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BACKGROUND: Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. METHODS: We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1year follow-up data were gathered. RESULTS: At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). CONCLUSIONS: Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.
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BACKGROUND: Magnetic resonance imaging and computed tomography in patients with ventricular tachycardia (VT) after myocardial infarction (MI) helps to delineate scar from healthy tissue. Image-guided VT ablation has not yet been studied on a large scale. OBJECTIVE: The aim of the meta-analysis was to compare the long-term outcome of image-guided VT ablation with a conventional approach for VT after MI. METHODS: Eight electronic bibliographic databases were searched to identify all relevant studies from 2012 until 2018. The search for scientific literature was performed for studies that described the outcome of VT ablation in patients with an ischaemic substrate. The outcome of image-guided ablation was compared with the outcome of conventional ablations. RESULTS: Of the 2990 citations reviewed for eligibility, 38 articles-enrolling a total of 7748 patients-were included into the meta-analysis. Five articles included patients with image-guided ablation. VT-free survival was 82% [74-90] in the image-guided VT ablation versus 59% [54-64] in the conventional ablation group (pâ¯< 0.001) during a mean follow-up of 35 months. Overall survival was 94% [90-98] in the image-guided versus 82% [76-88] in the conventional VT ablation group (pâ¯< 0.001). CONCLUSIONS: Image-guided VT ablation in ischaemic VT was associated with a significant benefit in VT-free and overall survival as compared with conventional VT ablation. Visualising myocardial scar facilitates substrate-guided ablation procedures, pre-procedurally and by integrating imaging during the procedure, and may consequently improve long-term outcome.
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BACKGROUND: Postprocedural complications after elective cardiac interventions include hematomas and infections. Telemedical wound assessment using mobile phones with integrated cameras may improve quality of care and help reduce costs. AIMS: We aimed to study the feasibility of telemedical wound assessment using a mobile phone. The primary aim was the number of patients who were able to upload their pictures. Secondary aims were image interpretability, agreement between nurse practitioners, and patient evaluation of the intervention. METHODS: This is a prospective study of all consecutive patients who underwent an elective cardiac intervention. Patients were instructed to photograph their wound or puncture site after hospital discharge and upload the pictures to a secure email address 6 days after hospital discharge. Received photos were assessed by 2 nurse practitioners. The intervention was evaluated using a peer-reviewed questionnaire and photo assessment scheme. RESULTS: In total, 46 eligible patients were included in the study, with 5 screen failures (eg, clinical stay ≥ 6 days) and 1 patient lost to follow-up. Thirty-three of 40 patients (83%) were able to upload their pictures. Smartphone users were more successful in uploading their pictures compared with feature phone users (93% vs 55%, P < .01). Eighty-eight percent of the clinical pictures were interpretable. The interobserver variability had an agreement between 93% and 97%. CONCLUSIONS: Patients are able to take and upload the mobile clinical photos to the secure email address, and the vast majority was interpretable. Smartphone users were more successful than feature phone users in uploading their pictures. The interobserver variability was good.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Enfermedades Cardiovasculares/cirugía , Teléfono Celular , Fotograbar , Herida Quirúrgica/patología , Telemedicina , Adulto , Anciano , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
Contact force (CF) is one of the major determinants for sufficient lesion formation. CF-guided procedures are associated with enhanced lesion formation and procedural success. We report our initial experience in epicardial ventricular tachycardia (VT) ablation with a force-sensing catheter using a new approach with an angioplasty balloon. Two patients with arrhythmogenic right ventricular cardiomyopathy who underwent prior unsuccessful endocardial ablation were treated with epicardial VT ablation. CF data were used to titrate force, power and ablation time.
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BACKGROUND: The implantable cardioverter defibrillator (ICD) is effective in preventing sudden cardiac death. However, in elderly patients (aged 75 years or older) the role of ICDs is still not well-defined and controversial. METHODS: We retrospectively analysed all clinical and survival data of all ICD patients who were ≥75 years at the date of implantation in the Erasmus MC, Rotterdam, the Netherlands and the University Hospital, Basel, Switzerland. Kaplan-Meier survival analysis was performed, and mortality predictors were identified. Mortality of the cohort was compared with a random sample of patients aged 60-70 years originating from the same database and to an age- and sex-matched cohort of Dutch persons. RESULTS: The study cohort consisted of 179 patients aged 75 years or older who were implanted between February 1999 and July 2008. The median follow-up time was 2.0 (IQR 2.8) years. Survival rates after 1, 2 and 3 years were 87, 82, 75 %, respectively. Survival was similar for primary and secondary prevention. Mortality in this study population could be predicted by combining four clinical risk factors: QRS duration >120 ms, NYHA class > II, renal failure and atrial fibrillation (AF). Survival was worse compared with the group of ICD patients aged 60-70 years and to the age- and sex-matched group of elderly persons. However, survival was not significantly worse when comparing elderly ICD patients without additional risk factors to the general population. CONCLUSIONS: Elderly patients still have an acceptable survival probability independent of prevention indication, certainly if there are no additional clinical risk factors. The presence or absence of additional clinical risk factors should be taken into account when making the decision for implantation, since they strongly correlate with survival.
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OBJECTIVE: To assess the outcome and associated risks of atrial defragmentation for the treatment of long-standing persistent atrial fibrillation (LSP-AF). METHODS: Thirty-seven consecutive patients (60.4 ± 7.3 years; 28 male) suffering from LSP-AF who underwent pulmonary vein isolation (PVI) and linear ablation were compared. All patients were treated with the Stereotaxis magnetic navigation system (MNS). Two groups were distinguished: patients with (n = 20) and without (n = 17) defragmentation. The primary endpoint of the study was freedom of AF after 12 months. Secondary endpoints were AF termination, procedure time, fluoroscopy time and procedural complications. Complications were divided into two groups: major (infarction, stroke, major bleeding and tamponade) and minor (fever, pericarditis and inguinal haematoma). RESULTS: No difference was seen in freedom of AF between the defragmentation and the non-defragmentation group (56.2 % vs. 40.0 %, P = 0.344). Procedure times in the defragmentation group were longer; no differences in fluoroscopy times were observed. No major complications occurred. A higher number of minor complications occurred in the defragmentation group (45.0 % vs. 5.9 %, P = 0.009). Mean hospital stay was comparable (4.7 ± 2.2 vs. 3.4 ± 0.8 days, P = 0.06). CONCLUSION: Our study suggests that complete defragmentation using MNS is associated with a higher number of minor complications and longer procedure times and thus compromises efficiency without improving efficacy.
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Percutaneous epicardial mapping and ablation is an emerging method to treat ventricular tachycardias (VT), premature ventricular complexes (PVC), and accessory pathways. The use of a remote magnetic navigation system (MNS) could enhance precision and maintain safety. This multiple case history demonstrates the feasibility and safety of the MNS-guided epicardial approach in mapping and ablation of ischaemic VT, outflow tract PVCs, and a left-sided accessory pathway. All patients had previously undergone endocardial mapping for the same arrhythmia. MNS could present an advantage from more precise navigation for mapping and maintaining catheter stability during energy application.
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We present a unique case where early proarrhythmic and late antiarrhythmic characteristics of interatrial conduction delay were observed during the long-term progression of HCM. Occurrence of AT constantly increased as the interatrial conduction delay became more prominent, while the P-wave width in sinus rhythm and the AT cycle length both showed an instantaneous increase in parallel. As the interatrial delay reached a critical point, the right and left atrial P-wave became virtually separated, as demonstrated by the findings of ECGs and echocardiography. This phenomenon resulted in the complete cessation of tachycardias.
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Fibrilación Atrial/fisiopatología , Cardiomiopatía Hipertrófica/fisiopatología , Electrocardiografía , Atrios Cardíacos/fisiopatología , Sistema de Conducción Cardíaco/fisiopatología , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/etiología , Cardiomiopatía Hipertrófica/complicaciones , Cardiomiopatía Hipertrófica/diagnóstico , Progresión de la Enfermedad , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A baffle puncture is a challenging procedure but can be safely done using direct visualization of the region of interest. To our knowledge, however, it has never been performed in a patient with dextrocardia. We present a 62-year-old male with dextrocardia, right isomerism, congenitally corrected transposition of the great arteries, persistent left-sided superior and inferior caval veins, atrial septum defect, and pulmonary valve stenosis. The atrial septum defect was surgically closed with a Teflon patch, a variant Mustard operation was performed, and also a prosthetic tricuspid valve was implanted. The patient developed multiple episodes of atrial tachycardia leading to acute heart failure on many occasions. An electrophysiological study was undertaken in order to create a bi-atrial electro-anatomical map. Owing to the presence of a prosthetic tricuspid valve, the femoral venous access was used and a baffle puncture was performed using continuous monitoring with fluoroscopy and transoesophageal echocardiography (TEE). The baffle puncture was successful and the tachycardia was ablated in the systemic venous atrium. To our knowledge, we present the very first case report demonstrating a successful baffle puncture in a patient with dextrocardia and Mustard correction. Direct imaging using TEE seems to be a very useful tool for guiding the puncture.
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Fibrilación Atrial/diagnóstico por imagen , Procedimientos Quirúrgicos Cardíacos/métodos , Ablación por Catéter/métodos , Dextrocardia/cirugía , Ecocardiografía Transesofágica/métodos , Punciones/métodos , Anomalías Múltiples/diagnóstico , Anomalías Múltiples/cirugía , Fibrilación Atrial/cirugía , Mapeo del Potencial de Superficie Corporal , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Dextrocardia/diagnóstico , Ecocardiografía Transesofágica/instrumentación , Estudios de Seguimiento , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Resultado del TratamientoRESUMEN
AIMS: Arrhythmias occurring late after repair of tetralogy of Fallot (ToF) are common. Due to the risk of sudden cardiac death, attention is focused towards ventricular tachycardias (VT). The aims of this study were to determine the clinical profile of patients with known benign and malignant arrhythmias and to assess patients with palpitations without documented arrhythmias. METHODS AND RESULTS: Fifty-two patients with prior ToF repair were included in this study (mean follow-up: 18+/-7.3 years). Echocardiographic measurements such as left ventricular ejection fraction, left and right atrial (LA and RA) diameters, left and right ventricular diameters (LVEDD and RVEDD), pulmonary and tricuspid regurgitation (TI and PI) and electrocardiographic parameters such as QRS duration, P-wave duration, P-wave dispersion were obtained and compared in patients with and without a history of palpitations. The same comparisons were performed between patients with documented supraventricular tachycardias (SVT) and VT. Twenty-seven of 52 patients had a clinical history of palpitations. The remaining 25 patients served as controls. Eleven patients had documented SVT and 6 patients had documented VT. In patients with documented SVT, the RA size and the QRS durations were significantly higher than in the controls (RA: 55.3+/-5.6 vs. 47.4+/-4.8 mm, P=0.03, QRS: 160.0+/-25.9 vs. 131.8+/-26.1 ms, P=0.01). In patients with VT, the LVEDD, LA, and QRS durations showed significantly higher values compared with the control patients (LVEDD: 53.5+/-4.7 vs. 45.6+/-6.8 mm; LA: 56.0+/-3.4 vs. 48.5+/-4.8 mm, P=0.01; QRS: 169.5+/-29.7 ms vs. 131.8+/-26.1 ms; P=0.001). The only significant differences between patients with and without palpitations were the RA size (58.2+/-3.9 vs. 50.5+/-5.2 mm, P=0.02) and the P-wave dispersion (26.8+/-15.2 vs. 16.6+/-4.3 ms, P=0.04). CONCLUSION: Our present data suggest that undocumented arrhythmias are most likely SVTs and are associated with increased RA size.
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Muerte Súbita Cardíaca/prevención & control , Ecocardiografía/métodos , Electrocardiografía , Taquicardia Ventricular/diagnóstico , Tetralogía de Fallot/cirugía , Adulto , Factores de Edad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Estudios de Cohortes , Electrocardiografía Ambulatoria , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Sistema de Registros , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Taquicardia Ventricular/etiología , Taquicardia Ventricular/mortalidad , Tetralogía de Fallot/diagnóstico por imagen , Tetralogía de Fallot/mortalidad , Factores de TiempoRESUMEN
Monomorphic ventricular tachycardia (VT) and symptomatic monomorphic PVCs originating from the region of the right and left outflow tracts are increasingly treated by radiofrequency (RF) catheter ablation. Technical difficulties in catheter manipulation to access these outflow tract areas, very accurate mapping and reliable catheter stability are key issues for a successful treatment in this vulnerable region. VT ablation from the aortic sinus cusp (ASC) in particular carries a significant risk of perforation, of creating left coronary artery injury and of damage to the aorta and the aortic valve.This case series describes RF ablation of VT originating in the outflow region using the remote magnetic navigation system (MNS). Potential advantages of the MNS are catheter flexibility, steering accuracy and reproducibility to navigate to a desired location with a low probability of perforating the myocardium. This report supports the idea of using advanced MNS technology during RF ablation in regions which are difficult to reach and thin walled, such as parts of the outflow tract and the ASC. (Neth Heart J 2009;17:245-9.).
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OBJECTIVES: We aimed to test the maximum voltage-guided cavotricuspid isthmus (CTI) ablation technique during ongoing atrial flutter. BACKGROUND: Former pathological and electrophysiological studies clarified that the cavotricuspid isthmus is composed of distinct muscular bundles, which are responsible for the conduction of electrical activation. Based on this observation, a maximum voltage-guided ablation technique (MVGT) was developed. This technique was assessed during pacing from the coronary sinus and was reported to be a feasible method to reach bidirectional isthmus block without the need for a complete anatomic ablation line. METHODS: This was a prospective, randomized single center study. Twenty patients underwent CTI ablation during atrial flutter. In group I (10 pts) CTI ablation was performed with complete anatomical ablation line. In group II (10 pts) ablation was guided by the highest amplitude potentials on the CTI sequentially until bidirectional isthmus block was reached. The following parameters were compared: acute success rate, procedure time, fluoroscopy time, number of radiofrequency (RF) applications and total RF duration. RESULTS: In all patients, atrial flutter terminated during ablation. Bidirectional isthmus block could be achieved in all pts. Procedure time was shorter in group II (107 +/- 40 vs 68 +/- 19 min, p < 0.01). Significantly less fluoroscopy was used in group II (22.6 +/- 10.6 vs 12.1 +/- 3.8 min, p < 0.01). There were less RF applications in group II (27.1 +/- 21.5 vs 5.9 +/- 2.4, p < 0.001). CONCLUSIONS: (1) The major finding of this study is that MVGT is a feasible method even during ongoing atrial flutter. (2) Our data confirm that MVGT is an effective technique for CTI ablation with considerable decrease in procedure and fluoroscopy times.
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Aleteo Atrial/patología , Técnicas Electrofisiológicas Cardíacas , Válvula Tricúspide/anatomía & histología , Anciano , Seno Coronario/patología , Femenino , Fluoroscopía/métodos , Bloqueo Cardíaco , Sistema de Conducción Cardíaco , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , Válvula Tricúspide/patologíaRESUMEN
Parkinson's disease (PD) and Alzheimer's dementia (AD) are often associated with an autonomic neuropathy. The extent of autonomic involvement, however is poorly defined and unpredictable. In order to assess the autonomic cardiovascular regulation baroreflex sensitivity (BRS) was determined non-invasively in 23 patients (age: 65 +/- 9.3 years) with PD and 24 patients with AD (age: 72.3 +/- 7.2 years). The results were compared with those on 22 healthy age- and sex-matched volunteers. Patients with PD and AD exhibited marked abnormalities in cardiovascular autonomic reflex regulation showed by markedly depressed BRS. The possible predictive value of centrally based depression of baroreflex sensitivity necessitates further studies.
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Enfermedad de Alzheimer/fisiopatología , Barorreflejo/fisiología , Enfermedad de Parkinson/fisiopatología , Anciano , Análisis de Varianza , Presión Sanguínea , Femenino , Humanos , Masculino , Análisis por Apareamiento , Persona de Mediana EdadRESUMEN
Electrophysiological mapping and ablation techniques are increasingly used to diagnose and treat many types of supraventricular and ventricular tachycardias. These procedures require an intimate knowledge of intracardiac anatomy and their use has led to a renewed interest in visualization of specific structures. This has required collaborative efforts from imaging as well as electrophysiology experts. Classical imaging techniques may be unable to visualize structures involved in arrhythmia mechanisms and therapy. Novel methods, such as intracardiac echocardiography and three-dimensional echocardiography, have been refined and these technological improvements have opened new perspectives for more effective and accurate imaging during electrophysiology procedures. Concurrently, visualization of these structures noticeably improved our ability to identify intracardiac structures. The aim of this review is to provide electrophysiologists with an overview of recent insights into the structure of the heart obtained with intracardiac echocardiography and to indicate to the echo-specialist which structures are potentially important for the electrophysiologist.
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Mapeo del Potencial de Superficie Corporal/métodos , Ablación por Catéter/métodos , Ecocardiografía Tridimensional/métodos , Aumento de la Imagen/métodos , Cirugía Asistida por Computador/métodos , Mapeo del Potencial de Superficie Corporal/instrumentación , Mapeo del Potencial de Superficie Corporal/tendencias , Ablación por Catéter/instrumentación , Ablación por Catéter/tendencias , Ecocardiografía Tridimensional/instrumentación , Ecocardiografía Tridimensional/tendencias , Humanos , Aumento de la Imagen/instrumentación , Cirugía Asistida por Computador/instrumentación , Cirugía Asistida por Computador/tendenciasRESUMEN
Current pacing practice is undergoing continuous and substantial changes. Initially pacing had an exclusively palliative role, since it was reserved for patients developing complete heart block or severe symptomatic bradycardia. With the appearance of novel pacing indications such as pacing for heart failure and atrial fibrillation, the effect of pacing site on cardiac function has become a critically important issue and a subject for consideration. It seems that the classical pacing site in the right ventricular apex is no longer the gold standard because of possible disadvantageous effects on cardiac function. The aim of this review article is to discuss the effect of right ventricular apical pacing on cardiac function including cellular and hemodynamic changes. We also aim to discuss the role of alternative pacing sites in the light of cardiac function.
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The authors present a patient with a specific ECG pattern and a history of syncope and malignant ventricular arrhythmias. Patients without demonstrable structural heart disease and an ECG pattern of RBBB and ST segment elevation in leads V1 through V3 are at risk for sudden cardiac death. They demonstrate the role of cardiac electrophysiology study including programmed ventricular stimulation and pharmacological testing in evaluation of patients with possible Brugada syndrome. The authors emphasize the role of implantable cardioverter defibrillator (ICD) therapy in treatment of patients with Brugada syndrome.
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Bloqueo de Rama/complicaciones , Bloqueo de Rama/fisiopatología , Muerte Súbita Cardíaca/etiología , Sistema de Conducción Cardíaco/fisiopatología , Biomarcadores , Bloqueo de Rama/terapia , Muerte Súbita Cardíaca/prevención & control , Desfibriladores Implantables , Electrocardiografía , Humanos , Masculino , Persona de Mediana Edad , SíndromeRESUMEN
BACKGROUND: Hybrid therapy for atrial fibrillation class 1C and class III antiarrhythmic drugs (AAD) can convert atrial fibrillation (AF) into an isthmus-dependent atrial flutter (AFL) in more than 10% of patients. Hybrid pharmacological and ablative therapy offers a safe and effective approach to achieving and maintaining sinus rhythm. We evaluated the efficacy of this hybrid approach in the management of paroxysmal or persistent AF. METHODS: Eighteen patients with symptomatic AF treated with AAD and typical anticlockwise/clockwise AFL underwent radiofrequency (RF) ablation of AFL with an anatomical approach. RESULTS: RF ablation was successful in all patients. All but one patient continued with AAD. Four patients (22%) had recurrences of AFL. Two of them also had a recurrence of AF. Another three patients had recurrences of AF only, and finally, one patient developed an atrial tachycardia more than one year after the procedure. In conclusion, 11 patients (61%) did not experience recurrences of AF/AFL after tricuspid valve annulus (TV)-inferior caval vein (IVC) isthmus ablation with continuing antiarrhythmic drugs. CONCLUSION: Hybrid pharmacological and ablative therapy is a safe and effective treatment for the management of patients with symptomatic AF.
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Aberrant ventricular conduction is a rare phenomenon as compared with the more frequently occurring antrioventricular conduction disturbances. It leads to widening of the QRS complex, which is either due to a complete or functional block in one of the bundle branches or a block within the intramyocardial conduction system itself. Mechanisms that are potentially involved in the genesis of aberrant ventricular conduction are sudden shortening of cycle length (tachycardia-dependent phase III), antegrade block with retrograde concealed conduction, or bradycardia-dependent block (enhanced phase IV). In this paper, we present a patient with aberrant ventricular conduction with the occurrence of a tachycardia-dependent, as well as a bradycardia-dependent bundle branch block, which is an even rarer phenomenon.