Abstract Objectives: To examine changes in surgeon volume over time and evaluate the influence of surgeon volume on complications of abdominal radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH) for cervical cancer. Design: A retrospective cohort study. Setting: 42 hospitals in China. Population: 14536 patients undergoing ARH and 8148 patients underwent LRH. Methods: The influence of the surgeon volume of ARH and LRH on surgical complications was examined using multivariable logistic regression models. Main outcome measures: Intraoperative complications and postoperative complications. Results: In the ARH cohort, the mean surgeon case volume increased from 3.5 cases in 2004 to 8.7 cases in 2013 and then decreased to 4.9 cases in 2016. The number of surgeons performing LRH increased from 1 surgeon with 1 patient (mean cases=1) in 2004 to 183 surgeons who operated on 2,206 patients in 2016 (mean cases=12.1) (P< 0.01). In the ARH, patients treated by intermediate-volume surgeons had more postoperative complications (OR=1.55, 95% CI=1.11-2.15). In the laparoscopic surgery cohort, surgeon volume had no independent effect on intraoperative or postoperative complications (P=0.46; P=0.13). Conclusions: The performance of ARH by intermediate-volume surgeons is associated with an increased risk of postoperative complications. However, surgeon volume may have little effect on intraoperative or postoperative complications after LRH.

Background Acute pulmonary exacerbation (APE) in cystic fibrosis patients is frequent and associated with a decline in pulmonary function, quality of life and survival. Tobramycin is often used in regimens requiring activity against Pseudomonas aeruginosa, however, an important number of centers do not use official dosing recommendation. The current dosing strategy may be suboptimal. Methods This retrospective cohort analysis was performed on all adult cystic fibrosis patients that were admitted at a tertiary care facility for treatment of APE and with tobramycin between January 2015 and December 2019. The primary objective was to evaluate the predictive performance of previously published pharmacokinetic (PK) models and, secondly, to evaluate potential factors that impact clinical outcomes. Clinical outcomes were only evaluated in a sub-group of patients with cultures positive for P. aeruginosa. Results A total of 202 APEs from 51 patients were included in the PK analysis. Two population PK models were assessed and failed to fit our data. In all, 109 APEs from 32 patients were included in the clinical analysis. Factors that significantly impacted clinical outcome were the number of prior APE and concomitant antibiotics. Clinical success rate for regimens containing at least one active agent against P. aeruginosa according to its susceptibility was 67%. Conclusion Population PK models evaluated in this study cannot be used to perform simulations. A new model must be developed for our population. In patients positive for P. aeruginosa, Ceftazidime in combination to tobramycin may be a superior regimen. APE history remains predictive for outcomes in adult CF patients treated for an APE.

This report entails a case of an 11-year-old Chinese boy with cystic fibrosis (CF), who bears the c.1521_1523delCTT/c.3874-4522A>G genotype, which is extremely rare in Chinese population. Notably, the deep intron mutation c.3874-4522A>G was the first time identified among Chinese patients, which was reported mainly associated with mild phenotype. It is generally considered that a mild allele sustains CFTR function in a dominant fashion, even if paired with a severe allele. However, in the present report, the c.3874-4522A>G mutation was found related to severe pulmonary diseases, including early symptom onset, progressive bronchiectasis, recurrent airway P. aeruginosa combined with MRSA, rapid decline of lung function, and poor weight gain, which suggesting severe phenotype. Despite intensive chest care and optimized therapy, the child ultimately died of cardiopulmonary failure 3 months after discharge.

The paper is concerned with the SIZR mathematical model for an outbreak of zombie infection with time-dependent infection rate. This class of the SIZR model involves equations that relate the susceptible S(t), the infected I(t), the zombie Z(t), and removed population R(t). The well poseness of the model is presented. The proposed model is then outstretched to the fractional order mathematical model with three different derivative operators i.e., Caputo, Caputo-Fabrizio, and Atangana-Baleanu fractional derivative operator. The conditions under which the model has a unique solution are established for different derivative operators. Using the numerical scheme which was proposed by Atangana and Toufik the numerical solutions are presented for the different fractional derivative operators.

Background: Left atrial appendage occlusion (LAAO) has historically been performed using intraprocedural transesophageal echocardiography (TEE) and fluoroscopy. Multiple recent reports have described the feasibility and advantages of utilizing two-dimensional intracardiac echocardiography (ICE) for LAAO. However, in inexperienced hands, safe manipulation of the ICE catheter in the left atrium (LA) can be challenging. Objective: To assess the feasibility and efficacy of three-dimensional (3D) ICE mapping in guiding LAAO device implant compared to standard TEE imaging. Methods: We retrospectively included patients who underwent LAAO in our institution from January 2017 and October 2021. We compared baseline demographics, intraprocedural data, post-procedural complications, and outcomes. P= value of <0.05 was considered significant. A linear regression model was performed using ICE and TEE as dependent variables to model contrast dose. Results: 130 patients underwent LAAO device implantation, of which 57 underwent ICE guided LAAO and 73 underwent TEE guided implantation. There was no difference in baseline demographics or post-procedural outcomes between both groups. There was no difference in the total procedure time between ICE and TEE groups, 86 (72-107) and 83 (72-111) minutes (p=0.65), respectively. Conversely, total fluoroscopic time was significantly shorter in ICE arm 7.8 (5.6-11), compared to TEE arm 12.9 (10.5-17.6) (p= <0.001). In patients undergoing LAAO device implantation using 3D ICE technique, with each additional ICE-guided procedure, the contrast dose decreased by 0.87 mL (correlation r = -0.48, p<0.001). Conclusion: 3D ICE is safe and feasible in guiding LAAO device implantation. When compared to TEE technique, total fluoroscopic time was shorter. Additionally, with more procedures utilizing 3D ICE, contrast dose decreased in a linear fashion.

It is established $L^{p}$ estimates for the fractional $\Phi$-Laplacian operator defined in bounded domains where the nonlinearity is subcritical or critical in a suitable sense. Furthermore, using some fine estimates together with the Moser’s iteration, we prove that any weak solution for fractional $\Phi$-Laplacian operator defined in bounded domains belongs to $L^\infty(\Omega)$ under appropriate hypotheses on the $N$-function $\Phi$. Using the Orlicz space and taking into account the fractional setting for our problem the main results are stated for a huge class of nonlinear operators and nonlinearities.

Introduction Left bundle branch pacing (LBBP) has emerged in recent years as a new pacing modality, providing patients with a narrower paced QRS than conventional pacing and stable pacing parameters. At the same time, there is a growing concern about the use of fluoroscopy in pacemaker implantations, given its harmful effects to both patients and operators. However, there are no prior experiences of zero fluoroscopy in LBBP procedure. Methods We conducted an observational prospective study recruiting consecutive patients that underwent zero fluoroscopy LBBP pacemaker implantation. A 6-month follow-up visit was programmed for every patient. The main goal of our study was to assess the efficacy, feasibility and safety of the procedure. Results From January 2021 to February 2022, we included 10 patients, 8 males. The average age was 63 ± 4 years. The procedure was successful in all patients. We observed a significant reduction in paced QRS width compared with basal QRS width (149 ms vs 116 ms, p= 0.02). All device parameters remained stable at 6-month follow-up: no significant differences in mean impedance (700.5 vs 494 Ohm, p=0.09), capture threshold (0.67 vs 0.83V @ 0.4ms, p=0.27) or R-wave amplitude (10.6 vs 13.92 mV, p= 0.19). No complications were reported in any case. Conclusion Zero fluoroscopy LBBP is feasible and safe, and it may be considered an optimal election in cases where radiation exposure is contraindicated or especially undesirable and as an alternative in all other cases.

In the present paper we investigate the qualitative behaviour of a fractional SEIR model with general incidence rate function and time delay where the fractional derivative is defined in the Caputo sense. The basic reproduction number $\mathcal{R}_{0}$ is derived using the method of next generation matrix and we give a complete study of local stability of both free and endemic equilibrium. Using Liapunov method we prove the global stability of free and endemic equilibrium under some hypotheses on the parameters of the system. Finally to illustrate our results, we use the model to predict the first peak of the COVID-19 epidemic in Algeria.

In this paper we study the partial differential equation with piecewise constant argument of the form : \[ \begin{array}{lll} x_t(t,s)=&A(t)x(t,s)+B(t,s)x([t],s)+C(t,s)x(t,[s])+\\[0.5cm] &D(t,s)x([t],[s])+f(x(t,[s])),\ \ t,s\in \R^{+}=(0,\infty) \end{array} \] where $A(t)$ is a $k\times k$ invertible and continuous matrix function on $\R^{+}$, $B(t,s)$, $C(t,s)$, $D(t,s)$ are $k \times k$ continuous and bounded matrix functions on $\R^{+}\times \R^{+}$, $[t]$, $[s]$ are the integral parts of $t,s$ respectively and $f:\R^k\rightarrow \R^k$ is a continuous function. More precisely under some conditions on the matrices $A(t)$, $B(t,s)$, $C(t,s)$, $D(t,s)$ and the function $f$ we investigate the asymptotic behaviour of the solutions of the above equation. \end{abstract}

Background: Randomized controlled trials (RCTs) are the gold-standard for benefit-risk assessments during drug approval processes. Real-word data (RWD) and the resulting real-world evidence (RWE) are becoming increasingly important for assessing the effectiveness of drug products after marketing authorization showing how RCT results are transferred into real life care. The effectiveness of allergen immunotherapy (AIT) has been assessed in several RWE studies based on large prescription databases. Methods: We performed a literature search for retrospective cohort assessments of prescription databases in Europe to provide an overview on the methodology, long-term effectiveness outcomes and adherence to AIT. Results: 13 respective publications were selected. AIT was more effective in reducing the progression of allergic rhinitis (AR) compared to a non-AIT control group receiving only symptomatic treatment for AR for up to 6 years. The development and progression of asthma was hampered for most endpoints in patients treated with most preparations compared to the non-AIT group, receiving only anti-asthmatic medication. The results for “time to onset” of asthma were inconsistent. Adherence to AIT decreased during the recommended 3-years treatment period, however in most studies higher adherence to subcutaneous than to sublingual AIT was shown. Conclusion: The analysis of long-term effectiveness outcomes of the RWE studies based on prescription databases confirms the long-term efficacy of AIT demonstrated in RCTs. Progression of rhinitis and asthma symptoms as well as delayed onset of asthma triggered by different allergens, real life adherence to the treatment shows differences in particular application routes.

We reported one of the rare, documented cases of a girl with LVNC associated jSLE with a past history of Hashimoto's thyroiditis.Thus, the association between jSLE, and LVNC should be considered, and requires further research in order to find the probable mechanism joining both entities.

In this paper, we investigate the existence and attractivity of mild solutions to fractional evolution equations with Caputo fractional derivative on an infinite interval. Our methods are based on fractional calculus, semigroup theory, compactness methods and the measure of noncompactness. Several sufficient conditions for the existence of solutions to the given problem are proposed. Examples illustrating the main results are presented.

The three lowest spin states (S=0,1,2) of twelve representative Na13+ isomers have been studied using both, KS-DFT via three hybrid density functionals, and benchmark multireference CASSCF and CASPT2 methods with a couple of Dunning’s correlation consistent basis sets. CASSCF(12,12) geometry optimizations were carried out. Since 12 electrons in 12 active orbitals span the chemically-significant complete valence space, the results of the present study provide benchmarks for Na13+. The CASPT2(12,12)/cc-pVTZ* lowest energy structures are three nearly degenerate singlets (S=0): an isomer formed from two pentagonal bipyramids fused together (PBPb), a capped centered-squared antiprism [CSAP-(1,3)] and an optimum tetrahedral OPTET(II) structure, the last two lying 0.88 and 1.63 kcal/mol above the first, respectively. The lowest triplet (S=1) and quintet (S=2) states lie 4.33 and 3.77 kcal/mol above the singlet global minimum, respectively. The latter is a deformed icosahedron while the former is a CSAP-(1,3). The flatness of the potential energy surface of this cluster suggests a rather strong dynamical character at finite temperature. Prediction of the lowest energy structures and electronic properties is crucially sensitive both to non-dynamical and dynamical electron correlation treatment. The CASPT2 vertical ionization energy is 3.66 eV, in excellent agreement with the $3.6 \pm 0.1$ eV experimental figure. All the isomers are found to have a strong multireference character, thus making Kohn-Sham density functional theory fundamentally inappropriate for these systems. Only large multiconfigurational complete active space self-consistent field (CASSCF) wavefunctions provide a reliable zeroth-order description; then the dynamic correlation effects must be properly taken into account for a truly accurate account of the structural and energetic features of alkali-metal clusters.

The ghost condensation of the early universe in a pre-big bang phase has been presented in this paper through duration of a non-singular bounce. The undergoing universe contracts and passes smoothly in an expanding universe via a post-big bang phase. Initially developing and then taming any ghost like instabilities, the Null Energy Condition (NEC) is explicitly violated through the curvature mechanism of an adiabatic perturbed metric. The vacuum state of the ongoing phase is stabilized via a La-grangian that in essence stabilizes the vacuum state under the higher order derivatives. The violation of the NEC regards a catastrophic vacuum instability, which re-emerges with a correction valid at small energies and momenta, below the UV-cutoff scale that, could potentially be problematic if one tries to construct a UV-completed theory of this Ekpyrotic model. The scale-invariant curvature perturbation, that arises and is sourced out of the scale-invariant entropy perturbations sourced by 2-Ekpyrotic scalar fields, that, in contrast, becomes constant on the super-horizon limits, due to the non-singular nature of the background geometry. Apart, from the ghost condensates, this theory addresses the new Ekpyrotic theory which in order becomes a distinguishable alternative to inflation theory for the birth of the universe. As per the recent WMAP data, the Ekpyrotic model has a spectral red tilt that shows the bounced scalar potential falling through a negative phase shift during the matter-fluid fluctuations in the hot big bang phase.

A novel high gain flexible receiving antenna is proposed, which can be used for microwave wireless power transmission(MWPT). The antenna consists of a three-layer toroidal structure in a generalized iterative design with a coplanar waveguide(CPW) feed, and the radiator is integrated on Kapton substrate. In order to improve the gain of the antenna, an air-gap and flexible reflector are loaded at the back of the antenna. The antenna has a peak gain of 9.51dBi at 5.8 GHz. To characterize the stability of the antenna, the fabricated prototype uses three configurations of 85 mm, 60 mm and 45 mm respectively. The S11 of the antenna remains < -10dB, and the maximum harvesting efficiency is 71.3%.

Aim: Although current guidelines recommend 3-6 months of dual antiplatelet therapy (DAPT) for patients without indications for anticoagulation after transcatheter aortic valve replacement (TAVR), evidence-based evidence was lacking. Our aim was to review the most recent evidence comparing the safety and efficacy of both treatment modalities, single antiplatelet therapy (SAPT) and DAPT, after TAVR. Methods: We systematically searched the literature on Embase, PubMed, Cochrane and Medline until January 5, 2022. Our primary outcome indicators were: all-cause mortality, stroke and total bleeding rates, and secondary outcome indicators were: cardiovascular mortality, myocardial infarction (MI) and the incidence of major and life-threatening bleeding (LTB). A random-effects model was used, and subgroup analyses were performed according to study type and follow-up time. Results: A total of 14 studies (4 RCTs, 10 observational studies) involving 21,546 patients were finally screened. Compared with the DAPT treatment modality, patients in the SAPT group showed a significant difference in short-term cardiovascular mortality after TAVR (RR [95% CI] =0.39 [0.19-0.78], P = 0.008) and a significantly lower risk of bleeding (RR [95% CI] =0.56 [0.48-0.65], P <0.001). There was also a significant difference in the incidence of major bleeding and LTB (RR [95% CI] =0.59[0.47-0.76], P <0.0001), but no statistically significant difference in other aspects. Conclusion: Compared with DAPT treatment modalities, the choice of SAPT for patients without anticoagulation indication after TAVR better reduces the risk of postoperative bleeding and short-term cardiovascular death without increasing the incidence of all-cause mortality, stroke, and MI.

Dietary metabarcoding has vastly improved our ability to analyse the diets of animals, but it is hampered by a plethora of technical limitations including potentially reduced data output due to the disproportionate amplification of the DNA of the focal predator, here termed ‘the predator problem’. We review the various methods commonly used to overcome this problem, from deeper sequencing to exclusion of predator DNA during PCR, and how they may interfere with increasingly common multi-predator-taxon studies. We suggest that multi-primer approaches with an emphasis on achieving both depth and breadth of prey detections may overcome the issue to some extent, although multi-taxon studies require further consideration, as highlighted by an empirical example. We also review several alternative methods for reducing the prevalence of predator DNA that are conceptually promising but require additional empirical examination. The predator problem is a key constraint on molecular dietary analyses but, through this synthesis, we hope to guide researchers in overcoming this in an effective and pragmatic way.

Giant clams are ecologically important, benefitting species of all trophic levels. But numerous populations have declined drastically in numbers due to past intensive exploitation that led to their listing in both CITES Appendix II and IUCN Red List of Threatened Species.. However, giant clams are notoriously difficult to identify, and recent molecular work has revealed that morphological misidentification of giant clams have confounded current population assessments and extinction risk.  The most recent study of the status of giant clams in the Samoan Archipelago was published in a journal over 20 years ago, without molecular corroboration of visual identifications. Using morphologic characteristics and ezRAD genetic techniques, we identify the existence of Tridacna noae in the Samoan Archipelago, presenting the first observation and a resulting range expansion. Accurately identifying the extant species in the archipelago is the first step towards a much-needed population status assessment to effectively manage these long-lived species.

Attempts over the past 30 years to explain geographic variation in the strength of herbivore pressure gave rise to the latitudinal herbivory hypothesis. However, this long-standing hypothesis has rarely been tested using community-level data. In this study, we selected 43 grassland sites along a 1,500-km latitudinal gradient (c. 27°N to 39°N) on the Qinghai-Tibetan Plateau. We calculated community-wide herbivory at each site by summing herbivory across plant species weighted by the biomass of each species; we then investigated how abiotic and biotic latitudinal correlates drove community-wide herbivory via their effects on intraspecific herbivory variability and species’ turnover. We found that community-wide herbivory decreased with latitude, mirroring intraspecific herbivory variability. Furthermore, intraspecific herbivory variability was driven by climatic factors, but not edaphic or plant community factors. Overall, our study highlights the importance of considering both intraspecific herbivory variability and species’ turnover for predicting how climate change will alter community-wide herbivory.

The study by Worck et al. raises interesting findings with regard to left atrial posterior wall ablation. The utility of ablation at the CRZ -- which may represent epicardial connection via the septopulmonary bundle -- warrants future research. Upcoming trials utilising existing technology, along with increased availability of pulsed field ablation, will advance our knowledge of the impact of left atrial posterior wall isolation.

A 50-year-old female presented with a history of fatigue after activities. Transthoracic echocardiography showed a 2.8 cm dilatation at the ostium of the left coronary artery and a 7.1×7.4 cm cyst-like aneurysm at the upper back of the left atrium, interlinking an anomalous fistula from the left coronary artery to the right atrial appendage, accompanied by moderate mitral and tricuspid regurgitation. Cardiac 3D-computed tomography identified the diagnosis of ruptured aortic sinus aneurysm (RASA) and a giant left coronary artery aneurysm fistula to the right atrium. Transesophageal echocardiogram and surgical vision confirmed these findings. Surgeries including RASA repair, coronary artery bypass grafting, and mitral and tricuspid valvuloplasty were then performed. Procedures proceeded successfully, the patient was fully recovered and discharged home.

A 49-year-old male presented to hospital with symptoms of acute cerebral infarction and pulmonary embolism who underwent transcatheter closure of atrial septal defect a year ago. Transthoracic echocardiography showed a 13×9 mm hypoechoic mass attached to the left-atrial side of the device, which was suspected to be neoplasm or thrombus. The patient was indicated for surgery after multidisciplinary discussion due to ineffective medical therapy and typical stroke and pulmonary embolism symptoms. Three-dimensional transesophageal echocardiography (3D-TEE) revealed left-atrial vegetation (21×16 mm) and right-atrial vegetation (8×6 mm) attached to the device, which were confirmed as thrombus by surgical separation and laboratory examination. This case highlights the importance of 3D-TEE and a multidisciplinary team in the diagnosis and therapy of device-related thrombus.

We describe a 13-year-old boy with a bilateral hemorrhagic lesion in basal ganglia related to mild traumatic brain injury. Due to the severity of the traumatic brain injury, we did not expect the injury to either side of the basal ganglia. So tha

ABSTRACTPeripartum cardiomyopathy is an idiopathic cardiomyopathy that most commonly affects women in the third trimester of pregnancy or in the first five months of the postpartum period. It has been associated with a myriad of different findings on electrocardiograms and arrhythmias. This review discusses these electrocardiogram changes and arrhythmias in regards to prevalence, genetic landscape, screening and prognostication implications, and management. Keywords: Cardiology, electrophysiology, peripartum, cardiomyopathy, arrhythmia, pregnancy              INTRODUCTIONPeripartum cardiomyopathy (PPCM) in the United States has an incidence rate of 1 in 1,000 to 1 in 4,000. (1) The most commonly used definition for PPCM was developed by the 2010 European Society of Cardiology Working Group on Peripartum Cardiology, which described it as 1.     an idiopathic cardiomyopathy with the absence of other identifiable causes of HF, 2.     left ventricular ejection fraction (EF) less than 45%, 3.     within the 3rd trimester of pregnancy or five months following the pregnancy in the postpartum period. (2)  Patients with PPCM are at a high likelihood of recurrent hospital readmissions. Half of these admissions are cardiac-related, and approximately 15% of these cardiac-related admissions are secondary to arrhythmias. (3) Arrhythmias are not uncommon in this population and have been associated with increased maternal mortality. (4,5) In a retrospective study published in 2017 that used the Healthcare Utilization Project Nationwide Inpatient Sample database, there was a prevalence of 18.7% of arrhythmias in patients hospitalized with PPCM from a total of 9841 patients. (6) Within this population, 4.2% of the arrhythmias were characterized as ventricular tachycardia, followed by atrial fibrillation (AF) at 1% and ventricular fibrillation (VF) at 1%. (6) The remaining burden of arrhythmias were classified as “unspecified arrhythmias”. Among these 9,841 patients, 6.8% of them had implantable cardioverter-defibrillator (ICD) placement, permanent pacemaker (PPM) placement in 3.4%, catheter ablation in 1.9%, and electrical cardioversion in 0.3%.  Genetic Landscape of PPCMPeripartum cardiomyopathy and its genetic underpinnings remains poorly described in literature. Multiple genetic variants have been historically associated with peripartum cardiomyopathy, including TTN, FLNC, DSP and BAG3. (7) These genetic variants are often seen in dilated cardiomyopathy, supporting a similar genetic predisposition. In a study of 172 patients with PPCM, about 15% of them harbored bore truncating loss-of-function variants in TTN (TTNtvs), similarly to a group of patients with dilated cardiomyopathy. (8) The significance of TTN genetic mutations remains unknown, however a post hoc analysis of the Investigations of Pregnancy Associated Cardiomyopathy (IPAC) cohort showed that patients with TTNtvs have worse cardiac outcomes compared to patients without TTNtvs at 1 year follow up. (8) Patients with these TTN truncating variants often have lower ejection fractions, conferring more aggressive disease since ejection fraction is a strong predictor of clinical outcomes in PPCM. (7) Patients with truncating variants in FLNC have higher rates of malignant arrhythmias and may warrant aggressive antiarrhthmyic management. (9,10) These findings suggest the importance of genetic-phenotypic manifestations, which has therapeutic implications. For example, gene-specific therapies in dilated cardiomyopathy have led to lower thresholds for considering placement of defibrillator devices in patients with the truncated FLNC variant. In a article by Goli et al., this same approach is recommended to patients with PPCM who harbor a truncated FLNC variant. (7) These findings are summarized in Table 1. Further studies are warranted to investigate the diagnostic and therapeutic implications of these genetic variants in the setting of PPCM, especially from an arrhythmogenic standpoint. ELECTROGRAM FINDINGS In patients with PPCM, normal ECGs are rare. (11) Common ECG findings include sinus tachycardia, ST-segment changes, Q waves primarily in the anterior precordial leads, prolonged PR and QRS intervals, T wave inversions, and QTc interval prolongation. (13-15) A few of the most common abnormalities on the initial ECG at the time of diagnosis were T-wave changes (59% of patients), sinus tachycardia (45% of patients), QTc changes (44% of patients), P wave abnormalities (29% of patients), and QRS axis deviation (25% of patients). (13-16) Many cases of dilated cardiomyopathy that are not PPCM have a prevalence of bundle branch blocks in about 25-30% of patients. (17,18) However, in patients with PPCM, QRS complexes are often wider but do not usually meet the criteria of being >120 msec, and seldom have left or right bundle branch blocks. (13-15) Only about 1% to 5% of patients have a either a right or left bundle branch block. (13,15) QRS duration in patients with PPCM has been shown to be moderately correlated (r=0.4; p<0.003) with left ventricular end-systolic dimension (LVESD), left ventricular end-diastolic dimension (LVEDD), and left ventricular end-systolic volume index (LVESVI). (14) Honigberg et al. found that patients with an initially abnormal ECG at the time of diagnosis (those with a bundle branch block, ventricular hypertrophy, ST-segment elevation/depression, or atrial abnormalities) were more likely to have a larger left ventricular end-diastolic dimension (58 vs. 54 mm, P= 0.002). (13) Sinus tachyardia is also associated with an ejection fraction <35% (P= 0.006), and QRS, LBBB, and LVH were all associated with LVEDD >55 mm (P= 0.018, 0.017, and 0.017, respectively). (19) PROGNOSTICATION OF ECG FINDINGS An increase in incidence of sinus arrhythmia during follow-up visits is associated with an event-free survival, including no death or readmissions. (16) Major T wave changes on the initial ECG are associated with a lower ejection fraction at the time of diagnosis and during the 6-month follow-up. (15,16) However in a study by Honigberg et al., T wave inversions were not associated with worse outcomes. (13) Another PPCM cohort study published in 2019 showed that positive T waves in aVR were associated with adverse cardiac outcomes. (20) ST-segment elevation and depression are associated with a decreased EF at 6-month follow-up. (15) Sinus tachycardia was found to be an independent predictor of poor outcomes. (16,21) Prolonged QTc was also found to be associated with adverse cardiac outcomes. (16)  Left atrial abnormalities were associated with a lower EF at 6 and 12 month follow up, and predicted decreased event-free survival at 1 year follow-up compared to those with no left atrial abnormalities (75% vs 97%, P= 0.008). (13) These left atrial abnormalities on ECG are 96% specific for left atrial enlargement seen on echocardiogram, however only 38% sensitive. Left ventricular hypertrophy (LVH) identified on baseline ECG using the Cornell voltage criteria or the Sokolow-Lyon criteria was associated with a lower EF at initial time of diagnosis, compared to those without LVH on ECG (27% versus 35%, P= 0.03). Normal ECGs at baseline during initial diagnosis are associated with complete recovery of EF (EF > 50%) in about 84% of patients as compared to 49% of patients who had abnormal ECGs at baseline. (13) Also, event-free survival was found in 100% of patients who had normal ECGs at baseline versus 85% in patients with abnormal ECGs (p= 0.01). (13) Patients with an abnormal ECG at baseline (those with a bundle branch block, ventricular hypertrophy, ST-segment elevation/depression, or atrial abnormalities) are more likely to require inotropic therapy. (13) As for patients who present with PPCM and persistent bradyarrhythmia, approximately 7% of these patients will require permanent pacing. (22) These findings are summarized in Table 2. ARRHYTHMIAS IN PPCMThe true prevalence of brady- and tachyarrhythmias may be underdiagnosed since an ECG only screens at one point in time. (13-15) The majority of patients who are diagnosed with PPCM and undergo ECG testing are found to be in sinus rhythm, often including sinus tachycardia. (14,15,21) Patients that present in sinus tachycardia often have decreasing heart rates on subsequent visits. (16,23) There was a mean reduction of 27 beats/minute on 6-month follow-up appointments in one study. (15) About 25% of patients have normalization of these ECG abnormalities on follow-up appointments 6-months post-diagnosis. (15)  Ambulatory ECG monitoring can extend the recording time to screen for arrhythmias while also allowing for more accurate monitoring during everyday activities. A study done by Diao et al. showed that the Holter monitor was able to diagnose a greater frequency of premature atrial and ventricular contractions as compared to a 10-second ECG in patients diagnosed with PPCM. (21) In this study, premature atrial contractions were seen in 21% of all patients, premature ventricular contractions in 36.8% of patients, and sinus tachycardia in 89.4% of patients.  A recent clinical trial recruited 40 pregnant patients that had symptoms of arrhythmia and/or structural heart disease, and were randomized to a 24-holter ECG monitor versus a 24-holter ECG monitor plus an implantable loop recorder (holter-ILR group). (37) The holter monitor detected arrhythmias in 13% of patients in the holter monitor only group, and 24% of patients in the holter-ILR group. In the holter-ILR group, the ILR detected arrhythmias in 53% of patients. Seven patients were missed by the holter monitor in the holter-ILR group which included 4 patients with SVT, 1 with premature ventricular complexes, and 2 with paroxysmal AF. (37) External and implantable loop recorders are the preferred method of cardiac recording when infrequent arrhythmias are suspected.  1.     Ventricular arrhythmias Ventricular arrhythmias may occur in up to 20% of all patients with PPCM. (21) Cases of peripartum polymorphic ventricular tachycardia such as Torsades de pointes, monomorphic ventricular tachycardia, and ventricular fibrillation has been described. (25-27) Ventricular tachyarrhythmias are the culprit in 25-39% of all-cause mortality and are an independent predictor of in-hospital mortality, increased hospital costs, and longer length of hospitalization. (22,28,29) Severely reduced EF significantly increases the risk of non-life-sustaining arrhythmias, which may still occur even after normalization of EF. A study done by Duncker et al. reported that 3 out of 12 women with PPCM were found to have a total of 4 episodes of ventricular fibrillation over a 2.5 year period. (30) One patient developed the episode of VF after her EF was found to have improved to 45%. Although this study has a poor sample size, equating the risk of VT/VF with the EF as a sole factor is not a reliable method of risk stratification.  Included within the subset of ventricular arrhythmias, it is important to be aware that frequent premature ventricular contractions (PVCs) can further induce cardiogenic dysfunction and systolic failure. This is highly dependent on the frequency of the PVCs, as a PVC burden that is at least 24% of all beats has a high sensitivity and specificity in determining whether there is a dysfunctional left ventricle. (31-33) Long-term recurrence of ventricular arrhythmia is highly dependent on recovery of the ventricular tissue.  2.     Supraventricular arrhythmias and atrial fibrillationSupraventricular arrhythmias are not common in patients diagnosed with PPCM and are found in less than 1% of patients. (16) Similarly, only 1% to 3% of patients with PPCM have atrial fibrillation. (6,34) On the contrary, supraventricular tachycardia (SVT) in pregnant patients without diagnosed PPCM is seen in about 24 per 100,000 admissions, making it the most common arrhythmia in pregnancy. (35)  MANAGEMENT AND PREVENTIONManagement of Peripartum CardiomyopathyThe management of PPCM is dependent on the timeframe of PPCM. In the antepartum period, not all contemporary guidelines of treating heart failure apply as many of the mineralocorticoid receptor antagonists (MRA), ACE-inhibitors (ACE-I), and angiotensin receptor blockers (ARBs) have toxic effects on the fetus and should be avoided during pregnancy. Nitrates and hydralazine are the preferred treatment as a form of afterload reduction. Loop diuretics including furosemide can also be considered in cases where acute pulmonary vascular congestion is suspected. Beta-blockers should be initiated with caution. In the postpartum period, guideline-directed medical therapy (GDMT) guidelines for heart failure with reduced ejection fraction apply to the treatment of PPCM patients. (38) This includes beta-blockers, ACE-I/ARBs, MRAs and SGLT-2 inhibitors. Given that elevated prolactin level in PPCM has been hypothesized to be pathogenic in PPCM, bromocriptine was proposed as a option for theapy. (39-41) However, the use of bromocriptine therapy in PPCM remains controversial. (1) If a patient is started on bromocriptine, concomitant anticoagulant therapy should be considered to decrease risk of thromboembolic complications. (42) A study conducted in South Africa reported improved outcomes in patients diagnosed with PPCM who had elevated inflammatory markers and were treated with pentoxifylline, however further investigation is warranted. (43) Management of Supraventricular TachycardiaTreatment is dependent on patient hemodynamics. During both the ante- and postpartum periods, patients that are hemodynamically stable should undergo vagal maneuvers to terminate the rhythm. If unsuccessful, adenosine can be considered. Beta-blockers can also be considered, especially for prophylactic purposes. If none of these pharmacological agents are successful in controlling the SVT, or if hemodynamic instability ensues, next best step would be to utilize direct current cardioversion (DCCV). In the setting of pre-excitation, prevention therapy should include the use procainamide, while avoiding AV nodal blocking agents. Table 3 provides more guidance on the associations of certain anti-arrhythmic medications in the antepartum and postpartum periods that can be considered for the management of such arrhythmias. (42,44-54) Finally, catheter ablation may be warranted in difficult to control or refractory SVTs. Electroanatomic mapping systems are preferred in this population, especially during the antepartum period, to reduce exposure of fluoroscopy. (55) Radiation exposure during a fluoroscopy-utilized procedure is unlikely to cause fetal harm given that the uterus is not within the field of view. For example, when the field of view is the chest from a posterior-anterior or lateral view, the mGy dose that the fetus is exposed to is <0.002. Most fetal adverse effects typically occur when mGy is at least 50-100, hence a non-concerning amount of radiation absorption. (56) Nonetheless, there has been great enthusiasm for electroanatomic mapping systems and this is the preferred option in capable centers to avoid radiation exposure. Management of Atrial Fibrillation or FlutterAtrial fibrillation or flutter should be managed with a goal of rate versus rhythm control and anticoagulation, similarly to the non-PPCM population. Beta-blocker therapy is often the initial medication class of choice for rate control. Atenolol should be avoided during the antepartum period and postpartum  if breastfeeding. Sotalol can be considered for rhythm control as it is considerably safe in pregnancy and in the postpartum period. There is limited safety data on dofetilide in pregnancy. Dronedarone and amiodarone are contraindicated in pregnancy and the postpartum period as there remains a risk of neonatal toxicity with lactation. If refractory, digoxin can be considered. Due to reduced ejection fraction in PPCM, calcium-channel blockers are generally contraindicated. (57) DCCV is preferred for patients with hemodynamic instability or if symptomatic and refractory to medical therapy. Catheter ablation (zero-fluoroscopy preferred) is an option if medications fail however is often deferred until the postpartum period. (58,59)  Anticoagulation with heparin products, particulary low-molecular weight heparin (LMWH), is the preferred method during pregnancy as this does not cross the placenta, and is less likely to cause bleeding, osteoporosis, or thrombocytopenia as compared to unfractionated heparin. LMWH should be discontinued about 12 hours prior to delivery, and resumed about 24 hours after cesarean delivery, 12 hours after vaginal delivery, and 2-12 hours after epidural removal. (60) Direct oral anticoagulant therapy (DOAC) should be avoided during the antepartum period given minimal data regarding its use in pregnancy and known fetal toxicity with some of the common DOAC medications. (61) However, in the postpartum period, DOACs are safe to use and often utilized. Management of Ventricular TachycardiaPatients with PPCM are at high risk of developing ventricular arrhythmias and hemodynamic instability. Medications that are commonly used within the third trimsester of pregnancy should be utilized cautiously as these medicaitons can prolong the QTc and increase the risk of ventricular arrhythmias. These medications include oxytocin, anesthetics such as sevoflurane, and anti-emetics. In both the antepartum and postpartum periods, ultimate treatment should be targeted at repleting deficient electrolytes or cessation of culprit medications.  In both the antepartum and postpartum period, hemodynamically stable ventricular tachycardia can be managed with beta-blockers, lidocaine, and sotalol, as these medications are generally safe in pregnancy and in the postpartum period. These medications are also effective as prophylactic agents. During the antepartum period, procainimide and quinidine can be considered if refractory to other initial pharmacological agents, however, their use should be limited considering their risk of fetal toxicity. Quinidine should be avoided during breastfeeding. Procainamide can be considered during breastfeeding if used at the lowest dose possible. Verapamil can be considered in the setting of fascicular VT, however, should be utilized cautiously given it crosses the placenta and is secreted into breast milk. (62) Magnesium intravenous therapy can be used in the setting of polymorphic VT or torsade de pointes. (48) If hemodynamic instability ensues, DCCV should be of high priority. VT ablation is also a possible intervention in the antepartum period, however, is often deferred until the postpartum period.  (63) Utilization of electroanatomic mapping systems is preferred if ablation is done during pregnancy. (64)  Management of Cardiac ArrestApproximately 2.2% of patients with PPCM and arrhythmias develop cardiac arrest. (6) During cardiac arrest, medications and defibrillation should not be withheld for concerns of maternal and/or fetal teratogenicity or toxicity, done at the same doses as in the non-pregnant population. Compressions are recommended in concordance with the ACLS guidelines. In the antepartum period, manual lateral displacement of the uterus could be done to prevent aortocaval compression. Within 4 minutes of resuscitation efforts without achievement of ROSC, emergency C-section should be considered to maximize chance of fetal viability. (65) Management of Premature Ventricular ComplexesIf frequent PVCs are contributing to cardiomyopathy in PPCM, treatment is warranted. First-line therapy includes beta-blockers. Catheter ablation can also be considered for these patients if they fail medical management in both the antepartum and post-partum periods. (33) A meta-analysis of 27 cases demonstrated that ablation in the pregnant population during the antepartum period is an effective therapeutic approach regardless of ejection fraction. (55) Complications included one case of pre-eclampsia complicated by placental abruption five weeks after ablation and one case of microcephaly. Ablation modalities that use intracardiac echocardiogram and electroanatomic mapping systems are preferred, and should be completed in left lateral decubitus positioning for prevention of aortocaval compression.  In the post-partum period, catheter ablation modalities are highly dependent on center specific guidelines and protocols.  Direct-Current CardioversionDCCV is an efficacious modality for terminating tachyarrhythmias in patients with PPCM. (66) Infrequent complications during the antepartum period include increased uterine contractions, spontaneous preterm deliveries, fetal cardiovascular distress, and maternal death. (67-69) During the antepartum period, defibrillator pads should be placed away from the gravid uterus, positioned in the left lateral decubitus position, fetal monitoring to assess for fetal compromise, and resources available for emergency cesarean section. (69,70) The postpartum patient can undergo DCCV similarly to the non-pregnant population.  Pacemaker ImplantationApproximately 7% of patients with PPCM and persistent bradycardia will require PPM placement. (22) Device implantation can be conducted using minimal fluoroscopy methods and an electroanatomic navigation guidance system. (71) One consideration for patients who are pacemaker dependent undergoing cesarean delivery is to reprogram the pacemaker into an asynchronous mode and use bipolar cautery. This is done to avoid any pacemaker inhibiton caused by noise interference. (72)  Implantable Cardioverter DefibrillatorIndications for placement of an ICD in patients in the United States include those with severely reduced EF < 35% despite optimal medical therapy or as secondary prevention in those with ventricular arrhythmias. (22,73) ICD placement should be considered in patients with PPCM, however, exercised with caution. (74-76) In PPCM, about 41.5% to 57.5% of all patients undergo complete left ventricular (LV) recovery. (34) LV recovery is most often seen within the first six months after the diagnosis of PPCM, and rarely occurring past the 12-month mark. Patients with PPCM who do not undergo ventricular recovery within six months following delivery have been associated with high mortality rates, and ICD may provide benefit in these groups of patients. (77-79) ICD implantation can be done by utilizing minimal fluoroscopy, electroanatomic navigation guidance systems, and transesophageal guidance. (80-85) Cardiac resynchronization therapy can also be considered for patients with PPCM who fail to undergo complete LV recovery within a 6-month time span. (86) Specific to defibrillator therapy, an alternative option is fluoro-less implantation of a subcutaneous ICD system which is often used in patients with complex anatomy and difficult endovascular lead access. (87-89) For patients at high risk of sudden cardiac death without left ventricular recovery, a subcutaneous ICD is a safe alternative. The 2022 ESC guidelines classify the S-ICD as a class-lla recommendation for patients who require ICD without the need for cardiac resynchronization therapy or pacing for bradycardia. (90,91) However, given recent innovative advancements in cardiovascular medicine, the inability to pace may eventually be overcome with use of leadless pacemakers. Inactivation of the S-ICD may be warranted near delivery considering risk of inappropriate shock deliveries, emphasizing the importance of frequent patient monitoring and availability for manual shock delivery. A wearable cardioverter defibrillator (WCD) is also an option as a temporary measure. In a study by Duncker et al., 4 out of 7 patients with PPCM and an EF < 35% received biphasic shocks from their WCD for an episode of ventricular fibrillation. (30) Another multicenter analysis done in 16 medical centers in Germany showed that 12% of patients with newly diagnosed PPCM and EF <35% had a cumulative rate of 8 ventricular tachyarrhythmias during the period they wore a WCD (mean wear time was 120 days). (92) These tachyarrhythmias included VF, sustained VT, and non-sustained VT. CONCLUSIONPeripartum cardiomyopathy is associated with a myriad of different findings on the electrocardiogram and carries a significant risk of arryhthmias. 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Clin Res Cardiol. 2017;106:582-589. doi: 10.1007/s00392-017-1090-5         Central Illustration: