Cardioneuroablation in Patients with Vasovagal Syncope:An updated systematic review and meta-analysis.

BACKGROUND: Cardioneuroablation (CNA) is a novel procedure that shows promising results in reducing syncope recurrence in patients with refractory vasovagal syncope (VVS). However, its effectiveness and safety remain controversial. OBJECTIVE: We conducted an updated meta-analysis evaluating CNA efficacy and safety in patients with refractory VVS. METHODS: PubMed, Embase, and Cochrane databases were systematically searched for CNA studies in refractory VVS patients. Our primary efficacy endpoint was (1) syncope recurrence, and our safety endpoint was (2) periprocedural complications. Prespecified subgroup analyses were performed for (1) ganglionated plexi(GP) targeting method and (2) GP location of ablation. RESULTS: We included 27 observational studies and one RCT encompassing 1153 patients with refractory VVS who underwent CNA. The median age was 39.6 years, and the follow-up was 21.4 months. The overall weighted rate of syncope recurrence after CNA was 5.94% (95% CI: 3.37 to 9.01; I2 = 64%), and the rate of periprocedural complications was 0.99% (95% CI: 0.14 to 2.33; I2: 0%). Our prespecified subgroup analysis among the GP targeting methods and GP ablation location showed a higher prevalence of syncope recurrence in the electroanatomic mapping subgroup (6.21%; 95% CI 2.93 to 10.28; I2 = 0%) and in the right atrium approach (15.78%; 95% CI 3.61 to 33.14; I2 = 65.2%). CONCLUSION: This study supports the efficacy and safety of CNA in preventing syncope recurrence in patients with VVS. Furthermore, the EAM method of GP targeting and the RA approach were associated with higher syncope recurrence rate than other methods.

Atrial Fibrillation Ablation in Systolic Dysfunction: Clinical and Echocardiographic Outcomes / Ablação da Fibrilação Atrial na Disfunção Sistólica: Evolução Clínica e Ecocardiográfica

Background: Heart failure and atrial fibrillation (AF) often coexist in a deleterious cycle. Objective: To evaluate the clinical and echocardiographic outcomes of patients with ventricular systolic dysfunction and AF treated with radiofrequency (RF) ablation. Methods: Patients with ventricular systolic dysfunction [ejection fraction (EF) <50%] and AF refractory to drug therapy underwent stepwise RF ablation in the same session with pulmonary vein isolation, ablation of AF nests and of residual atrial tachycardia, named "background tachycardia". Clinical (NYHA functional class) and echocardiographic (EF, left atrial diameter) data were compared (McNemar test and t test) before and after ablation. Results: 31 patients (6 women, 25 men), aged 37 to 77 years (mean, 59.8±10.6), underwent RF ablation. The etiology was mainly idiopathic (19 p, 61%). During a mean follow-up of 20.3±17 months, 24 patients (77%) were in sinus rhythm, 11 (35%) being on amiodarone. Eight patients (26%) underwent more than one procedure (6 underwent 2 procedures, and 2 underwent 3 procedures). Significant NYHA functional class improvement was observed (pre-ablation: 2.23±0.56; postablation: 1.13±0.35; p<0.0001). The echocardiographic outcome also showed significant ventricular function improvement (EF pre: 44.68%±6.02%, post: 59%±13.2%, p=0.0005) and a significant left atrial diameter reduction (pre: 46.61±7.3 mm; post: 43.59±6.6 mm; p=0.026). No major complications occurred. Conclusion: Our findings suggest that AF ablation in patients with ventricular systolic dysfunction is a safe and highly effective procedure. Arrhythmia control has a great impact on ventricular function recovery and functional class improvement. .

Fundamento: Insuficiência cardíaca e fibrilação atrial (FA) frequentemente coexistem em um ciclo deletério. Objetivo: Avaliar a evolução clínica e ecocardiográfica de portadores de disfunção ventricular e FA tratados com ablação por radiofrequência (RF). Métodos: Portadores de disfunção sistólica [fração de ejeção (FE) < 50%] e FA rebelde a tratamento clínico foram submetidos à ablação por RF escalonada em três etapas na mesma sessão com isolamento das veias pulmonares, ablação dos ninhos de FA, pesquisa e ablação de taquicardias atriais e "taquicardia de background". Os dados clínicos (classe funcional da NYHA) e ecocardiográficos (FE; diâmetro do átrio esquerdo) pré- e pós-procedimento foram comparados (teste de McNemar e teste t, respectivamente). Resultados: 31 pacientes (6 mulheres, 25 homens) de 37 a 77 anos (média, 59,8 ± 11 anos) foram submetidos à ablação por RF. A cardiopatia foi predominantemente idiopática (19 p; 61%). Na evolução média de 20,3 ± 17 meses, 24 pacientes (77%) estavam em ritmo sinusal, sendo 11 (35%) com amiodarona. Oito pacientes (26%) foram submetidos a mais de um procedimento (6 submetidos a 2 procedimentos e 2 a 3 procedimentos). Observou-se melhora expressiva da classe funcional da NYHA (pré-ablação: 2,23 ± 0,56; pós: 1,13 ± 0,35; p < 0,0001). A avaliação ecocardiográfica evolutiva também mostrou melhora significativa da função ventricular (FE pré: 44,68% ± 6,02%; pós: 59% ± 13,2%; p = 0,0005) e redução significativa no diâmetro do átrio esquerdo (pré: 46,61 ± 7,3 mm; pós: 43,59 ± 6,6 mm; p = 0,026). Não ocorreram complicações maiores. Conclusão: Os resultados deste estudo sugerem que ablação de FA em portadores de disfunção ventricular seja um procedimento seguro e com eficácia elevada a médio prazo. O controle da arritmia tem grande impacto na recuperação da função ventricular e na melhora clínica avaliada pela classe funcional. .

Diagnóstico eletrocardiográfico de infarto do miocárdio em portador de marcapasso / Eletrocardiographic diagnosis of acute myocardial infarction in a patient with ventricular pacing

O diagnóstico de infarto agudo do miocárdio (IAM) ou isquemia em portadores de marcapasso é um desafio para o cardiologista. A decisão terapêutica mais adequada geralmente é baseada no eletrocardiograma, porém a presença do ritmo de marcapasso pode limitar seu valor diagnóstico. Relata-se o caso de um portador de marcapasso com diagnóstico de IAM e as dificuldades diagnósticas encontradas na interpretação eletrocardiograma.