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Prasugrel and ticagrelor, new P2Y12-ADP receptor antagonists, are associated with greater pharmacodynamic inhibition and reduction of cardiovascular events in patients with an acute coronary syndrome. However, evidence is lacked about the effects of achieving faster and stronger cyclooxygenase inhibition with intravenous lysine acetylsalicylate (LA) compared to oral aspirin. Recently, we demonstrated in healthy volunteers that the administration of intravenous LA resulted in a significantly reduction of platelet reactivity compared to oral aspirin. Loading dose of LA achieves platelet inhibition faster, and with less variability than aspirin. However, there are no data of this issue in patients with an ST-segment elevation myocardial infarction (STEMI). This is a prospective, randomized, multicenter, open platelet function study conducted in STEMI patients. Subjects were randomly assigned to receive a loading dose (LD) of intravenous LA 450 mg plus oral ticagrelor 180 mg, or LD of aspirin 300 mg plus ticagrelor 180 mg orally. Platelet function was evaluated at baseline, 30 min, 1 h, 4 h and 24 h using multiple electrode aggregometry and vasodilator-stimulated phosphoprotein phosphorylation (VASP). The primary endpoint of the study is the inhibition of platelet aggregation (IPA) after arachidonic acid (AA) 0.5 mM at 30 min. Secondary endpoints were the IPA at 1, 4, and 24 h after AA, and non-AA pathways through the sequence (ADP and TRAP). A total of 32 STEMI patients were randomized (16 LA, 16 aspirin). The inhibition of platelet aggregation after AA 0.5 mM at 30 min was greater in subjects treated with LA compared with aspirin: 166 vs. 412 respectively (p = 0.001). This differential effect was observed at 1 h (p = 0.01), but not at 4 and 24 h. Subjects treated with LA presented less variability and faster inhibition of platelet aggregation wit AA compared with aspirin. The administration of intravenous LA resulted in a significantly reduction of platelet reactivity compared to oral aspirin on ticagrelor inhibited platelets in patients with STEMI. Loading dose of LA achieves an earlier platelet inhibition, and with less variability than aspirin.Trial Registration: Unique identifier: NCT02929888; URL: http://www.clinicaltrials.gov.
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Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Ticagrelor , Inibidores da Agregação Plaquetária/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Estudos Prospectivos , Aspirina/uso terapêutico , Aspirina/farmacologia , Plaquetas , Cloridrato de Prasugrel/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Resultado do Tratamento , Intervenção Coronária Percutânea/efeitos adversosRESUMO
There is a lack of direct evidence regarding gut microbiota dysbiosis and changes in short-chain fatty acids (SCFAs) in heart failure (HF) patients. We sought to assess any association between gut microbiota composition, SCFA production, clinical parameters, and the inflammatory profile in a cohort of newly diagnosed HF patients. In this longitudinal prospective study, we enrolled eighteen newly diagnosed HF patients. At admission and after 12 months, blood samples were collected for the assessment of proinflammatory cytokines, monocyte populations, and endothelial dysfunction, and stool samples were collected for analysis of gut microbiota composition and quantification of SCFAs. Twelve months after the initial HF episode, patients demonstrated improved clinical parameters and reduced inflammatory state and endothelial dysfunction. This favorable evolution was associated with a reversal of microbiota dysbiosis, consisting of the increment of health-related bacteria, such as genus Bifidobacterium, and levels of SCFAs, mainly butyrate. Furthermore, there was a decrease in the abundance of pathogenic bacteria. In vitro, fecal samples collected after 12 months of follow-up exhibited lower inflammation than samples collected at admission. In conclusion, the favorable progression of HF patients after the initial episode was linked to the reversal of gut microbiota dysbiosis and increased SCFA production, particularly butyrate. Whether restoring butyrate levels or promoting the growth of butyrate-producing bacteria could serve as a complementary treatment for these patients deserves further studies.
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Microbioma Gastrointestinal , Insuficiência Cardíaca , Humanos , Disbiose , Estudos Prospectivos , Ácidos Graxos Voláteis , ButiratosRESUMO
RATIONALE: Costly proprietary panoramic multielectrode (64-256) acquisition systems are being increasingly used together with conventional electroanatomical mapping systems for persistent atrial fibrillation (PersAF) ablation. However, such approaches target alleged drivers (rotational/focal) regardless of their activation frequency dynamics. OBJECTIVES: To test the hypothesis that stable regions of higher than surrounding instantaneous frequency modulation (iFM) drive PersAF and determine whether rotational activity is specific for such regions. METHODS AND RESULTS: First, novel single-signal algorithms based on instantaneous amplitude modulation (iAM) and iFM to detect rotational-footprints without panoramic multielectrode acquisition systems were tested in 125 optical movies from 5 ex vivo Langendorff-perfused PersAF sheep hearts (sensitivity/specificity, 92.6/97.5%; accuracy, 2.5-mm) and in computer simulations. Then, 16 pigs underwent high-rate atrial pacing to develop PersAF. After a median (interquartile range [IQR]) of 4.4 (IQR, 2.5-9.9) months of high-rate atrial pacing followed by 4.1 (IQR, 2.7-5.4) months of self-sustained PersAF, pigs underwent in vivo high-density electroanatomical atrial mapping (4920 [IQR, 4435-5855] 8-second unipolar signals per map). The first 4 out of 16 pigs were used to adapt ex vivo optical proccessing of iFM/iAM to in vivo electrical signals. In the remaining 12 out of 16 pigs, regions of higher than surrounding average iFM were considered leading-drivers. Two leading-driver + rotational-footprint maps were generated 2.6 (IQR, 2.4-2.9) hours apart to test leading-driver spatiotemporal stability and guide ablation. Leading-driver regions (2.5 [IQR, 2.0-4.0] regions/map) exactly colocalized (95.7%) in the 2 maps, and their ablation terminated PersAF in 92.3% of procedures (radiofrequency until termination, 16.9 [IQR, 9.2-35.8] minutes; until nonsustainability, 20.4 [IQR, 12.8-44.0] minutes). Rotational-footprints were found at every leading-driver region, albeit most (76.8% [IQR, 70.5%-83.6%]) were located outside. Finally, the translational ability of this approach was tested in 3 PersAF redo patients. CONCLUSIONS: Both rotational-footprints and spatiotemporally stable leading-driver regions can be located using iFM/iAM algorithms without panoramic multielectrode acquisition systems. In pigs, ablation of leading-driver regions usually terminates PersAF and prevents its sustainability. Rotational activations are sensitive but not specific to such regions. Single-signal iFM/iAM algorithms could be integrated into conventional electroanatomical mapping systems to improve driver detection accuracy and reduce the cost of patient-tailored/mechanistic approaches.
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Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Mapeamento Potencial de Superfície Corporal/métodos , Ablação por Cateter/métodos , Frequência Cardíaca/fisiologia , Imageamento Tridimensional/métodos , Potenciais de Ação/fisiologia , Adulto , Idoso , Animais , Fibrilação Atrial/diagnóstico por imagem , Feminino , Humanos , Preparação de Coração Isolado/métodos , Masculino , Pessoa de Meia-Idade , Ovinos , SuínosRESUMO
Anatomical-based approaches, targeting either pulmonary vein isolation (PVI) or additional extra PV regions, represent the most commonly used ablation treatments in symptomatic patients with atrial fibrillation (AF) recurrences despite antiarrhythmic drug therapy. PVI remains the main anatomical target during catheter-based AF ablation, with the aid of new technological advances as contact force monitoring to increase safety and effective radiofrequency (RF) lesions. Nowadays, cryoballoon ablation has also achieved the same level of scientific evidence in patients with paroxysmal AF undergoing PVI. In parallel, electrical isolation of extra PV targets has progressively increased, which is associated with a steady increase in complex cases undergoing ablation. Several atrial regions as the left atrial posterior wall, the vein of Marshall, the left atrial appendage, or the coronary sinus have been described in different series as locations potentially involved in AF initiation and maintenance. Targeting these regions may be challenging using conventional point-by-point RF delivery, which has opened new opportunities for coadjuvant alternatives as balloon ablation or selective ethanol injection. Although more extensive ablation may increase intraprocedural AF termination and freedom from arrhythmias during the follow-up, some of the targets to achieve such outcomes are not exempt of potential severe complications. Here, we review and discuss current anatomical approaches and the main ablation technologies to target atrial regions associated with AF initiation and maintenance.
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Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Veias Pulmonares/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Humanos , Resultado do TratamentoRESUMO
AIMS: Atrial electrical remodelling (AER) is a transitional period associated with the progression and long-term maintenance of atrial fibrillation (AF). We aimed to study the progression of AER in individual patients with implantable devices and AF episodes. METHODS AND RESULTS: Observational multicentre study (51 centres) including 4618 patients with implantable cardioverter-defibrillator +/-resynchronization therapy (ICD/CRT-D) and 352 patients (2 centres) with pacemakers (median follow-up: 3.4 years). Atrial activation rate (AAR) was quantified as the frequency of the dominant peak in the signal spectrum of AF episodes with atrial bipolar electrograms. Patients with complete progression of AER, from paroxysmal AF episodes to electrically remodelled persistent AF, were used to depict patient-specific AER slopes. A total of 34 712 AF tracings from 830 patients (87 with pacemakers) were suitable for the study. Complete progression of AER was documented in 216 patients (16 with pacemakers). Patients with persistent AF after completion of AER showed â¼30% faster AAR than patients with paroxysmal AF. The slope of AAR changes during AF progression revealed patient-specific patterns that correlated with the time-to-completion of AER (R2 = 0.85). Pacemaker patients were older than patients with ICD/CRT-Ds (78.3 vs. 67.2 year olds, respectively, P < 0.001) and had a shorter median time-to-completion of AER (24.9 vs. 93.5 days, respectively, P = 0.016). Remote transmissions in patients with ICD/CRT-D devices enabled the estimation of the time-to-completion of AER using the predicted slope of AAR changes from initiation to completion of electrical remodelling (R2 = 0.45). CONCLUSION: The AF progression shows patient-specific patterns of AER, which can be estimated using available remote-monitoring technology.
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Fibrilação Atrial , Remodelamento Atrial , Desfibriladores Implantáveis , Marca-Passo Artificial , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Pré-Escolar , HumanosRESUMO
INTRODUCTION: Recurrences after atrial fibrillation (AF) ablation are still common. Among the reported clinical and imaging predictors of recurrences, diagnosis-to-ablation time (DAT) has been defined as a predictor of ablation outcome in single-center studies. We aimed to validate DAT in a multicenter real-life cohort. METHODS: This was a multicenter study including consecutive patients undergoing first paroxysmal and persistent AF ablation with radiofrequency or cryoballoon catheters during 2013. Cox proportional hazard regression models were performed to identify predictors of recurrence. RESULTS: In total, 309 patients were included across nine centers (71% men, 57 ± 10 years old, 46% with hypertension, and 66% with CHA2 DS2 -VASc ≤ 1). Most patients had paroxysmal AF (67%) and underwent radiofrequency ablation (68%) with a median DAT of 51 (43) months. Patients with DAT ≤ 1 year (16.6%) were less likely to have repeat procedures (4% vs 18%; P = .017). The adjusted proportional hazards Cox model identified hypertension (P = .005), heart failure (P = .011), nonparoxysmal AF (P = .038), DAT > 1 year (P = .007), and LA diameter (P = .026) as independent predictors for AF recurrence. DAT > 1 year was the only modifiable factor independently associated with recurrence (HR 4.2 [95% CI, 1.5-11.9]) CONCLUSION: Diagnosis-to-ablation time is a modifiable factor independently associated with recurrent arrhythmia and repeat ablation after first AF ablation. An early intervention strategy during the first year from AF diagnosis might improve outcomes.
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Fibrilação Atrial/cirurgia , Ablação por Cateter , Criocirurgia , Veias Pulmonares/cirurgia , Tempo para o Tratamento , Potenciais de Ação , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Criocirurgia/efeitos adversos , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Veias Pulmonares/fisiopatologia , Recidiva , Medição de Risco , Fatores de Risco , Espanha , Fatores de Tempo , Resultado do TratamentoRESUMO
AIMS: We aimed to study the differences in biventricular scar characterization using bipolar voltage mapping compared with state-of-the-art in vivo delayed gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) imaging and ex vivo T1 mapping. METHODS AND RESULTS: Ten pigs with established myocardial infarction (MI) underwent in vivo scar characterization using LGE-CMR imaging and high-density voltage mapping of both ventricles using a 3.5-mm tip catheter. Ex vivo post-contrast T1 mapping provided a high-resolution reference. Voltage maps were registered onto the left and right ventricular (LV and RV) endocardium, and epicardium of CMR-based geometries to compare voltage-derived scars with surface-projected 3D scars. Voltage-derived scar tissue of the LV endocardium and the epicardium resembled surface projections of 3D in vivo and ex vivo CMR-derived scars using 1-mm of surface projection distance. The thinner wall of the RV was especially sensitive to lower resolution in vivo LGE-CMR images, in which differences between normalized low bipolar voltage areas and CMR-derived scar areas did not decrease below a median of 8.84% [interquartile range (IQR) (3.58, 12.70%)]. Overall, voltage-derived scars and surface scar projections from in vivo LGE-CMR sequences showed larger normalized scar areas than high-resolution ex vivo images [12.87% (4.59, 27.15%), 18.51% (11.25, 24.61%), and 9.30% (3.84, 19.59%), respectively], despite having used optimized surface projection distances. Importantly, 43.02% (36.54, 48.72%) of voltage-derived scar areas from the LV endocardium were classified as non-enhanced healthy myocardium using ex vivo CMR imaging. CONCLUSION: In vivo LGE-CMR sequences and high-density voltage mapping using a conventional linear catheter fail to provide accurate characterization of post-MI scar, limiting the specificity of voltage-based strategies and imaging-guided procedures.
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Potenciais de Ação , Arritmias Cardíacas/diagnóstico , Cicatriz/diagnóstico por imagem , Técnicas Eletrofisiológicas Cardíacas , Sistema de Condução Cardíaco/fisiopatologia , Imageamento por Ressonância Magnética , Infarto do Miocárdio/diagnóstico por imagem , Miocárdio/patologia , Animais , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/fisiopatologia , Cicatriz/etiologia , Cicatriz/patologia , Cicatriz/fisiopatologia , Meios de Contraste/administração & dosagem , Modelos Animais de Doenças , Frequência Cardíaca , Masculino , Meglumina/administração & dosagem , Infarto do Miocárdio/complicações , Infarto do Miocárdio/patologia , Infarto do Miocárdio/fisiopatologia , Compostos Organometálicos/administração & dosagem , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Sus scrofaRESUMO
AIMS: Myocardial infarction (MI) alters cardiac fibre organization with unknown consequences on ventricular arrhythmia. We used diffusion tensor imaging (DTI) of three-dimensional (3D) cardiac fibres and scar reconstructions to identify the main parameters associated with ventricular arrhythmia inducibility and ventricular tachycardia (VT) features after MI. METHODS AND RESULTS: Twelve pigs with established MI and three controls underwent invasive electrophysiological characterization of ventricular arrhythmia inducibility and VT features. Animal-specific 3D scar and myocardial fibre distribution were obtained from ex vivo high-resolution contrast-enhanced T1 mapping and DTI sequences. Diffusion tensor imaging-derived parameters significantly different between healthy and scarring myocardium, scar volumes, and left ventricular ejection fraction (LVEF) were included for arrhythmia risk stratification and correlation analyses with VT features. Ventricular fibrillation (VF) was the only inducible arrhythmia in 4 out of 12 infarcted pigs and all controls. Ventricular tachycardia was also inducible in the remaining eight pigs during programmed ventricular stimulation. A DTI-based 3D fibre disorganization index (FDI) showed higher disorganization within dense scar regions of VF-only inducible pigs compared with VT inducible animals (FDI: 0.36; 0.36-0.37 vs. 0.32; 0.26-0.33, respectively, P = 0.0485). Ventricular fibrillation induction required lower programmed stimulation aggressiveness in VF-only inducible pigs than VT inducible and control animals. Neither LVEF nor scar volumes differentiated between VF and VT inducible animals. Re-entrant VT circuits were localized within areas of highly disorganized fibres. Moreover, the FDI within heterogeneous scar regions was associated with the median VT cycle length per animal (R2 = 0.5320). CONCLUSION: The amount of scar-related cardiac fibre disorganization in DTI sequences is a promising approach for ventricular arrhythmia stratification after MI.
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Cicatriz , Imagem de Tensor de Difusão/métodos , Coração/fisiopatologia , Imageamento por Ressonância Magnética/métodos , Infarto do Miocárdio/complicações , Miocárdio/patologia , Taquicardia Ventricular , Animais , Cicatriz/diagnóstico por imagem , Cicatriz/patologia , Cicatriz/fisiopatologia , Medição de Risco , Suínos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/fisiopatologiaRESUMO
Atrial fibrillation (AF) is already the most commonly occurring arrhythmia. Catheter pulmonary vein ablation has emerged as a treatment that is able to make the arrhythmia disappear; nevertheless, recurrence to arrhythmia is very frequent. In this study, it is proposed to perform an analysis of the electrical signals recorded from bipolar catheters at three locations, pulmonary veins and the right and left atria, before to and during the ablation procedure. Principal Component Analysis (PCA) was applied to reduce data dimension and Granger causality and divergence techniques were applied to analyse connectivity along the atria, in three main regions: pulmonary veins, left atrium (LA) and right atrium (RA). The results showed that, before the procedure, patients with recurrence in the arrhythmia had greater connectivity between atrial areas. Moreover, during the ablation procedure, in patients with recurrence in the arrhythmial both atria were more connected than in patients that maintained sinus rhythms. These results can be helpful for procedures designing to end AF.
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INTRODUCTION: An empirical sequence of burst antitachycardia pacing (ATP) is effective in terminating fast ventricular tachycardias (FVT) in patients with implantable cardioverter-defibrillators (ICDs). We aimed to determine whether multiple ATP bursts for termination of FVT results in shock reduction compared to a single ATP burst. METHODS AND RESULTS: We analyzed data from the Umbrella trial, a multicenter prospective observational study of ICD patients followed by the CareLink Monitoring System. We compared the safety and effectiveness of a single ATP burst (Group 1) with a strategy of successive ATP sequences (Group 2) for termination of FVT episodes (cycle lengths 250-320 milliseconds) before shock therapy. Over a mean follow-up of 35 months, a total of 650 FVT episodes were detected in 154 patients (mean cycle length: 299 ± 18 milliseconds). Effectiveness of the first burst ATP in Group 1 was 73% and shocks were required in 27% of episodes. Effectiveness of the first burst ATP in Group 2 was 77%, and this increased to 91% with the third or successive ATP bursts. Shocks were required in 9% of episodes in group 2, representing a 67% reduction in the need of high-energy shocks. Median duration of FVT episodes and mortality in both groups were similar. Multivariate analysis indicated that programming multiple ATP bursts (OR 3.4, 95%CI 1.7-6.8, P = 0.001) was an independent predictor of ATP effectiveness. CONCLUSION: This study provides first evidence that a strategy of multiple burst ATP sequences for termination of FVT episodes leads to a clinically meaningful reduction in the need for shocks.
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Estimulação Cardíaca Artificial/métodos , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Traumatismos por Eletricidade/prevenção & controle , Taquicardia Ventricular/terapia , Potenciais de Ação , Idoso , Estimulação Cardíaca Artificial/efeitos adversos , Cardioversão Elétrica/efeitos adversos , Traumatismos por Eletricidade/diagnóstico , Traumatismos por Eletricidade/etiologia , Traumatismos por Eletricidade/fisiopatologia , Desenho de Equipamento , Falha de Equipamento , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Espanha , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
AIMS: The Atrial Fibrillation Ablation Pilot Study is a prospective registry designed to describe the clinical epidemiology of patients undergoing an atrial fibrillation (AFib) ablation, and the diagnostic/therapeutic processes applied across Europe. The aims of the 1-year follow-up were to analyse how centres assess in routine clinical practice the success of the procedure and to evaluate the success rate and long-term safety/complications. METHODS AND RESULTS: Seventy-two centres in 10 European countries were asked to enrol 20 consecutive patients undergoing a first AFib ablation procedure. A web-based case report form captured information on pre-procedural, procedural, and 1-year follow-up data. Between October 2010 and May 2011, 1410 patients were included and 1391 underwent an AFib ablation (98.7%). A total of 1300 patients (93.5%) completed a follow-up control 367 ± 42 days after the procedure. Arrhythmia documentation was done by an electrocardiogram in 76%, Holter-monitoring in 52%, transtelephonic monitoring in 8%, and/or implanted systems in 4.5%. Over 50% became asymptomatic. Twenty-one per cent were re-admitted due to post-ablation arrhythmias. Success without antiarrhythmic drugs was achieved in 40.7% of patients (43.7% in paroxysmal AF; 30.2% in persistent AF; 36.7% in long-lasting persistent AF). A second ablation was required in 18% of the cases and 43.4% were under antiarrhythmic treatment. Thirty-three patients (2.5%) suffered an adverse event, 272 (21%) experienced a left atrial tachycardia, and 4 patients died (1 haemorrhagic stroke, 1 ventricular fibrillation in a patient with ischaemic heart disease, 1 cancer, and 1 of unknown cause). CONCLUSION: The AFib Ablation Pilot Study provided crucial information on the epidemiology, management, and outcomes of catheter ablation of AFib in a real-world setting. The methods used to assess the success of the procedure appeared at least suboptimal. Even in this context, the 12-month success rate appears to be somewhat lower to the one reported clinical trials.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Ablação por Cateter/mortalidade , Eletrocardiografia , Humanos , Estimativa de Kaplan-Meier , Readmissão do Paciente/estatística & dados numéricos , Projetos Piloto , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/mortalidade , Estudos Prospectivos , Recidiva , Resultado do TratamentoRESUMO
BACKGROUND: Catheter ablation (CA) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation (AF) when compared with antiarrhythmic drug therapy (ADT). No randomized studies have compared the two strategies in persistent AF. The present randomized trial aimed to compare the effectiveness of CA vs. ADT in treating persistent AF. METHODS AND RESULTS: Patients with persistent AF were randomly assigned to CA or ADT (excluding patients with long-standing persistent AF). Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting >24 h that occurred after a 3-month blanking period. Secondary endpoints were any atrial tachyarrhythmia lasting >30 s, hospitalization, and electrical cardioversion. In total, 146 patients were included (aged 55 ± 9 years, 77% male). The ADT group received class Ic (43.8%) or class III drugs (56.3%). In an intention-to-treat analysis, 69 of 98 patients (70.4%) in the CA group and 21 of 48 patients (43.7%) in the ADT group were free of the primary endpoint (P = 0.002), implying an absolute risk difference of 26.6% (95% CI 10.0-43.3) in favour of CA. The proportion of patients free of any recurrence (>30 s) was higher in the CA group than in the ADT group (60.2 vs. 29.2%; P < 0.001) and cardioversion was less frequent (34.7 vs. 50%, respectively; P = 0.018). CONCLUSION: Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up. CLINICAL TRIAL REGISTRATION INFORMATION: NCT00863213 (http://clinicaltrials.gov/ct2/show/NCT00863213).
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Antiarrítmicos/uso terapêutico , Fibrilação Atrial/terapia , Ablação por Cateter/métodos , Ablação por Cateter/efeitos adversos , Doença Crônica , Término Precoce de Ensaios Clínicos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Resultado do TratamentoRESUMO
INTRODUCTION: New generation open-irrigated catheters aim to improve irrigation efficiency. This may change lesion patterns, challenging operators. Indeed, safety issues have recently arisen. We aimed to experimentally assess 4 open-irrigated catheters, comparing lesion size, safety, and heat transfer. METHODS: The thigh lesion model was employed in 6 anesthetized pigs to assess the morphology of perpendicular and tangential lesions (n = 140) created by the newer catheters ThermoCool® SF, CoolFlex™, and Blazer™ Open-Irrigated, and the standard ThermoCool®, at a constant power of 30 W (60 seconds). To evaluate the propensity for deep-tissue overheating, a set of 120 applications were performed at 50 W (180 seconds) comparing pop rates. Thermal assessment of the lesion generation process (20 W, 60 seconds, n = 32) was performed with an infrared camera on bovine ventricular tissue. RESULTS: At 30 W, the newer catheters showed lower temperature readings compared with the ThermoCool®. No major efficacy or safety differences were found at tangential applications; however, at perpendicular applications: (1) the SF at 17 mL/min better preserved the superficial layers and focused its maximum thermal effect deeper, but at recommended flow rates (8 mL/min) it generated the largest superficial lesions; (2) CoolFlex™ created smaller lesions than SF and readily induced steam pops at 50 W without temperature control; and (3) no major differences were found comparing Blazer™ Open-Irrigated and ThermoCool®. CONCLUSIONS: The lower temperature readings in the newer catheters make them more prone to deliver the maximum programmed power. Under experimental conditions, the SF catheter focuses its maximum effect deeper and the CoolFlex™ can be more prone to induce steam pops at high power settings.
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Temperatura Corporal/fisiologia , Cateteres Cardíacos , Procedimentos Cirúrgicos Cardíacos/instrumentação , Ablação por Cateter/instrumentação , Coração/fisiologia , Irrigação Terapêutica/instrumentação , Animais , Procedimentos Cirúrgicos Cardíacos/métodos , Ablação por Cateter/métodos , Transferência de Energia , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Suínos , Irrigação Terapêutica/métodos , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: In Spain there is a lack of population data that specifically compare hospitalization for systolic and diastolic heart failure (HF). We assessed clinical characteristics, in-hospital mortality and 30-day cardiovascular readmission rates differentiating by HF type. METHODS: We conducted a retrospective observational study of patients discharged with the principal diagnosis of HF from The National Health System' acute hospital during 2016-2019, distinguishing between systolic and diastolic HF. The source of the data was the Minimum Basic Data Set. The risk-standardized in-hospital mortality ratio and risk-standardized 30-day cardiovascular readmission ratio were calculated using multilevel risk adjustment models. RESULTS: The 190,200 episodes of HF were selected. Of these, 163,727 (86.1%) were classified as diastolic HF and were characterized by older age, higher proportion of women, diabetes mellitus, dementia and renal failure than those with systolic HF. In the multilevel risk adjustment models, diastolic HF was a protective factor for both in-hospital mortality (odds ratio [OR]: 0.79; 95% confidence interval [CI]: 0.75-0.83; P<.001) and 30-day cardiovascular readmission versus systolic HF (OR: 0.93; 95% CI: 0.88-0.97; P=.002). CONCLUSIONS: In Spain, between 2016 and 2019, hospitalization episodes for HF were mostly due to diastolic HF. According to the multilevel risk adjustment models, diastolic HF compared to systolic HF was a protective factor for both in-hospital mortality and 30-day cardiovascular readmission.
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Insuficiência Cardíaca Sistólica , Insuficiência Cardíaca , Humanos , Feminino , Insuficiência Cardíaca Sistólica/diagnóstico , Insuficiência Cardíaca Sistólica/terapia , Espanha/epidemiologia , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/diagnóstico , Hospitalização , Readmissão do Paciente , Estudos Retrospectivos , Mortalidade Hospitalar , HospitaisRESUMO
In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals' opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.
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Cardiologia , Humanos , Espanha , Masculino , Feminino , Inquéritos e Questionários , Pessoa de Meia-Idade , Adulto , Procedimentos Cirúrgicos Cardiovasculares/estatística & dados numéricos , Atitude do Pessoal de Saúde , Cardiologistas/estatística & dados numéricosRESUMO
Atrial fibrillation (AF) causes progressive structural and electrical changes in the atria that can be summarized within the general concept of atrial remodeling. In parallel, other clinical characteristics and comorbidities may also affect atrial tissue properties and make the atria susceptible to AF initiation and its long-term persistence. Overall, pathological atrial changes lead to atrial cardiomyopathy with important implications for rhythm control. Although there is general agreement on the role of the atrial substrate for successful rhythm control in AF, the current classification oversimplifies clinical management. The classification uses temporal criteria and does not establish a well-defined strategy to characterize the individual-specific degree of atrial cardiomyopathy. Better characterization of atrial cardiomyopathy may improve the decision-making process on the most appropriate therapeutic option. We review current scientific evidence and propose a practical characterization of the atrial substrate based on 3 evaluation steps starting with a clinical evaluation (step 1), then assess outpatient complementary data (step 2), and finally include information from advanced diagnostic tools (step 3). The information from each of the steps or a combination thereof can be used to classify AF patients in 4 stages of atrial cardiomyopathy, which we also use to estimate the success on effective rhythm control.
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Fibrilação Atrial , Cardiomiopatias , Átrios do Coração , Humanos , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Fibrilação Atrial/etiologia , Cardiomiopatias/diagnóstico , Cardiomiopatias/fisiopatologia , Cardiomiopatias/etiologia , Cardiomiopatias/complicações , Átrios do Coração/fisiopatologia , Remodelamento Atrial/fisiologiaRESUMO
BACKGROUND: The implantable loop recorder (ILR) is a useful tool for diagnosing paroxysmal conditions potentially related to arrhythmias. Most investigations have focused on selected clinical studies or high-volume centers. The aim of this study was to evaluate the indications and outcomes of the ILR in real clinical practice. METHODS AND RESULTS: This was a prospective, multicenter registry of patients undergoing ILR implantation for clinical indications (April 2006-December 2008). Clinical characteristics (symptoms, arrhythmias, treatments) were recorded in a database. Follow-up data at 1 year or after the occurrence of the first episode were also recorded. Total enrollment: 743 patients (male, 413, 55.6%; 64.9 ± 16 years); 228 (30.7%) had structural heart disease (SHD), and 183 (24.6%), bundle branch block (BBB). Recurrent syncope (76.4%) was the most common indication for implantation. Complete follow-up was obtained for 680 patients (91.5%). Three hundred and twenty-five patients (48%) presented 414 events, with a final diagnosis in 230 patients (70.8% of patients with events; 33.1% of patients with follow-up). Syncope secondary to bradyarrhythmia was the most frequent diagnosis. Similar rates of final diagnoses were noted in subgroups of SHD, BBB and normal heart. Regarding the cause of implantation, higher event rates were registered among patients with recurrent syncope. CONCLUSIONS: One-third of patients obtained a final diagnosis with the ILR, independent of the baseline characteristics. Only the cause of implantation provided different rates of final diagnosis.
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Arritmias Cardíacas , Bases de Dados Factuais , Eletrodos Implantados , Sistema de Registros , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , EspanhaRESUMO
During atrial fibrillation (AF), multiple wandering propagation wavelets at high rates drift around both atria under controversial hierarchical models. Antiarrhythmic drugs modify the cardiac ionic currents supporting the fibrillation process within the atria, and can alter AF propagation dynamics and even terminate the arrhythmia. However, some other drugs, theoretically nonantiarrhythmic, may slightly block particular cardiac ionic currents through uncertain mechanisms in such a subtle way at regular heart rates that may have been pharmacologically overlooked. These potential effects might be better exposed at much higher activation rates as in AF, where atrial cells depolarize over 400 times per second. In this review, we aimed to compile and discuss results from several studies evaluating the net effect of profound sedation with propofol on atrial cells and atrioventricular (AV) conduction. Propofol is a very commonly used anesthetic agent, and its possible effect on AF dynamics has systematically not been taken into account in the myriad of clinical studies dealing with AF intracardiac recordings. The possible effect of sedation with propofol on AF was evaluated through the analysis of AF propagation patterns before and after its infusion in a series of patients submitted to pulmonary vein ablation. Effect on AV conduction will be discussed as well.
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Anestesia Geral/estatística & dados numéricos , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Sistema de Condução Cardíaco/efeitos dos fármacos , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca/efeitos dos fármacos , Propofol/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Humanos , PrevalênciaRESUMO
INTRODUCTION: Heart failure (HF) is one of the leading causes of hospitalization and death in elderly patients. However, there is limited evidence on readmission and mortality 1-year after discharge for HF. METHODS: Retrospective analysis of the Minimum Basic Data Set, including HF episodes, discharged from Spanish hospitals between 2016 and 2018 in ≥ 75 years. We calculated: (a) the rate of readmissions due to circulatory system diseases (CSD) 365 days after index episode; (b) in-hospital mortality in readmissions; and (c) predictors of mortality and readmission. RESULTS: We included 178,523 patients (59.2% women) aged 85.1 ± 5.5 years. The most frequent comorbidities were arrhythmias (56.0%) and renal failure (39.5%). During the follow-up, 48,932 patients (27.4%) had at least one readmission for CSD and a crude rate of 40.2%, the most frequent one HF (52.8%). The median between the date of readmission and discharge from the last admission was 70 days [IQI 24; 171] for the first readmission. The most relevant predictors of the number of readmissions were valvular heart disease and myocardial ischemia. During the readmissions, 26,757 patients (79.1%) died, representing a cumulative in-hospital mortality of 47,945 (26.9%). The factors in the index episode predictors of mortality during readmissions were cardio-respiratory failure and stroke. The number of readmissions was a risk factor for in-hospital mortality (OR 1.13; 95% CI 1.11-1.14). CONCLUSIONS: The readmission rate for CSD 1-year after the index episode of HF in patients ≥ 75 years was 28.4%. The cumulative in-hospital mortality rate during the readmissions was 26.9%, and the number of rehospitalizations was identified as one of the main predictors of mortality.
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Insuficiência Cardíaca , Readmissão do Paciente , Idoso , Humanos , Feminino , Masculino , Estudos Retrospectivos , Mortalidade Hospitalar , Espanha/epidemiologia , Insuficiência Cardíaca/terapia , Fatores de Risco , Hospitais PúblicosRESUMO
BACKGROUND: Reaching the public health organizations targets of influenza vaccination in at-risk patient groups remains a challenge worldwide. Recognizing the relationship between the healthcare system characteristics and the economic environment of the population with vaccination uptake can be of great importance to improve. METHODS: Several characteristics were correlated in this retrospective ecological study with data from 6.8 million citizens, 15,812 healthcare workers across 258 primary care health centers, and average income by area of the care center in Spain. RESULTS: No correlation between HCW vaccination status and patient vaccination was found. A weak negative significant correlation between the size of the population the care center covers and their vaccination status did exist (6 mo.-59 yr., r = 0.19, p = 0.002; 60-64 yr., r = 0.23, p < 0.001; ≥65 yr., r = 0.23, p ≥ 0.001). The primary care centers with fewer HCWs had better uptake in the at-risk groups in the age groups of 60-64 yr. (r = 0.20, p = 0.002) and ≥65 (r = 0.023, p ≥ 0.001). A negative correlation was found regarding workload in the 6 mo.-59 yr. age group (r = 0.18, p = 0.004), which showed the at-risk groups that lived in the most economically deprived areas were more likely to be vaccinated. CONCLUSIONS: This study reveals that the confounding variables that determine influenza vaccination in a population and in HCWs are complex. Future influenza campaigns should address these especially considering the possibility of combining influenza and SARS-CoV-2 vaccines each year.