Minimal fluoroscopy approach for right-sided supraventricular tachycardia ablation with a novel ablation technology: Insights from the multicenter CHARISMA clinical registry.

BACKGROUND: No data exist on the ability of the novel Rhythmia 3-D mapping system to minimize fluoroscopy exposure during transcatheter ablation of arrhythmias. We report data on the feasibility and safety of a minimal fluoroscopic approach using this system in supraventricular tachycardia (SVT) procedures. METHODS: Consecutive patients were enrolled in the CHARISMA registry at 12 centers. All right-sided procedures performed with the Rhythmia mapping system were analyzed. The acquired electroanatomic information was used to reconstruct 3-D cardiac geometry; fluoroscopic confirmation was used whenever deemed necessary. RESULTS: Three hundred twenty-five patients (mean age = 56 ± 17 years, 57% male) were included: 152 atrioventricular nodal reentrant tachycardia, 116 atrial flutter, 41 and 16 right-sided accessory pathway and atrial tachycardia, respectively. Overall, 27 481 s of fluoroscopy were used (84.6 ± 224 s per procedure, equivalent effective dose = 1.1 ± 3.7 mSv per patient). One hundred ninety-two procedures (59.1%) were completed without the use of fluoroscopy (zero fluoroscopy, ZF). In multivariate analysis, the presence of a fellow in training (OR = 0.15, 95% CI: 0.05-0.46; p = .0008), radiofrequency application (0.99, 0.99-1.00; p = .0002), and mapping times (0.99, 0.99-1.00; p = .042) were all inversely associated with ZF approach. Acute procedural success was achieved in 97.8% of the cases (98.4 vs. 97% in the ZF vs. non-ZF group; p = .4503). During a mean of 290.7 ± 169.6 days follow-up, no major adverse events were reported, and recurrence of the primary arrhythmia was 2.5% (2.1 vs. 3% in the ZF vs. non-ZF group; p = .7206). CONCLUSIONS: The Rhythmia mapping system permits transcatheter ablation of right-sided SVT with minimal fluoroscopy exposure. Even more, in most cases, the system enables a ZF approach, without affecting safety and efficacy.

Occlusion tool software for pulmonary vein occlusion verification in atrial fibrillation cryoballoon ablation.

BACKGROUND: Optimal pulmonary vein (PV) occlusion, usually verified with selective contrast injection, is mandatory to obtain an effective PV isolation during cryoballoon (CB) ablation. AIM OF THE STUDY: The purpose of this study was to verify the feasibility and the accuracy of a new dielectric sensing system in assessing PV occlusion during CB ablation in patients with atrial fibrillation (AF). METHODS: We enrolled 28 consecutive patients with paroxysmal or persistent AF. After transseptal access, a detailed image reconstruction of left atrium and PVs was achieved with an octapolar or decapolar mapping catheter (Achieve catheter, Medtronic Inc.) and KODEX-EPD system (EPD Solutions, a Philips company). The degree of PV occlusion with the inflated Arctic Front Advance Cryoballoon (Medtronic Inc.) was verified using the new "occlusion tool" software module (EPD Solutions, a Philips company) and compared to an angiogram obtained with contrast medium injection in each PV. RESULTS: A total of 105 PV CB occlusion were tested. The new occlusion tool software module showed a 91% sensitivity and 76% specificity in assessing a complete PV occlusion verified with contrast medium injection. The positive predictive value was 80%, and the negative predictive value was 88.6%. Mean procedure time was 81 ± 17 minutes. Mean fluoroscopy time was 6 ± 2 minutes. No 30-day complications were observed. CONCLUSION: The new dielectric imaging system was able to assess the degree of PV occlusion during a CB ablation with good sensitivity and specificity.

A new mapping method with the Rhythmia™ navigation system reduces radiation exposure. Preliminary experience in SVT procedures.

PURPOSE: Electrophysiological studies and ablation procedures expose both physicians and patients to a significant amount of radiation. Most 3-D mapping systems provide improved tracking of catheters and enable radiation exposure to be reduced or even eliminated. However, there are no data on the ability of the Rhythmia ™ mapping system (Boston Scientific) to minimize fluoroscopy time and dose. METHODS: Here, we report on the feasibility and safety of a novel non-fluoroscopic approach (NFA) that uses the Rhythmia ™ mapping system and a novel navigation-enabled ablation catheter in SVT and atrial flutter procedures, and describe in detail our modified procedural work-flow. A total of 20 consecutive patients who were referred to our center for RF ablation of SVT arrhythmias were included in this analysis to test our procedural work flow. RESULTS: In our preliminary experience of the NFA work-flow, fluoroscopy times and radiological exposure were significantly reduced in comparison with the conventional approach. CONCLUSION: In our preliminary experience, arrhythmia ablation through a near-zero fluoroscopy approach involving the use of a novel ablation technology and the Rhythmia™ mapping system proved to be safe, feasible and effective in common atrial arrhythmias.

Interatrial conduction times in paroxysmal atrial fibrillation patients with normal atrial volume and their correlation with areas of local prolonged bipolar electrograms.

BACKGROUND: Recent evidence has shown that the presence of abnormal substrate can be demonstrated also among patients with "lone" AF. OBJECTIVES: Interatrial conduction slowing is likely to characterize patients with paroxysmal atrial fibrillation (AF) and it could be correlated to the left atrium area of prolonged local bipolar endocardial electrograms. METHODS: P-wave duration (PWD), amplified PWD and endocavitary interatrial conduction time (IACT), were analyzed in 60 patients; 30 undergoing de novo ablation for paroxysmal AF with normal atrial volumes and without any other cardiac disease and 30 of similar age undergoing electrophysiological study for atrioventricular nodal reentrant tachycardia or atrioventricular re- entrant tachycardia. In patients with AF, voltage maps and local bipolar electrograms (LBE) duration map were evaluated. RESULTS: Although PWD was <120 ms in 28 patients with AF and in 29 controls, patients with AF exhibited longer PWD, amplified-PWD and IACT. Although low-voltage areas (<0.5 mV) were not found in the study population, 28 of them demonstrated areas with LBE longer than 60 ms. These LBE were found mainly in the roof of the left atrium and their extension was correlated to IACT (R = 0.51, p = 0.004). IACT >135.5 ms identified the subjects who experienced AF with 90% sensitivity and 97% specificity. CONCLUSION: A subclinical interatrial conduction disturbance is demonstrable in subjects with paroxysmal AF and normal left atrial volume. IACT has a good correlation to the areas of abnormal LBE in the left atrium. IACT >135 ms identified subjects who have experienced AF.

High density mapping of aortic cusps improves near field detection of pre-potentials during premature ventricular contractions.

Recognition of pre-potentials during activation mapping of aortic cusp premature ventricular contractions is useful to localize the precise site of origin and is an indicator of successful ablation, but sometimes these electrograms can be blunt and have low amplitude. High resolution mapping in the aortic cusp region allows improved near field detection of these signals in very few beats.

Fainting episode in a pacemaker dependent patient with two implanted devices. Too much of a good thing!

A 73 year old man with CRT-D system and pacemaker dependence was admitted to the emergency department due to a syncopal episode. The device interrogation was performed. An RV ventricular sensing test was executed in VVI mode at 50 b/m. During testing the patient developed transient loss of consciousness with full recovery after stopping the sensing test. Applying asynchronous pacing mode, a pacing spike occurred at a faster rate of 65 b/m without evoking any ventricular capture. Looking at the chest X-ray, we found an abandoned right sided, single chamber VVI pacemaker in a submuscular pocket. The CRT-D system was positioned on the left side. The abandoned pacemaker was in ERI and it switched to VVI 65 b/m resulting in inhibition CRTD device during sensing test. This troubleshooting highlights the possible interference between two devices.

Functional substrate analysis in patients with persistent atrial fibrillation.

OBJECTIVES: The aim of this study was to describe the correlation between atrial electrogram duration map (AEDUM), spatiotemporal electrogram dispersion (STED) and low voltage areas (LVA) in patients with persistent atrial fibrillation (PsAF). BACKGROUND: The degree of left atrial (LA) tissue remodelling and augmented anisotropic conduction is one of the major issues related to PsAF ablation outcome. METHODS: This study enrolled consecutive patients with PsAF undergoing pulmonary vein isolation. In all patients, voltage, AEDUM and STED maps were created, and the correlation was reported between these three mapping methods. RESULTS: A total of 40 patients with PsAF were enrolled. The mean age was 62.2 ± 7.4 years, and males were 72.5% (n = 29). The overall bipolar voltage of the LA was 3.06 ± 1.87 mV. All patients had at least one AEDUM area (overall AEDUM area: 21.8 ± 8.2 cm2); the mean longest electrogram (EGMs) duration was 90 ± 19 ms. STED areas with < 120 ms was 46.3 ± 20.2 cm2 which covered 45 ± 22% of the LA surface. AEDUM and STED areas were most frequently reported on the roof, the anterior wall and the septum. The extension of the AEDUM areas was significantly smaller than STED areas with CL < 120 ms (21.8 ± 8.2 vs 46.3 ± 20.2; p-value < 0.0001). In 24 patients (60%), AEDUM areas was entirely included in the STED areas with CL < 120 ms. In the three (7.5%) patients with LVA, no correspondence with STED and AEDUM was noted. CONCLUSION: AEDUM and STED maps allow to identify areas of conductive dysfunction as a possible atrial substrate even if a normal voltage is detected.

Comparative long term effects of nebivolol and carvedilol in hypertensive heart failure patients.

BACKGROUND: Beta-blockers improve left ventricular (LV) systolic function and prognosis in patients with chronic heart failure (CHF), but their different pleiotropic properties may influence their cardiovascular effects. This open-label study compared the effects of long-term treatment with nebivolol versus carvedilol on LV ejection fraction (LVEF), in hypertensive CHF patients. Secondary end points were to assess the effect of the 2 beta-blockers on exercise capacity and clinical outcome. METHODS AND RESULTS: A total of 160 hypertensive CHF patients, with LVEF <40% and in New York Heart Association (NYHA) functional class I, II, or III, were randomly assigned to receive nebivolol or carvedilol for 24 months. At baseline and at the end of treatment, all patients underwent clinical evaluation, echocardiography, and 6-minute walking test. The target doses were 10 mg/d for nebivolol and 50 mg/d for carvedilol. Compared with baseline values, LVEF increased by a similar extent in the carvedilol (C) and nebivolol (N) groups (C from 36.1% (SD 1.5%) to 40.9% (SD 1.9%), P < .001; N from 34.1% (SD 1.8%) to 38.5% (SF 2.2%), P < .001). Heart rate and NYHA functional class decreased significantly in both groups, and the 6-minute walking distance increased (C from 420 m (SD 104 m) to 490 m (SD 115 m), P < .001; N from 421 m (SD 118 m) to 487 m (SD 138 m), P < .001). During 24 months, 21 carvedilol recipients (26%) and 18 nebivolol recipients (22%) had cardiac events, including 3 and 4 deaths, respectively. CONCLUSION: In the long term, nebivolol and carvedilol appear to be similarly effective in the treatment of hypertensive patients with CHF.

A novel Ventricular map of Electrograms DUration as a Method to identify areas of slow conduction for ventricular tachycardia ablation: The VEDUM pilot study.

BACKGROUND: Bipolar electrogram (EGM) duration is indicative of local activation property and, if prolonged, is useful to discover areas of slow conduction favoring arrhythmias. OBJECTIVE: The present study aimed to create a map of EGM duration during the ventricular tachycardia (VT) (Ventricular Electrograms DUration as a Method map [VEDUM map]) to verify if the slowest activation area is crucial for reentry and could represent a suitable target for rapid VT interruption during ablation. METHODS: Prospectively 30 patients were enrolled for this study. Twenty-one patients were selected, and 24 VT maps with complete circuit delineation (>90% tachycardia cycle length) were analyzed. Activation and VEDUM maps during VT as well as voltage maps during sinus rhythm were created. RESULTS: Twenty-two of 24 VTs (88%) were interrupted during the first radiofrequency delivery (mean time 7.3 ± 5.4 seconds; range 3-25 seconds) at the area with the longest EGM duration (212 ± 47 ms; range 113-330 ms). The mean percentage of the cycle length of VT covered by the EGM with the longest duration was 58% ± 12%. In 9 patients (37%), the longest EGM was located at the isthmus entrance, at the exit in 7 maps (30%), and the mid-isthmuses in 8 maps (33%). In 6 patients (25%), the EGM covered the full diastolic phase. The mean isthmus width was 28 ± 11 mm (range 16-48 mm; median 25 mm). CONCLUSION: A VEDUM map is highly accurate in defining a conductive vulnerable zone of the VT circuit. The longest EGM duration within the isthmus is highly predictive of rapid VT termination at the first radiofrequency delivery even in the case of large isthmuses.

Outcome of a Modified Sympathicotomy for Cardiac Neuromodulation of Untreatable Ventricular Tachycardia.

OBJECTIVES: This study aimed to describe the preliminary results of a modified sympathicotomy for cardiac sympathetic denervation (CSD), which may reduce the predictive risk and intraoperative surgical time of the procedure. BACKGROUND: CSD, in patients with refractory ventricular tachycardia (VT), is comprehensively recognized as an important treatment option for patients with structural heart disease as well as congenital inherited arrhythmia syndrome. METHODS: We consecutively enrolled 5 patients with refractory VT. Baseline demographic, medical, and surgical data as well as arrhythmia outcomes and procedural complications were evaluated. RESULTS: A total of 5 patients (mean age: 67.4 years) were enrolled for the treatment of refractory VT with a modified CSD technique. In 3 of 5 patients, an overall reduction in VT burden (ranging from 75% to 100%) and VT number was observed after the CSD despite an in-hospital early recurrence. CONCLUSIONS: A modified CSD (sympathicotomy T2-T5) with stellate ganglion sparing and the use of unipolar radiofrequency is feasible, effective, and safe in the setting of untreatable VT.

Increasing pace mapping properties in parahissian premature ventricular contraction. Novel insight from HD grid multipolar catheter.

A 23-year-old athlete with symptomatic low burden premature ventricular contraction (PVC) with left bundle branch block morphology and inferior axis morphology was sent to our department for RV mapping and PVC ablation. Exit zone of the PVC was easily and clearly defined by the bipoles A3-A4 achieving optimal and detailed pacemapping (Panels A-C) near the His bundle (yellow dots). The spatial conformation and the smooth shape of the catheter would definitely help everyday procedures in the setting of low burden PVC/noninducible focal ventricular arrhythmia, especially when the focus is located very close to the conductive tissue.

Magnetic resonance coronary angiography: present clinical applications.

Coronary angiography is presently considered the gold standard test for the assessment of coronary artery disease. However, owing to the exposure to ionizing radiations, the invasiveness, and the incidence of major complications (0.3-1.1%), investigators are attempting to develop safer, non-invasive techniques. Cardiovascular magnetic resonance proved to be an extremely safe tool with a wide range of clinical applications. Its flexibility and non-invasiveness allow the evaluation of the heart and coronary arteries in one single setting, with the possibility of quantifying several cardiac physiological parameters. Multiple techniques have been applied to overcome the substantial difficulties in coronary artery imaging: respiration artifacts are suppressed by breath-holding or respiratory gating, cardiac motion artifacts are reduced by diastolic gating with ultra fast sequences and the signal-to-noise ratio can be increased with contrast agents. In several clinical trials, magnetic resonance coronary angiography has been successfully used to assess coronary artery stenoses, coronary artery bypass grafts and anomalous coronary artery origins and course. Considering the continuing developments in magnet coils, in software technology and in innovative imaging approaches, it is likely that magnetic resonance coronary angiography will in the future play an important role in the evaluation of coronary artery disease.

Comparison of Microlife BP A200 Plus and Omron M6 blood pressure monitors to detect atrial fibrillation in hypertensive patients.

INTRODUCTION: Self-monitoring home blood pressure (BP) devices are currently recommended for long-term follow-up of hypertension and its management. Some of these devices are integrated with algorithms aimed at detecting atrial fibrillation (AF), which is common essential hypertension. This study was designed to compare the diagnostic accuracy of two widely diffused home BP monitoring devices in detecting AF in an unselected population of outpatients referred to a hypertension clinic because of high BP. METHODS: In 503 consecutive patients the authors simultaneously compared the accuracy of the Microlife(®) BP A200 Plus (Microlife) and the OMRON(®) M6 (OMRON) home BP devices, in detecting AF. RESULTS: Systolic and diastolic BP as well as heart rate (HR) values detected by the two devices were not significantly different. Pulse irregularity was detected in 124 and 112 patients with the OMRON M6 and Microlife BP A200 Plus devices, respectively. Simultaneous electrocardiogram (ECG) recording revealed that pulse irregularity was due to AF in 101 patients. Pulse irregularity detected by the OMRON M6 device corresponded to AF in 101, to supraventricular premature beats in 18, and to frequent premature ventricular beat in five patients, respectively. Pulse irregularity detected by the Microlife BP A200 Plus device corresponded to AF in 93, to supraventricular premature beats in 14, and to ventricular premature beats in five patients. The sensitivity for detecting AF was 100%, the specificity was 92%, and diagnostic accuracy 95% for the OMRON M6 and 100%, 92%, and 95 for the Microlife BP A200 Plus, respectively. AF was newly diagnosed by ECG recordings in 47 patients, and was detected in all patients by the OMRON device, and in 42 patients by the Microlife device. CONCLUSION: These results indicate that OMRON M6 is more accurate than Microlife BP A200 Plus in detecting AF in patients with essential hypertension. Widespread use of these devices in hypertensive patients could be of clinical benefit for the early diagnosis and treatment of this arrhythmia and related consequences.

Long-term effects of nutraceuticals (berberine, red yeast rice, policosanol) in elderly hypercholesterolemic patients.

INTRODUCTION: Statins are at the forefront of strategies to manage dyslipidemia, although they are not always well tolerated. At 6-7 months after the drug was supplied, discontinuation rates averaged 30%. Alternate agents to statins have been studied. Some nutraceuticals demonstrated an efficacy in reducing cholesterol concentrations. However, there are no data regarding the use of nutraceuticals in elderly dyslipidemic patients. The purpose of this study was to examine the efficacy, safety, and tolerability of a nutraceutical-based protocol in elderly hypercholesterolemic patients previously intolerant to statins. METHODS: This study was performed as a randomized, prospective, parallel group, single-blind study. Patients were included in the study if they had high total cholesterolemia, high low-density lipoprotein cholesterol (LDL-C), >75 years of age, statin-intolerant, and were refusing other pharmaceutical treatments for hypercholesterolemia. At the baseline visit, eligible patients were randomized to either nutraceutical-combined pill (containing berberine 500 mg, policosanol 10 mg, red yeast rice 200 mg, folic acid 0.2 mg, coenzyme Q10 2.0 mg, and astaxanthin 0.5 mg) or placebo, and the first dose was dispensed. The efficacy, safety, and tolerability of the proposed treatment were fully assessed after 3, 6, and 12 months of treatment. RESULTS: Out of 106 consecutive patients screened, 80 eligible patients were randomized to receive either nutraceutical-combined pill (40 patients) or placebo (40 patients). No patients were lost and no deaths occurred during the follow-up. There was a statistically significant reduction in total cholesterolemia (-20%), LDL-C (-31%), and insulin resistance (-10%) with nutraceutical treatment. No significant changes were detected for plasma high-density lipoprotein cholesterol (HDL-C). Furthermore, no statistical differences were found between baseline and end-study safety parameters. Medication compliance and tolerability were high. CONCLUSION: In this study the authors have demonstrated that combined nutraceuticals significantly reduce cholesterolemia and achieved acceptable plasma LDL-C levels in elderly hypercholesterolemic patients who were previously statin-intolerant. Combined nutraceuticals is also safe and well tolerated in these patients.

Effectiveness of nebivolol and hydrochlorothiazide association on blood pressure, glucose, and lipid metabolism in hypertensive patients.

INTRODUCTION: Only 50% of hypertensive patients receive an appropriate treatment to normalize blood pressure (BP). Although monotherapy is often adequate in normalizing BP, it is sometimes necessary to start with combination therapy. The aim of the study was to evaluate the efficacy of nebivolol alone and in association with hydrochlorothiazide (HCT) in reducing BP in hypertensive patients with new-onset, mild-to-moderate hypertension, and to assess the effect of combination therapy on glucose and lipid metabolism. METHODS: At enrollment, patients underwent a full cardiovascular and metabolic evaluation. Patients were then prescribed nebivolol (5 mg/day). After 1 month, in those patients whose BP was not normalized, HCT 12.5 mg was added and increased further to 25 mg after 1 month in those whose BP still was not normalized. All patients were assessed at monthly intervals for a further 5 months. RESULTS: We enrolled 233 treatment-naive patients. After the first month of treatment with nebivolol, 70% of patients had normalized BP. The addition of HCT increased responder rates to 94%. An improvement in glucose metabolism was noted with nebivolol alone (at 1 month, the reduction in Homeostasis Model Assessment of Insulin Resistance [HOMA-IR] was 26% and remained stable at 6 months); the adjunct of HCT blunted the reduction in HOMA-IR. No significant changes on lipid profile were noted with nebivolol, either alone or in combination therapy. CONCLUSION: Nebivolol is effective in mild-to-moderate hypertension and associated with favorable metabolic effects. The addition of HCT optimizes BP control in a high number of patients resistant to monotherapy without a negative impact on patients' glucose and lipid profile.