 130 milliseconds, a lower PVC burden of baseline, considered less than 17%, and larger [inaudible 00:38:33] greater than 6.3 cm. PVCs as a cause of [inaudible 00:38:35] are obviously a well-recognized treatable cause of myopathy, however again, it might be difficult to differentiate. Those patients whose PVCs are a result of the underlying myopathy versus those whose PVCs are the cause, and for whom ablation or suppression may reverse the myopathic process. The work of Penela et at offers an initial attempt at helping differentiate these processes, however validation of larger cohort is necessary. Next we review an article within the realm of syncopy entitled Prohormones in the Early Diagnosis of Cardiac Syncopy by Badertscher et al published in the Journal of the American Heart Association this month. They review the utility of circulating prohormones [inaudible 00:39:14] autonomic dysfunction or neurohormonal abnormalities, to differentiate cardiac from non-cardiac causes of syncopy in the emergency departments. They measured four novel prohormones in a multi-center study. In the emergency departments there is a specific protocol used to determine the perceived likelihood of the cause of syncopy to be cardiac versus non-cardiac. In addition to this, the prohormones are drawn. After this, everyone's final diagnosis was reached. Two independent cardiologists reviewed the cases to determine if it was a truly cardiac or non-cardiac cause of syncopy. Among 689 patients included, 125 overall were adjudicated as cardiac syncopy. Measure of the specific marker MR-proANP in combination with emergency department suspicion of syncopy, performed better than suspicion alone, to differentiate cardiac causes of syncopy. A combination of a circulating MR-proANP, less than 77, picomoles per liter, an [inaudible 00:40:17] probability of cardiac syncopy could be less than 20%, had a very high sensitivity negative predictive value of 99%. The significant resources are often used to manage patients with syncopy presenting to the emergency departments, and it's often extremely difficult at this stage to differentiate cardiac from non-cardiac causes of syncopy. And the amount of evaluation that can be done in the emergency department is often limited. Cardiac caused of syncopy are not good to miss, however, since these can include ventricular arrhythmias, and transient AV block, that might result in death as well. As is well-recognized, emergency department evaluation in clinical [inaudible 00:40:49] are limited in terms of their utility. This raises the utility of objective measures to help differentiates. These data suggest that circulating prohormones [inaudible 00:40:59] your hormonal function drawn during your emergency department evaluation, may be a useful adjunct to differentiate cardiac from non-cardiac syncopy. Whether they can be used to prospectively differentiate those patients requiring inpatient admission or now, however, remains to be seen. The last two articles we'll choose to focus on will fall under the realm of broader, other EP concepts. The first article we will review is by Varghese et al published in Cardiovascular Research entitled Low-Energy Defibrillation With Nanosecond Electric Shocks. Varghese et al reviewed the potential of low-energy nanosecond duration shocks for defibrillation in rapid hearts. In induced fibrillation examples, the repeated defibrillated nanosecond impulses as low as three kilovolts demonstrated effective defibrillation. The energy required is significantly lower than from monophasic shocks and longer pulse durations. Furthermore, there was no detectable evidence of electroporation, namely cardiac or so injury after defibrillation. Using nanosecond impulses, it may be feasible to defibrillate the heart with significantly lower energies. The implications for patients experiencing defibrillation, for example pain, is unclear without in-human studies. However, the ability to use lower energies could have implications in battery life. Further [inaudible 00:42:11] studies will be critical to study ambulatory efficacy as this research is performed in [inaudible 00:42:19] hearts. Finally, we review an article published in Circulation entitled Mortality in Supravascular Events After Heart Rhythm Disorder Management Procedures by Lee et al. Amongst three centers, a retrospective cohort study regarding the mortality and risk of supravascular events, was performed. They included a variety of heart rhythm [inaudible 00:42:40] procedures, including defibrillation threshold testing, lead extraction, device implant, and invasive electrophysiology studies and ablation procedures. Amongst 48,913 patients, 62,065 procedures were performed and an overall mortality of .36% was seen. Supravascular [inaudible 00:42:58] was lower at .12%. Interestingly, and expectedly, the highest risk was seen with lead extraction patients, with an overall mortality risk of 1.9%. Less than half of the deaths seen, however, were directly attributable to the procedure itself. The most common cause of procedural death was cardiac tamponade, largely seen amongst device implant patients. This is critical, as the number of ablation and other invasive electrophysiology procedures performed, is increasing. These data provide a large, contemporary experience regarding the overall risk attributable to a variety of heart rhythm disorder procedures. Interestingly, half of the procedure related deaths were associated with device implantation procedures. With the predominant cause being tamponade, highlighting the importance of early recognition of this treatable complication. Tamponade may not always be considered as a major issue after device implantation, however these data clearly suggest that it is. In addition, extraction, as expected, carried the highest incident of both supravascular events and mortality. Though, this is likely related to the higher rate of core morbidity in this population, including active infection. In summary, this month, we have reviewed 20 articles in various areas of electrophysiology published across the literature. Particularly high impact articles range from those reviewing experience regarding left atrial appendage closure and the efficacy of this, to the utility of using atrial fibrillation to predict risk and long term morbidity and mortality in hypertrophic cardiomyopathy, to further evidence regarding the safety of magnetic resonance imaging in legacy pacemakers and defibrillators, and novel considerations regarding supraventricular tachycardias and there diagnosis and management, especially invasively. Other potential groundbreaking articles included evidence that we can successfully use formal and fixed paraffin-embedded tissue that can be as old as 15 years, to successfully identify genetic mutations that might be responsible for sudden death. And evidence that using novel techniques, we might be able to perform completely noninvasive therapies for arrhythmias by using radiation therapies. However questions were also raised such as regarding the role of hemodynamic support for VT ablation. How to better differentiate those patients who will have recovery of AV conduction from those who won't, as they meet class I indications post cardiac surgery? And whether other factors such as right ventricular pacing during [inaudible 00:45:28] study might further differentiate patients at risk for ventricular arrhythmias in spite of a low ejection fractions. Many of the papers had to deal with tranlational work that still remains to be proven in terms of value at a clinical level, such as demonstrating mechanisms underlying trousades de pointes. Or the potential value of low-energy defibrillation with nanosecond electric shocks. Clinical protocols involving the use of prohormones in the early diagnosis of cardiac syncopy. How to differentiate PVC induced from other causes of myopathy, and how to manage, in the long term, these devices. Also, likely requires further study. Finally, covering all areas of electrophysiology, we reviewed one large article focusing on mortality in supravascular events after heart rhythm management disorder procedures at large. This article highlights the importance of considering institutional experience and reporting it to use as a benchmark to help better optimize our counseling of patients, as well as our procedures and protocols. I appreciate everyone's attention to these key and hard-hitting articles that we just focused on from this past month of cardiac electrophysiology across the literature. Thanks for listening. Now, back to Paul. Dr. Paul Wong:                  Thanks Seraj. You did a terrific job surveying all journals for the latest articles on topics of interest in our field. There's not an easier way to stay in touch with the latest advance. These summaries, and a list of all major articles in our field each month, can be downloaded from the Circulation Arrhythmia and Electrophysiology website. We hope you'll find the journal to be the go-to place for everyone interested in the field. See you next month.  

Chinese Energetics with Paul Wong is a chance to open up your heart.  Paul has a unique approach to healing using both ancient wisdom blended with modern healing modalities such as Body Talk, Vortex Healing, Reiki, Matrix Energetics, Qigong and a wave of mystical practices. He has developed his own healing programme, The Art of Neutrality ™, which has grown out of his teachings and learnings and very recently has extended into a 'heart healing' process that he recognises is a major tool is shifting the consciousness of his clients into a space of love and oneness. Paul's own journey began with his own asthmatic condition that he wanted to heal.  Over 15 years he has worked with thousands of people all over the world with their emotional and physical challenges. During this interview with Paul he very generously offers to take us through a session to release 'unhelpful' emotions from our hearts.  In this session he focuses on clearly issues relating to our mothers - just by listening to this interview, you too can clear these maternal issues (and to some degree we all have them).   Notice how you can literally 'feel' the layers of emotions float away and you feel lighter and more energised at the end of the interview.   

For families who have children with special needs, this is the show you will want to tune into! Our special guest, Paul Wong has agreed to do LIVE energy healing for your children. All you have to do is call in! Paul Wong is a professional facilitator, instructor, and coach focused on consciousness work for rapid healing, and personal and professional performance. Paul started his holistic career as a Certified Yuen Practitioner and was personally trained by Grandmaster Yuen. Now, he has developed a consciousness shifting system based on his experiences working with thousands of people globally and the synthesis of the various healing arts from the Yuen Method, Qigong, Chinese medicine, EFT, hypnotherapy, Reiki, Bodytalk, Vortex Healing, Release Technique, Matrix Energetics, and other spiritual and mystical practices. To find out more about Paul, please visit his web site at www.chineseenergetics.com

For families who have children with special needs, this is the show you will want to tune into! Our special guest, Paul Wong has agreed to do LIVE energy healing for your children. All you have to do is call in! Paul Wong is a professional facilitator, instructor, and coach focused on consciousness work for rapid healing, and personal and professional performance. Paul started his holistic career as a Certified Yuen Practitioner and was personally trained by Grandmaster Yuen. Now, he has developed a consciousness shifting system based on his experiences working with thousands of people globally and the synthesis of the various healing arts from the Yuen Method, Qigong, Chinese medicine, EFT, hypnotherapy, Reiki, Bodytalk, Vortex Healing, Release Technique, Matrix Energetics, and other spiritual and mystical practices. To find out more about Paul, please visit his web site at www.chineseenergetics.com

  Paul Wong is a professional practitioner of Chinese Energetics, trained by Dr. Yuen. He has successfully worked on hundreds of people in the general public to remove pain, reduce emotional distress, and improve personal performance. Over the last 15 years, he practiced multiple disciplines such EFT, NLP, hypnotherapy, Reiki, Quantum Touch, Matrix Energetics, Reconnection, and other modalities. He finds the Chinese Energetics Yuen combined with concepts from other holistic disciplines to be highly effective. http://www.chineseenergetics.com/

Paul Wong is a Certified Master Practitioner/Instructor of Chinese Energetics Yuen Method, an energetic practice derived from ancient wellness technology of the Shaolin monastery. Paul teaches energetic foundation skills for accelerating natural self-healing and regeneration. He teaches practitioners how to correct for non-physical causes disturbing our wellness from the areas of emotional, mental, psychological, empathic/psychic, and spiritual categories. Paul Wong has worked with holistic arts for the last 15years. His background includes NLP, hypnotherapy, EFT, Reiki, Matrix Energetics, Reconnective Healing, Quantum Touch etc. His education includes a degree in Mechanical Engineering and MBA in Human Resources.Contact info:Chinese Energeticswww.ChineseEnergetics.compaul@ChineseEnergetics.com

Paul Wong is a Certified Master Practitioner/Instructor of Chinese Energetics Yuen Method, an energetic practice derived from ancient wellness technology of the Shaolin monastery. Paul teaches energetic foundation skills for accelerating natural self-healing and regeneration. He teaches practitioners how to correct for non-physical causes disturbing our wellness from the areas of emotional, mental, psychological, empathic/psychic, and spiritual categories. Paul Wong has worked with holistic arts for the last 15years. His background includes NLP, hypnotherapy, EFT, Reiki, Matrix Energetics, Reconnective Healing, Quantum Touch etc. His education includes a degree in Mechanical Engineering and MBA in Human Resources.Contact info:Chinese Energeticswww.ChineseEnergetics.compaul@ChineseEnergetics.com