RESUMO
BACKGROUND: Pacing lead-related tricuspid regurgitation (TR), a recognized complication of ventricular pacing lead implantation, may be affected by lead position or diameter. OBJECTIVE: This study sought to determine the effect of ventricular pacing lead position and diameter on pacing lead-related TR. METHODS: A randomized prospective trial compared pacing leads in the right ventricular apex (RVA), right ventricular septum (RVS), or left ventricle via the coronary sinus (LV-CS) in a 1:1:1 fashion. Patients undergoing implantable cardioverter-defibrillator lead implantation in the RVA (RVA-ICD) were enrolled in a comparison group. Patients with preexisting moderate or greater TR were excluded. Prospective clinical evaluation, transthoracic echocardiograms, and device interrogation occurred 24 hours and 12 months after device implantation. RESULTS: Sixty-three patients undergoing pacemaker implantation were randomized to RVA, RVS, or LV-CS pacing, and 48 RVA-ICD patients were enrolled as a comparison group. At 12 months, 6 patients (6.4%) developed moderate or greater TR. Moderate or greater TR was not significantly different between groups if analyzed by intention to treat (RVA 5.9%, RVS 10.0%, LV-CS 6.7%, and RVA-ICD 4.8%) or if analyzed by final lead location (RVA 4.8%, RVS 10.5%, LV-CS 8.3%, and RVA-ICD 5.1%). Ventricular lead-related complications occurred in 3 patients with right ventricular leads (3.2%) and 2 patients with LV-CS leads (11.1%) (P = .184). CONCLUSION: Neither pacing lead position nor diameter appears to affect TR development significantly. LV-CS leads failed to achieve a statistically significant reduction in TR as compared with right ventricular leads.
Assuntos
Desfibriladores Implantáveis/efeitos adversos , Ventrículos do Coração/diagnóstico por imagem , Marca-Passo Artificial/efeitos adversos , Taquicardia Ventricular/terapia , Insuficiência da Valva Tricúspide/etiologia , Idoso , Ecocardiografia , Falha de Equipamento , Feminino , Seguimentos , Humanos , Masculino , Estudos Prospectivos , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/fisiopatologiaRESUMO
In patients with unexplained cardiomyopathy, electroanatomical mapping can identify abnormal tissue to target during electrophysiology-guided endomyocardial biopsy (EP-guided EMB). The objective of this study is to determine whether catheter ablation performed in the same setting as EP-guided EMB increases procedural risk. Sixty-seven patients (mean age 54.4 ± 13.8, 57% male) undergoing EP-guided EMB were included. Radiofrequency catheter ablation was performed in 17 patients (25%) for ventricular arrhythmias and in 2 (3%) for typical atrial flutter. Femoral arterial access was obtained in 90% ablation patients and 40% biopsy-only patients; vascular access complications were more common in the ablation group than in the EMB-only group (p = 0.02). There were no significant differences in rate of tricuspid regurgitation, thromboembolism, or pericardial effusion, whether procedural anticoagulation was used. In conclusion, catheter ablation and procedural anticoagulation can be combined with EP-guided EMB with an increased risk of vascular access complications, but no significant increase in intracardiac complications.
Assuntos
Arritmias Cardíacas/patologia , Biópsia/métodos , Cardiomiopatias/patologia , Ablação por Cateter/métodos , Endocárdio/patologia , Miocardite/patologia , Miocárdio/patologia , Sarcoidose/patologia , Adulto , Idoso , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/cirurgia , Flutter Atrial/etiologia , Flutter Atrial/patologia , Flutter Atrial/cirurgia , Bloqueio Atrioventricular/patologia , Bloqueio Atrioventricular/cirurgia , Cardiomiopatias/complicações , Técnicas Eletrofisiológicas Cardíacas , Endocárdio/cirurgia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocardite/complicações , Complicações Pós-Operatórias/epidemiologia , Sarcoidose/complicações , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/patologia , Taquicardia Ventricular/cirurgia , Complexos Ventriculares Prematuros/etiologia , Complexos Ventriculares Prematuros/patologia , Complexos Ventriculares Prematuros/cirurgiaAssuntos
Complexos Atriais Prematuros/fisiopatologia , Sistema de Condução Cardíaco/fisiopatologia , Taquicardia por Reentrada no Nó Atrioventricular/fisiopatologia , Potenciais de Ação , Adulto , Complexos Atriais Prematuros/diagnóstico , Complexos Atriais Prematuros/cirurgia , Ablação por Cateter , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Sistema de Condução Cardíaco/cirurgia , Frequência Cardíaca , Humanos , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico , Taquicardia por Reentrada no Nó Atrioventricular/cirurgiaAssuntos
Fibrilação Atrial/diagnóstico por imagem , Flutter Atrial/diagnóstico por imagem , Ecocardiografia Transesofagiana/métodos , Comunicação Interatrial/diagnóstico por imagem , Idoso de 80 Anos ou mais , Fibrilação Atrial/terapia , Flutter Atrial/terapia , Eletrocardiografia/métodos , Humanos , Achados Incidentais , MasculinoRESUMO
INTRODUCTION: Despite many advances in nonpharmacologic management of ventricular arrhythmias, antiarrhythmic drugs remain important in both the acute conversion and chronic prevention of ventricular arrhythmias. AREAS COVERED: Key trials related to antiarrhythmic drug use are reviewed, emphasizing the impact of recent discoveries. Sodium channel blockers are discussed with an emphasis on recently identified specialized uses. Beta blockers, amiodarone, sotalol, and dofetilide are discussed together in the context of structural heart disease, because they do not increase mortality in this group of patients. Other medications found to reduce ventricular arrhythmia burden are discussed last. EXPERT OPINION: Since most patients with ventricular arrhythmias have structural heart disease, pharmacologic treatment is limited to amiodarone, d-,l-sotalol, and dofetilide (off-label indication), in conjunction with defibrillator implantation. While amiodarone has superior reduction in arrhythmias, its long-term extracardiac toxicities can cause significant morbidity. A trial of sotalol is reasonable if there are no contraindications, recognizing that over 20% of patients have to discontinue it because of adverse effects. Beta blockers are first line therapy for most patients. Genetic testing is particularly informative regarding treatment approach in long QT syndrome, Brugada syndrome, and catecholaminergic polymorphic VT. Research should continue to focus on developing more effective antiarrhythmic medications with less long-term toxicity.
Assuntos
Antiarrítmicos/uso terapêutico , Taquicardia Ventricular/tratamento farmacológico , Fibrilação Ventricular/tratamento farmacológico , Antagonistas Adrenérgicos beta/uso terapêutico , Quimioterapia Combinada , Humanos , Bloqueadores dos Canais de Potássio/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Bloqueadores dos Canais de Sódio/uso terapêuticoRESUMO
Given the high incidence of atrial fibrillation (AF) in the surgical population and the associated morbidity, physicians managing these complicated patients in the perioperative period need to be aware of the new and emerging trends in its therapy. The cornerstones of AF management have always been rate/rhythm control as well as anticoagulation. Restoration of sinus rhythm remains the fundamental philosophy as it maintains the atrial contribution to cardiac output and improves ventricular function. The recent years have seen a dramatic increase in the number of randomized AF trials that have made significant advances to our understanding of both pharmacologic and procedural management, from the introduction of the new generation of oral anticoagulants (NOAC's) to catheter approaches for AF ablation. This paper will summarize the newest data that will affect the perioperative management of these patients.
Assuntos
Fibrilação Atrial/terapia , Assistência Perioperatória/métodos , Antiarrítmicos/uso terapêutico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Ablação por Cateter/métodos , Cardioversão Elétrica/métodos , Fibrinolíticos/uso terapêutico , HumanosRESUMO
Patients with episodic sinus tachycardia and associated orthostatic intolerance present a diagnostic and management dilemma to the clinician. We define this group of disorders to include sinus node reentrant tachycardia (SNRT), inappropriate sinus tachycardia (IAST), and postural orthostatic tachycardia syndrome (POTS). After a brief review of the current understanding of the pathophysiology and epidemiology of this group of disorders, we focus on the diagnosis and management of IAST and POTS. Our approach attempts to recognize the considerable overlap in pathophysiology and clinical presentation between these two heterogeneous conditions. Thus, we focus on a mechanism-based workup and therapeutic approach. Sinus tachycardia related to identifiable causes should first be ruled out in these patients. Next, a basic cardiovascular and autonomic workup is suggested to exclude structural heart disease, identify a putative diagnosis, and guide therapy. We review both nonpharmacologic and pharmacologic therapy, with a focus on recent advances. Larger randomized control trials and further mechanistic studies will help refine management in the future.
Assuntos
Gerenciamento Clínico , Intolerância Ortostática , Postura , Taquicardia Sinusal , Humanos , Intolerância Ortostática/complicações , Intolerância Ortostática/fisiopatologia , Intolerância Ortostática/terapia , Nó Sinoatrial/fisiopatologia , Taquicardia Sinusal/complicações , Taquicardia Sinusal/fisiopatologia , Taquicardia Sinusal/terapiaRESUMO
The management of ventricular tachycardia and ventricular fibrillation in the cardiac intensive care unit can be complex. These arrhythmias have many triggers, including ischemia, sympathetic stimulation, and medication toxicities, as well as many different substrates, ranging from ischemic and nonischemic cardiomyopathies to rare genetic conditions such as Brugada syndrome and long QT syndrome. Different settings, such as congenital heart disease, postoperative ventricular arrhythmias, and ventricular assist devices, increase the complexity of management. This article reviews the variety of situations and cardiac conditions that give rise to ventricular arrhythmias, focusing on inpatient management strategies.