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BACKGROUND AND AIMS: Bloodstream infection (BSI) of any cause may lead to device infection in cardiac implantable electronic device (CIED) patients. Aiming for a better understanding of the diagnostic approach, treatment, and outcome, patients with an implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy and defibrillator (CRT-D) hospitalized with BSI were investigated. METHODS: This is a single-centre, retrospective, cohort analysis including consecutive ICD/CRT-D patients implanted between 2012 and 2021. These patients were screened against a list of all hospitalized patients having positive blood cultures consistent with diagnosed infection in any department of a local public hospital. RESULTS: The total cohort consisted of 515 patients. Over a median follow-up of 59 months (interquartile range 31-87 months), there were 47 BSI episodes in 36 patients. The majority of patients with BSI (92%) was admitted to non-cardiology units, and in 25 episodes (53%), no cardiac imaging was performed. Nearly all patients (85%) were treated with short-term antibiotics, whereas chronic antibiotic suppression therapy (n = 4) and system extraction (n = 3) were less frequent. Patients with BSI had a nearly seven-fold higher rate (hazard ratio 6.7, 95% confidence interval 3.9-11.2; P < .001) of all-cause mortality. CONCLUSIONS: Diagnostic workup of defibrillator patients with BSI admitted to a non-cardiology unit is often insufficient to characterize lead-related endocarditis. The high mortality rate in these patients with BSI may relate to underdiagnosis and consequently late/absence of system removal. Efforts to increase an interdisciplinary approach and greater use of cardiac imaging are necessary for timely diagnosis and adequate treatment.
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Terapia de Resincronización Cardíaca , Desfibriladores Implantables , Sepsis , Humanos , Estudios Retrospectivos , Desfibriladores Implantables/efectos adversos , Terapia de Resincronización Cardíaca/métodos , Antibacterianos/uso terapéutico , Sepsis/etiología , Dispositivos de Terapia de Resincronización Cardíaca , Resultado del TratamientoRESUMEN
AIMS: To investigate the role of genetic testing in patients with idiopathic atrioventricular conduction disease requiring pacemaker (PM) implantation before the age of 50 years. METHODS AND RESULTS: All consecutive PM implantations in Southern Switzerland between 2010 and 2019 were evaluated. Inclusion criteria were: (i) age at the time of PM implantation: < 50 years; (ii) atrioventricular block (AVB) of unknown aetiology. Study population was investigated by ajmaline challenge and echocardiographic assessment over time. Genetic testing was performed using next-generation sequencing panel, containing 174 genes associated to inherited cardiac diseases, and Sanger sequencing confirmation of suspected variants with clinical implication. Of 2510 patients who underwent PM implantation, 15 (0.6%) were young adults (median age: 44 years, male predominance) presenting with advanced AVB of unknown origin. The average incidence of idiopathic AVB computed over the 2010-2019 time window was 0.7 per 100 000 persons per year (95% CI 0.4-1.2). Most of patients (67%) presented with specific genetic findings (pathogenic variant) or variants of uncertain significance (VUS). A pathogenic variant of PKP2 gene was found in one patient (6.7%) with no overt structural cardiac abnormalities. A VUS of TRPM4, MYBPC3, SCN5A, KCNE1, LMNA, GJA5 genes was found in other nine cases (60%). Of these, three unrelated patients (20%) presented the same heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene. Diagnostic re-assessment over time led to a diagnosis of Brugada syndrome and long-QT syndrome in two patients (13%). No cardiac events occurred during a median follow-up of 72 months. CONCLUSION: Idiopathic AVB in adults younger than 50 years is a very rare condition with an incidence of 0.7 per 100 000 persons/year. Systematic investigations, including genetic testing and ajmaline challenge, can lead to the achievement of a specific diagnosis in up to 20% of patients. Heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene was found in an additional 20% of unrelated patients, suggesting possible association of the variant with the disease.
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Bloqueo Atrioventricular , Marcapaso Artificial , Adulto Joven , Humanos , Masculino , Adulto , Persona de Mediana Edad , Femenino , Trastorno del Sistema de Conducción Cardíaco/complicaciones , Bloqueo Atrioventricular/diagnóstico , Bloqueo Atrioventricular/epidemiología , Bloqueo Atrioventricular/genética , Marcapaso Artificial/efectos adversos , Pruebas Genéticas , AjmalinaRESUMEN
AIMS: Ajmaline challenge can unmask subcutaneous implantable cardioverter-defibrillator (S-ICD) screening failure in patients with Brugada syndrome (BrS) and non-diagnostic baseline electrocardiogram (ECG). The efficacy of the SMART Pass (SP) filter, a high-pass filter designed to reduce cardiac oversensing (while maintaining an appropriate sensing margin), has not yet been assessed in patients with BrS. The aim of this prospective multicentre study was to investigate the effect of the SP filter on dynamic Brugada ECG changes evoked by ajmaline and to assess its value in reducing S-ICD screening failure in patients with drug-induced Brugada ECGs. METHODS AND RESULTS: The S-ICD screening with conventional automated screening tool (AST) was performed during ajmaline challenge in subjects with suspected BrS. The S-ICD recordings were obtained before, during and after ajmaline administration and evaluated by the means of a simulation model that emulates the AST behaviour with and without SP filter. A patient was considered suitable for S-ICD if at least one sensing vector was acceptable in all tested postures. A sensing vector was considered acceptable in the presence of QRS amplitude >0.5 mV, QRS/T-wave ratio >3.5, and sense vector score >100. Of the 126 subjects (mean age: 42 ± 14 years, males: 61%, sensing vectors: 6786), 46 (36%) presented with an ajmaline-induced Brugada type 1 ECG. Up to 30% of subjects and 40% of vectors failed the screening during the appearance of Brugada type 1 ECG evoked by ajmaline. The S-ICD screening failure rate was not significantly reduced in patients with Brugada ECGs when SP filter was enabled (30% vs. 24%). Similarly, there was only a trend in reduction of vector-failure rate attributable to the SP filter (from 40% to 36%). The most frequent reason for screening failure was low QRS amplitude or low QRS/T-wave ratio. None of these patients was implanted with an S-ICD. CONCLUSION: Patients who pass the sensing screening during ajmaline can be considered good candidates for S-ICD implantation, while those who fail might be susceptible to sensing issues. Although there was a trend towards reduction of vector sensing failure rate when SP filter was enabled, the reduction in S-ICD screening failure in patients with Brugada ECGs did not reach statistical significance. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov Unique Identifier NCT04504591.
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Síndrome de Brugada , Desfibriladores Implantables , Adulto , Ajmalina/efectos adversos , Arritmias Cardíacas , Síndrome de Brugada/diagnóstico , Síndrome de Brugada/terapia , Electrocardiografía/métodos , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
AIMS: Data regarding the efficacy of catheter ablation in heart failure patients with severely dilated left atrium and reduced left ventricular ejection fraction (LVEF) are scanty. We sought to assess the efficacy of catheter ablation in patients with reduced LVEF and severe left atrial (LA) enlargement, and to compare it to those patients with preserved left ventricular function and equally dilated left atrium. METHODS AND RESULTS: Three patient groups with paroxysmal or persistent atrial fibrillation (AF) undergoing a first pulmonary vein isolation (PVI) were considered: Group 1 included patients with normal or mildly abnormal LA volume (≤41 mL/m2) and normal LVEF; Group 2 included patients with severe LA enlargement (>48 mL/m2) and normal LVEF; and Group 3 included patients with severe LA enlargement and reduced LVEF. Time to event analysis was used to investigate AF recurrences. The study cohort includes 439 patients; Group 3 had a higher prevalence of cardiovascular risk factors. LA enlargement was associated with a two-fold in risk of AF recurrence, on the contrary only a smaller non-significant increase of 30% was shown with the further addition of LVEF reduction. CONCLUSIONS: The long-term outcome of patients with severe LA dilatation and reduced LVEF is comparable to those with severe LA enlargement but preserved LVEF. Long-term efficacy of PVI is certainly affected by the enlargement of the left atrium, but less so by the addition of a reduced LVEF. CA remains the best strategy for rhythm control both in paroxysmal and persistent AF in this subgroup of patients.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/cirugía , Humanos , Venas Pulmonares/cirugía , Recurrencia , Volumen Sistólico , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
AIMS: To define the clinical characteristics and long-term clinical outcomes of a large cohort of patients with idiopathic ventricular fibrillation (IVF) and normal 12-lead electrocardiograms (ECGs). METHODS AND RESULTS: Patients with ventricular fibrillation as the presenting rhythm, normal baseline, and follow-up ECGs with no signs of cardiac channelopathy including early repolarization or atrioventricular conduction abnormalities, and without structural heart disease were included in a registry. A total of 245 patients (median age: 38 years; males 59%) were recruited from 25 centres. An implantable cardioverter-defibrillator (ICD) was implanted in 226 patients (92%), while 18 patients (8%) were treated with drug therapy only. Over a median follow-up of 63 months (interquartile range: 25-110 months), 12 patients died (5%); in four of them (1.6%) the lethal event was of cardiac origin. Patients treated with antiarrhythmic drugs only had a higher rate of cardiovascular death compared to patients who received an ICD (16% vs. 0.4%, P = 0.001). Fifty-two patients (21%) experienced an arrhythmic recurrence. Age ≤16 years at the time of the first ventricular arrhythmia was the only predictor of arrhythmic recurrence on multivariable analysis [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.18-0.92; P = 0.03]. CONCLUSION: Patients with IVF and persistently normal ECGs frequently have arrhythmic recurrences, but a good prognosis when treated with an ICD. Children are a category of IVF patients at higher risk of arrhythmic recurrences.
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Desfibriladores Implantables , Electrocardiografía , Paro Cardíaco Extrahospitalario/etiología , Sistema de Registros , Fibrilación Ventricular/complicaciones , Adolescente , Adulto , Niño , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/diagnóstico , Paro Cardíaco Extrahospitalario/terapia , Valores de Referencia , Estudios Retrospectivos , Factores de Tiempo , Fibrilación Ventricular/diagnóstico , Fibrilación Ventricular/fisiopatología , Adulto JovenRESUMEN
Aims: Phrenic nerve palsy (PNP) after mechanical transvenous lead extraction (TLE) was recently described for the first time. We aimed to analyse our TLE database for the presence of PNP. Methods and results: All consecutive patients referred to our institution were included in this study. Every available post-procedural chest X-ray was compared to the routinely performed pre-procedural radiographs. A newly elevated hemidiaphragm ipsilateral to TLE was considered indicative of PNP. Altogether 255 TLE procedures with extraction of 364 leads were performed. Most common TLE indication was lead malfunction (63%). Complete radiographic success rate was 97.3% with an in-hospital procedure-related major complication rate of 2.4%, including one intra-procedural death (0.4%). We identified five cases with PNP (2%), all occurring after laser-assisted TLE. Clinical presentation varied from subtle and aspecific chest pain/discomfort to severe and acute dyspnoea, with time to diagnosis varying from immediate to several weeks after the procedure. In 80% of cases, the explanted lead was a defibrillator electrode and the median lead dwelling time was 70.2 months (29.3; 1084.9). In four cases, the extraction was performed using high-energy laser (pulse repetition rate 80 Hz). Conclusion: The present study reports the incidence of PNP after laser-assisted TLE. We postulate that the thermal energy generated by laser is not dissipated quickly enough in occluded or heavily calcified lesions, injuring the ipsilateral phrenic nerve. Our findings advise to carefully consider to increase pulse repetition rate at the subclavian level. Larger, possibly prospective studies are needed to evaluate the real incidence through systematic radiological assessment after TLE.
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Remoción de Dispositivos , Diafragma/inervación , Terapia por Láser/efectos adversos , Rayos Láser , Traumatismos de los Nervios Periféricos , Nervio Frénico/lesiones , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/métodos , Desfibriladores Implantables , Remoción de Dispositivos/efectos adversos , Remoción de Dispositivos/instrumentación , Remoción de Dispositivos/métodos , Falla de Equipo/estadística & datos numéricos , Femenino , Humanos , Incidencia , Complicaciones Intraoperatorias/diagnóstico , Complicaciones Intraoperatorias/epidemiología , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Traumatismos de los Nervios Periféricos/diagnóstico , Traumatismos de los Nervios Periféricos/epidemiología , Traumatismos de los Nervios Periféricos/etiología , Radiografía Torácica/métodos , Ajuste de Riesgo , SuizaAsunto(s)
Ajmalina/uso terapéutico , Antiarrítmicos/uso terapéutico , Síndrome de Brugada , Desfibriladores Implantables/efectos adversos , Electrocardiografía , Síndrome de Brugada/tratamiento farmacológico , Síndrome de Brugada/fisiopatología , Remoción de Dispositivos , Humanos , Masculino , Persona de Mediana Edad , Falla de PrótesisRESUMEN
Background: Diagnosis of Brugada syndrome (BrS) may be established by exposing a Type 1 Brugada pattern using a sodium channel blocker. Data on the outcomes of different patient populations with drug-induced Type 1 Brugada pattern are limited. The present study reports on the characteristics and outcome of subjects with ajmaline induced Type 1 Brugada pattern. Methods: A multicenter retrospective study including all consecutive cases of ajmaline-induced Type 1 Brugada pattern from seven centers. Results: A total of 260 patients (69.9% males, mean age 43.4 ± 13.5) were included. Additional characteristics included history of syncope (n = 56, 21.5%), family history of BrS (n = 58, 22.3%) or sudden cardiac death (n = 47, 18.1%) and ventricular fibrillation (n = 3, 1.2%). Patients were divided into those meeting current diagnostic criteria for drug-induced BrS (DIBrS) and compared to the drug-induced Brugada pattern (DIBrECG). Females were significantly overrepresented in the DIBrS group (n = 50, 40% vs. n = 29, 21.5%, p = .001). A significantly higher prevalence of type 2/3 Brugada ECG at baseline was found in the DIBrECG group (n = 108, 80.8% vs. n = 75, 60% in the DIBrS, p = .026). During a median follow up of three (IQR 1.50-5.32) years, a single event of significant arrhythmia occurred in the DIBrS group. Conclusion: Less than half of subjects with ajmaline-induced Brugada pattern met current criteria for BrS. These individuals had very low rate of adverse outcomes during a follow up of 3 years, irrespective of the indication for the test or eligibility for the BrS diagnosis.
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BACKGROUND: Knowledge about impact of age and comorbidities on outcome in patients with leadless pacemakers (LPM) is limited. OBJECTIVES: To analyse outcome in LPM patients according to age and comorbidities. METHODS: This Swiss, multi-centre, retrospective analysis includes all patients with LPM implanted between 2015 and 2022. Charlson-Comorbidity-Index (CCI) was determined and patients were divided into a low- (CCIâ¯≤â¯5) and high- comorbidity (CCIâ¯>â¯5) group. Peri-procedural complications, in-hospital death, and all-cause mortalities were assessed. Finally, all-cause mortality according to three groups (CCIâ¯≤â¯3, 4-5, >5) was compared to age and sex-adjusted mortality in the general Swiss population. RESULTS: 863 patients (median age 81â¯years, 65% male, 42% with CCIâ¯>â¯5) were included. Peri-procedural/long-term complication rates did not differ between the low- vs. high-comorbidity groups (2.6% vs. 1.7%, pâ¯=â¯0.48 and 1.2% vs. 2.8%, pâ¯=â¯0.12, respectively). In-hospital (3.6% vs. 0.6%, pâ¯=â¯0.002) and all-cause mortality (HR 2.9, 95%CI 2.2-3.8, pâ¯<â¯0.001) were significantly higher in the high-comorbidity group resulting in a three-year mortality of 58% (95%CI 51-65%) vs. 22% (95%CI 17-27%) in the low-comorbidity group. In patients with a CCIâ¯≤â¯3, all-cause mortality was comparable to the age- and sex-adjusted mortality of the general Swiss population. CONCLUSIONS: In elderly patients with high comorbidity, LPM implantation was not associated with increased peri-procedural/long-term complications. All-cause mortality in LPM patients with a CCIâ¯≤â¯3 was comparable to age- and sex-adjusted mortality in the general Swiss population. Despite a relatively high three-year mortality due to competing risk factors, LPM implantation is safe, even in elderly patients with high comorbidity. CONDENSED ABSTRACT: In this Swiss, multi-centre, retrospective cohort analysis, 863 patients implanted with a leadless pacemaker were included and divided into a high-comorbidity (with a CCIâ¯>â¯5) and low-comorbidity (with a CCIâ¯≤â¯5) group. There was no between group difference in terms of implantation outcomes and peri-operative or long-term complications. Furthermore, all-cause mortality during follow-up in patients with a CCIâ¯≤â¯3 was comparable to age- and sex-adjusted mortality in the general Swiss population. These data indicate that LPM implantation is a safe procedure, even in elderly patients with high comorbidity.
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INTRODUCTION: Data on peri-operative management of direct-acting oral anticoagulants (DOACs) during transcatheter pacing leadless system (TPS) implantations remain limited. This study aimed to evaluate a standardized DOAC management regime consisting of interruption of a single dose prior to implantation and reinitiation within 6-24 h; also, patient clinical characteristics associated with this approach were identified. METHOD: Consecutive patients undergoing standard TPS implantation procedures from two Swiss tertiary centers were included. DOAC peri-operative management included the standardized approach (Group 1A) or other approaches (Group 1B). RESULTS: Three hundred and ninety-two pts (mean age 81.4 ± 7.3 years, 66.3% male, left ventricular ejection fraction 55.5 ± 9.6%) underwent TPS implantation. Two hundred and eighty-two pts (71.9%) were under anticoagulation therapy; 192 pts were treated with DOAC; 90 pts were under vitamin-K antagonist. Patients treated with DOAC less often had structural heart disease, diabetes mellitus, and advanced renal failure. The rate of major peri-procedural complications did not differ between groups 1A (n = 115) and 1B (n = 77) (2.6% and 3.8%, p = 0.685). Compared to 1B, 1A patients were implanted with TPS for slow ventricular rate atrial fibrillation (AF) (p = 0.002), in a better overall clinical status, and implanted electively (<0.001). CONCLUSIONS: Standardized peri-procedural DOAC management was more often implemented for elective TPS procedures and did not seem to increase bleeding or thromboembolic adverse events.
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After decades of clinical use, cardiac resynchronization therapy (CRT) can be considered an established therapy. However, there are multiple open questions to be addressed that shall further improve the proportion of patients responding to CRT. Progress in better understanding the relationship between electrical and mechanical disorder in patients with heart failure with ventricular conduction abnormalities is important. This article presents and discusses ongoing studies in different areas of CRT research, including patient selection by novel diagnostic tools, extension of clinical criteria, left ventricular lead positioning and pacing site selection, optimization of CRT delivery and programming, and selection of device type.
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Terapia de Resincronización Cardíaca , Desfibriladores Implantables , Insuficiencia Cardíaca , Frecuencia Cardíaca , Ventrículos Cardíacos , Humanos , Resultado del TratamientoRESUMEN
With the demographic evolution of the population, patients undergoing surgery today are older and have an increasing number of sometimes complex comorbidities. Cardiac implantable electronic devices (CIED) are also getting more and more complex with very sophisticated programming algorithms. It may be generally assumed that magnet application reverts pacing to an asynchronous mode in pacemakers and disables tachycardia detection/therapy in internal cardioverter-defibrillators. However, depending on device type, manufacturer and model, the response to magnet application may differ substantially. For these reasons, perioperative management of CIED patients is getting more and more challenging. With this review article we provide an overview of optimal perioperative management of CIED patients with a detailed description of CIED response to magnet application depending on manufacturer and device-type, which may help in providing a safe perioperative management plan for the CIED patient.
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BACKGROUND: Left ventricular non-compaction cardiomyopathy (LVNC) features extensive trabeculations. Involvement of the right ventricle (RV) has been reported; however, distinction from normal RV trabeculation is difficult. This study aimed at assessing RV morphology and function in LVNC by cardiac magnetic resonance (CMR) and transthoracic echocardiography (TTE). METHODS: Dimensional and functional parameters were assessed according to guidelines. Novel CMR parameters were RV end-diastolic (ED) trabeculated area, RV ED trabeculated volume, and RV ED non-compacted to compacted (NC/N) ratio in short axis (SAX) as well as in four-chamber view (4CH). RESULTS: Twenty patients with LVNC and 20 controls were included. RV size and function were comparable in LVNC and controls and exhibited a good correlation between TTE and CMR. Although RV trabeculated area, RV trabeculated volume, and RV ED NC/C ratio in SAX as well as in 4CH were larger in LVNC, there was a major overlap with values in controls. RV ED NC/C ratio in SAX correlated with LV ED NC/C ratio (not in 4CH). Quantitative assessment of RV non-compaction was not feasible in TTE. CONCLUSIONS: Right ventricle size and function in LVNC can be measured by CMR and TTE, while RV trabeculation can only be quantified by CMR. RV myocardium displays more trabeculations in LVNC; however, overlap with normal individuals is extensive, not allowing separation of patients with LVNC from controls.
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Cardiomiopatías , No Compactación Aislada del Miocardio Ventricular , Ventrículos Cardíacos , Humanos , No Compactación Aislada del Miocardio Ventricular/diagnóstico , No Compactación Aislada del Miocardio Ventricular/diagnóstico por imagen , Imagen por Resonancia Cinemagnética/métodos , Valor Predictivo de las PruebasRESUMEN
BACKGROUND: Remote monitoring (RM) technology embedded in cardiac rhythm devices permits continuous monitoring of device function, and recording of selected cardiac physiological parameters and cardiac arrhythmias and may be of utmost utility during Coronavirus (COVID-19) pandemic, when in-person office visit for regular follow-up were postponed. However, patients not alredy followed-up via RM represent a challenging group of patients to be managed during the lockdown. METHODS: We reviewed patient files scheduled for an outpatient visit between January 1, 2020 and May 11th, 2020 to assess the proportion of patients in whom RM activation was possible without office visit, and compared them to those scheduled for visit before the lockdown. RESULTS: During COVID-19 pandemic, RM activation was feasible in a minority of patients (7.8% of patients) expected at outpatient clinic for a follow-up visit and device check-up. This was possible in a good proportion of complex implantable devices such as cardiac resynchronization therapy and implantable cardioverter defibrillator but only in a minority of patients with a pacemaker the RM function could be activated during the period of restricted access to hospital. CONCLUSIONS: Our experience strongly suggest to consider the systematic activation of RM function at the time of implantation or - by default programming - in all cardiac rhythm management devices.
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Arritmias Cardíacas/terapia , COVID-19/prevención & control , Dispositivos de Terapia de Resincronización Cardíaca/normas , Desfibriladores Implantables/normas , Tecnología de Sensores Remotos/normas , Anciano , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/epidemiología , COVID-19/epidemiología , Dispositivos de Terapia de Resincronización Cardíaca/tendencias , Control de Enfermedades Transmisibles/normas , Control de Enfermedades Transmisibles/tendencias , Desfibriladores Implantables/tendencias , Femenino , Estudios de Seguimiento , Humanos , Masculino , Pandemias/prevención & control , Tecnología de Sensores Remotos/tendenciasRESUMEN
Background Short ECG P-wave duration has recently been demonstrated to be associated with higher risk of atrial fibrillation (AF). The aim of this study was to assess the rate of AF recurrence after pulmonary vein isolation in patients with a short P wave, and to mechanistically elucidate the observation by computer modeling. Methods and Results A total of 282 consecutive patients undergoing a first single-pulmonary vein isolation procedure for paroxysmal or persistent AF were included. Computational models studied the effect of adenosine and sodium conductance on action potential duration and P-wave duration (PWD). About 16% of the patients had a PWD of 110 ms or shorter (median PWD 126 ms, interquartile range, 115 ms-138 ms; range, 71 ms-180 ms). At Cox regression, PWD was significantly associated with AF recurrence (P=0.012). Patients with a PWD <110 ms (hazard ratio [HR], 2.20; 95% CI, 1.24-3.88; P=0.007) and patients with a PWD ≥140 (HR, 1.87, 95% CI, 1.06-3.30; P=0.031) had a nearly 2-fold increase in risk with respect to the other group. In the computational model, adenosine yielded a significant reduction of action potential duration 90 (52%) and PWD (7%). An increased sodium conductance (up to 200%) was robustly accompanied by an increase in conduction velocity (26%), a reduction in action potential duration 90 (28%), and PWD (22%). Conclusions One out of 5 patients referred for pulmonary vein isolation has a short PWD which was associated with a higher rate of AF after the index procedure. Computer simulations suggest that shortening of atrial action potential duration leading to a faster atrial conduction may be the cause of this clinical observation.
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Potenciales de Acción , Fibrilación Atrial , Ablación por Catéter , Electrocardiografía/métodos , Sistema de Conducción Cardíaco , Complicaciones Posoperatorias , Potenciales de Acción/efectos de los fármacos , Potenciales de Acción/fisiología , Adenosina/farmacología , Antiarrítmicos/farmacología , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Simulación por Computador , Femenino , Sistema de Conducción Cardíaco/efectos de los fármacos , Sistema de Conducción Cardíaco/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Venas Pulmonares/cirugía , Recurrencia , Canales de Sodio/fisiologíaRESUMEN
OBJECTIVES: The goal of this study was to develop a risk score model for patients with Brugada syndrome (BrS). BACKGROUND: Risk stratification in BrS is a significant challenge due to the low event rates and conflicting evidence. METHODS: A multicenter international cohort of patients with BrS and no previous cardiac arrest was used to evaluate the role of 16 proposed clinical or electrocardiogram (ECG) markers in predicting ventricular arrhythmias (VAs)/sudden cardiac death (SCD) during follow-up. Predictive markers were incorporated into a risk score model, and this model was validated by using out-of-sample cross-validation. RESULTS: A total of 1,110 patients with BrS from 16 centers in 8 countries were included (mean age 51.8 ± 13.6 years; 71.8% male). Median follow-up was 5.33 years; 114 patients had VA/SCD (10.3%) with an annual event rate of 1.5%. Of the 16 proposed risk factors, probable arrhythmia-related syncope (hazard ratio [HR]: 3.71; p < 0.001), spontaneous type 1 ECG (HR: 3.80; p < 0.001), early repolarization (HR: 3.42; p < 0.001), and a type 1 Brugada ECG pattern in peripheral leads (HR: 2.33; p < 0.001) were associated with a higher risk of VA/SCD. A risk score model incorporating these factors revealed a sensitivity of 71.2% (95% confidence interval: 61.5% to 84.6%) and a specificity of 80.2% (95% confidence interval: 75.7% to 82.3%) in predicting VA/SCD at 5 years. Calibration plots showed a mean prediction error of 1.2%. The model was effectively validated by using out-of-sample cross-validation according to country. CONCLUSIONS: This multicenter study identified 4 risk factors for VA/SCD in a primary prevention BrS population. A risk score model was generated to quantify risk of VA/SCD in BrS and inform implantable cardioverter-defibrillator prescription.