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BACKGROUND: Single-lead electrocardiogram (ECG) devices may allow detection and diagnosis of cardiac rhythms. However, data on their accuracy for detecting cardiac arrhythmias beyond atrial fibrillation are limited. We aimed to determine the accuracy of the AliveCor KardiaMobile (AC) (AliveCor Inc, Mountain View, CA, USA) for the diagnosis of arrhythmias against gold standard cardiac electrophysiology study (EPS). METHOD: Patients undergoing clinically indicated EPS underwent simultaneous rhythm recording with an AC, standard 12-lead ECG, and EP catheters for intracardiac electrograms. Rhythms recorded during EPS were classified based on electrogram, 12-lead ECG, and clinical findings. Blinded reviewers provided differential diagnoses for the single-lead AC tracings; a separate reviewer compared diagnoses made between the AC tracings and EPS findings. RESULTS: In 49 patients, 843 cardiac rhythms were captured during 502 AC recordings. Analysis of tracings containing sinus rhythm (n=273) returned an overall accuracy of 92%, with sensitivity and specificity values of 93% and 92%, respectively. Accuracy for tracings per rhythm was atrial fibrillation 91% (n=51); supraventricular tachycardia accuracy was 89% (n=191), ventricular tachycardia 91% (n=198), ventricular fibrillation 98% (n=11), and asystole 100% (n=5). Accuracy for supraventricular ectopy was 93% (n=28) and for premature ventricular complexes was 91% (n=86). Overall accuracy was 94% for solitary rhythms and 93% in tracings from patients with baseline bundle branch block. CONCLUSIONS: When compared against the gold standard EPS diagnosis, the interpretation of arrhythmias recorded by an AliveCor single-lead ECG device had reasonable diagnostic accuracy.
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IMPORTANCE: Randomised trials have shown that catheter ablation (CA) is superior to medical therapy for ventricular tachycardia (VT) largely in patients with ischaemic heart disease. Whether this translates to patients with all forms and stages of structural heart disease (SHD-e.g., non-ischaemic heart disease) is unclear. This trial will help clarify whether catheter ablation offers superior outcomes compared to medical therapy for VT in all patients with SHD. OBJECTIVE: To determine in patients with SHD and spontaneous or inducible VT, if catheter ablation is more efficacious than medical therapy in control of VT during follow-up. DESIGN: Randomised controlled trial including 162 patients, with an allocation ratio of 1:1, stratified by left ventricular ejection fraction (LVEF) and geographical region of site, with a median follow-up of 18-months and a minimum follow-up of 1 year. SETTING: Multicentre study performed in centres across Australia. PARTICIPANTS: Structural heart disease patients with sustained VT or inducible VT (n=162). INTERVENTION: Early treatment, within 30 days of randomisation, with catheter ablation (intervention) or initial treatment with antiarrhythmic drugs only (control). MAIN OUTCOMES, MEASURES, AND RESULTS: Primary endpoint will be a composite of recurrent VT, VT storm (≥3 VT episodes in 24 hrs or incessant VT), or death. Secondary outcomes will include each of the individual primary endpoints, VT burden (number of VT episodes in the 6 months preceding intervention compared to the 6 months after intervention), cardiovascular hospitalisation, mortality (including all-cause mortality, cardiac death, and non-cardiac death) and LVEF (assessed by transthoracic echocardiography from baseline to 6-, 12-, 24- and 36-months post intervention). CONCLUSIONS AND RELEVANCE: The Catheter Ablation versus Anti-arrhythmic Drugs for Ventricular Tachycardia (CAAD-VT) trial will help determine whether catheter ablation is superior to antiarrhythmic drug therapy alone, in patients with SHD-related VT. TRIAL REGISTRY: Australian New Zealand Clinical Trials Registry (ANZCTR) TRIAL REGISTRATION ID: ACTRN12620000045910 TRIAL REGISTRATION URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377617&isReview=true.
Assuntos
Ablação por Cateter , Isquemia Miocárdica , Taquicardia Ventricular , Humanos , Antiarrítmicos/uso terapêutico , Volume Sistólico , Estudos Prospectivos , Resultado do Tratamento , Função Ventricular Esquerda , Austrália/epidemiologia , Taquicardia Ventricular/cirurgia , Taquicardia Ventricular/etiologia , Isquemia Miocárdica/cirurgia , Ablação por Cateter/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
INTRODUCTION: Ventricular tachycardia (VT) can occur following valvular interventions. There are limited data describing substrate and ablation approaches in such patients. We sought to describe the clinical, electrophysiologic, electroanatomic features and catheter ablation outcomes of patients with VT following aortic and/or mitral valve intervention. METHODS: Over 12-years, consecutive patients with aortic valve replacement (AVR) and/or mitral valve replacement (MVR) or repair, undergoing VT ablation, were identified from two centers. Clinical and procedural parameters and outcomes are described. RESULTS: Twenty-three patients (age 66 ± 14years, 78% male, left ventricular ejection fraction 37 ± 16%), with prior AVR (mechanical n = 6, bioprosthetic n = 2, transcatheter n = 1), MVR (mechanical n = 5, bioprosthetic n = 1), mitral valve repair (n = 6) and both mechanical AVR and MVR (n = 2), underwent VT ablation. Sixteen had concurrent ischemic cardiomyopathy, 10 with prior bypass surgery. Left ventricular access was obtained in 21/23 (91%) patients (transseptal n = 14, retrograde aortic n = 5, transapical n = 2), with perivalvular scar identified in 17/21 (81%). Re-entrant VT isthmi involved the perivalvular regions in 12/23 (52%) patients, and regions remote from the valve in the remainder; 9% had nonscar-related VT. Intramural substrate was ablated from adjacent chambers in 5/23 (22%) patients and with half-normal saline irrigation in 8/23 (35%) patients. There were no instances of catheter entrapment. Following final ablation, VA-free survival was 78% at 13-months. CONCLUSION: Only half of VT circuits following valvular interventions involve the valve regions themselves, while the remainder involves unrelated regions. Catheter ablation is safe and efficacious at treating VT following valvular intervention, but novel strategies may be required.
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Ablação por Cateter , Taquicardia Ventricular , Idoso , Idoso de 80 Anos ou mais , Ablação por Cateter/efeitos adversos , Catéteres , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Volume Sistólico , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/cirurgia , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
Cardiac arrhythmias are associated with significant morbidity, mortality and economic burden on the health care system. Detection and surveillance of cardiac arrhythmias using medical grade non-invasive methods (electrocardiogram, Holter monitoring) is the accepted standard of care. Whilst their accuracy is excellent, significant limitations remain in terms of accessibility, ease of use, cost, and a suboptimal diagnostic yield (up to â¼50%) which is critically dependent on the duration of monitoring. Contemporary wearable and handheld devices that utilise photoplethysmography and the electrocardiogram present a novel opportunity for remote screening and diagnosis of arrhythmias. They have significant advantages in terms of accessibility and availability with the potential of enhancing the diagnostic yield of episodic arrhythmias. However, there is limited data on the accuracy and diagnostic utility of these devices and their role in therapeutic decision making in clinical practice remains unclear. Evidence is mounting that they may be useful in screening for atrial fibrillation, and anecdotally, for the diagnosis of other brady and tachyarrhythmias. Recently, there has been an explosion of patient uptake of such devices for self-monitoring of arrhythmias. Frequently, the clinician is presented such information for review and comment, which may influence clinical decisions about treatment. Further studies are needed before incorporation of such technologies in routine clinical practice, given the lack of systematic data on their accuracy and utility. Moreover, challenges with regulation of quality standards and privacy remain. This state-of-the-art review summarises the role of novel ambulatory, commercially available, heart rhythm monitors in the diagnosis and management of cardiac arrhythmias and their expanding role in the diagnostic and therapeutic paradigm in cardiology.
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Fibrilação Atrial , Dispositivos Eletrônicos Vestíveis , Humanos , Eletrocardiografia Ambulatorial/métodos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , EletrocardiografiaRESUMO
Cardiac vasculitis is recognized as a heterogeneous disease process with a wide spectrum of manifestations including pericarditis, myocarditis, valvular heart disease and less frequently, coronary artery vasculitis (CAV). CAV encompasses an emerging field of diseases which differ from conventional atherosclerotic disease and have a proclivity for the younger population groups. CAV portends multiple complications including the development of coronary artery aneurysms, coronary stenotic lesions, and thrombosis, all which may result in acute coronary syndromes. There are several aetiologies for CAV; with Kawasaki's disease, Takayasu's arteritis, Polyarteritis Nodosa, and Giant-Cell Arteritis more frequently described clinically, and in literature. There is a growing role for multi-modality imaging in assisting the diagnostic process; including transthoracic echocardiography, cardiac magnetic resonance imaging, computed tomography coronary angiography, fluorodeoxyglucose-positron emission tomography and conventional coronary angiogram with intravascular ultrasound. Whilst the treatment paradigms fundamentally vary between different aetiologies, there are overlaps with pharmacological regimes in immunosuppressive agents and anti-platelet therapies. Interventional and surgical management are is a consideration in select populations groups, within a multi-disciplinary context. Further large-scale studies are required to better appropriately outline management protocols in this niche population.
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Doença da Artéria Coronariana , Arterite de Células Gigantes , Síndrome de Linfonodos Mucocutâneos , Poliarterite Nodosa , Arterite de Takayasu , Técnicas de Imagem Cardíaca , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Arterite de Células Gigantes/diagnóstico por imagem , Arterite de Células Gigantes/epidemiologia , Arterite de Células Gigantes/terapia , Humanos , Síndrome de Linfonodos Mucocutâneos/diagnóstico por imagem , Síndrome de Linfonodos Mucocutâneos/epidemiologia , Síndrome de Linfonodos Mucocutâneos/terapia , Imagem Multimodal , Poliarterite Nodosa/diagnóstico por imagem , Poliarterite Nodosa/epidemiologia , Poliarterite Nodosa/terapia , Valor Preditivo dos Testes , Prognóstico , Arterite de Takayasu/diagnóstico por imagem , Arterite de Takayasu/epidemiologia , Arterite de Takayasu/terapiaRESUMO
INTRODUCTION: Testing for inducible ventricular tachycardia (VT) pre- and postablation forms the cornerstone of contemporary scar-related VT ablation procedures. There is significant heterogeneity in reported VT induction protocols. We examined the utility of an extensive induction protocol (up to 4 extra-stimuli [ES] ± burst ventricular pacing) compared to the current guideline-recommended protocol (up to 3ES, defined as limited induction protocol) in patients with scar-related VT. METHODS AND RESULTS: Sixty-two patients (age: 64 ± 14 years; left ventricular ejection fraction: 37 ± 13%, ischemic cardiomyopathy: 31, nonischemic cardiomyopathy: 31) with at least one inducible VT were included. An extensive testing protocol induced 11%-17% more VTs, compared to the limited induction protocol before, and after the final ablation. VT recurred in 48% of patients during a mean follow up of 566 ± 428 days. Patients who were noninducible for any VT using the limited induction protocol had worse ventricular arrhythmia (VA)-free survival (12 months, 43% vs. 82%; p = .03) and worse survival free of VA, transplantation and mortality (12 months 46% vs. 82%; p = .02), compared to patients who were noninducible for any VT using the extensive induction protocol. CONCLUSIONS: Between 11% and 17% of inducible VTs may be missed if 4ES and burst pacing are not performed in induction protocols before and after ablation. Noninducibility for any VT after an extensive induction protocol after the final ablation portends more favorable prognostic outcomes when compared with the current guideline-recommended induction protocol of up to 3ES. This data suggests that the adoption of an extensive induction protocol is of prognostic benefit after VT ablation.
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Cardiomiopatias , Ablação por Cateter , Taquicardia Ventricular , Adolescente , Cardiomiopatias/diagnóstico , Ablação por Cateter/efeitos adversos , Cicatriz/diagnóstico , Cicatriz/etiologia , Cicatriz/cirurgia , Humanos , Prognóstico , Recidiva , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: There is a paucity of data describing mortality after catheter ablation of ventricular tachycardia (VT). OBJECTIVES: We describe the causes and predictors of cardiac transplant and/or mortality following catheter ablation of structural heart disease (SHD) related VT. METHODS: Over 10-years, 175 SHD patients underwent VT ablation. Clinical characteristics, and outcomes, were compared between patients undergoing transplant and/or dying and those surviving. RESULTS: During 2.8 (IQR 1.9-5.0) years follow-up, 37/175 (21%) patients underwent transplant and/or died following VT ablation. Prior to ablation, these patients were older (70.3 ± 11.1 vs. 62.1 ± 13.9 years, P = 0.001), had lower left ventricular ejection fraction ([LVEF] 30 ± 12% vs. 44 ± 14%, P < 0.001), and were more likely to have failed amiodarone (57% vs. 39%, P = 0.050), compared to those that survived. Predictors of transplant and/or mortality included LVEF≤35% (HR 4.71 [95% CI 2.18-10.18], P < 0.001), age ≥ 65 years (HR 2.18 [95% CI 1.01-4.73], P = 0.047), renal impairment (HR 3.73 [95% CI 1.80-7.74], P < 0.001), amiodarone failure (HR 2.67 [95% CI 1.27-5.63], P = 0.010) and malignancy (HR 3.09 [95% CI 1.03-9.26], P = 0.043). Ventricular arrhythmia free survival at 6-months was lower in the transplant and/or deceased, compared to non-deceased group (62% vs. 78%, P = 0.010), but was not independently associated with transplant and/or mortality. The risk score, MORTALITIES-VA, accurately predicted transplant and/or mortality (AUC: 0.872 [95% CI 0.810-0.934]). CONCLUSIONS: Cardiac transplant and/or mortality after VT ablation occurred in 21% of patients. Independent predictors included LVEF≤35%, age ≥ 65 years, renal impairment, malignancy, and amiodarone failure. The MORTALITIES-VA score may identify patients at high-risk of transplant and/or dying after VT ablation.
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Amiodarona , Ablação por Cateter , Taquicardia Ventricular , Humanos , Idoso , Volume Sistólico , Função Ventricular Esquerda , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/cirurgia , Taquicardia Ventricular/etiologia , Ablação por Cateter/efeitos adversos , Resultado do Tratamento , RecidivaRESUMO
Uraemic Cardiomyopathy (UC) is recognised as an intricate and multifactorial disease which portends a significant burden in patients with End-Stage Renal Disease (ESRD). The cardiovascular morbidity and mortality associated with UC is significant and can be associated with the development of arrythmias, cardiac failure and sudden cardiac death (SCD). The pathophysiology of UC involves a complex interplay of traditional implicative factors such as haemodynamic overload and circulating uraemic toxins as well as our evolving understanding of the Chronic Kidney Disease-Mineral Bone Disease pathway. There is an instrumental role for multi-modality imaging in the diagnostic process; including transthoracic echocardiography and cardiac magnetic resonance imaging in identifying the hallmarks of left ventricular hypertrophy and myocardial fibrosis that characterise UC. The appropriate utilisation of the aforementioned diagnostics in the ESRD population may help guide therapeutic approaches, such as pharmacotherapy including beta-blockers and aldosterone-antagonists as well as haemodialysis and renal transplantation. Despite this, there remains limitations in effective therapeutic interventions for UC and ongoing research on a cellular level is vital in establishing further therapies.