Scar conducting channel characterization to predict arrhythmogenicity during ventricular tachycardia ablation.

AIMS: Heterogeneous tissue channels (HTCs) detected by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) are related to ventricular arrhythmias, but there are few published data about their arrhythmogenic characteristics. METHODS AND RESULTS: We enrolled 34 consecutive patients with ischaemic and non-ischaemic cardiomyopathy who were referred for ventricular tachycardia (VT) ablation. LGE-CMR was performed prior to ablation, and the HTCs were analyzed. Arrhythmogenic HTCs linked to induced VT were identified during the VT ablation procedure. The characteristics of arrhythmogenic HTCs were compared with those of non-arrhythmogenic HTCs. Three patients were excluded due to low-quality LGE-CMR images. A total of 87 HTCs were identified on LGE-CMR in 31 patients (age:63.8 ± 12.3 years; 96.8% male; left ventricular ejection fraction: 36.1 ± 10.7%). Of the 87 HTCs, only 31 were considered arrhythmogenic because of their relation to a VT isthmus. The HTCs related to a VT isthmus were longer [64.6 ± 49.4 vs. 32.9 ± 26.6 mm; OR: 1.02; 95% CI: (1.01-1.04); P < 0.001] and had greater mass [2.5 ± 2.2 vs. 1.2 ± 1.2 grams; OR: 1.62; 95% CI: (1.18-2.21); P < 0.001], a higher degree of protectedness [26.19 ± 19.2 vs. 10.74 ± 8.4; OR 1.09; 95% CI: (1.04-1.14); P < 0.001], higher transmurality [number of wall layers with CCs: 3.8 ± 2.4 vs. 2.4 ± 2.0; OR: 1.31; 95% CI: (1.07-1.60); P = 0.008] and more ramifications [3.8 ± 2.0 vs. 2.7 ± 1.1; OR: 1.59; 95% CI: (1.15-2.19); P = 0.002] than non-arrhythmogenic HTCs. Multivariate logistic regression analysis revealed that protectedness was the strongest predictor of arrhythmogenicity. CONCLUSION: The protectedness of an HTC identified by LGE-CMR is strongly related to its arrhythmogenicity during VT ablation.

Non-invasive assessment of pulmonary vein isolation durability using late gadolinium enhancement magnetic resonance imaging.

AIMS: Electrical reconnection of pulmonary veins (PVs) is considered an important determinant of recurrent atrial fibrillation (AF) after pulmonary vein isolation (PVI). To date, AF recurrences almost automatically trigger invasive repeat procedures, required to assess PVI durability. With recent technical advances, it is becoming increasingly common to find all PVs isolated in those repeat procedures. Thus, as ablation of extra-PV targets has failed to show benefit in randomized trials, more and more often these highly invasive procedures are performed only to rule out PV reconnection. Here we aim to define the ability of late gadolinium enhancement (LGE)-magnetic resonance imaging (MRI) to rule out PV reconnection non-invasively. METHODS AND RESULTS: This study is based on a prospective registry in which all patients receive an LGE-MRI after AF ablation. Included were all patients that-after an initial PVI and post-ablation LGE-MRI-underwent an invasive repeat procedure, which served as a reference to determine the predictive value of non-invasive lesion assessment by LGE-MRI.: 152 patients and 304 PV pairs were analysed. LGE-MRI predicted electrical PV reconnection with high sensitivity (98.9%) but rather low specificity (55.6%). Of note, LGE lesions without discontinuation ruled out reconnection of the respective PV pair with a negative predictive value of 96.9%, and patients with complete LGE lesion sets encircling all PVs were highly unlikely to show any PV reconnection (negative predictive value: 94.4%). CONCLUSION: LGE-MRI has the potential to guide selection of appropriate candidates and planning of the ablation strategy for repeat procedures and may help to identify patients that will not benefit from a redo-procedure if no ablation of extra-PV targets is intended.

Late gadolinium enhancement-MRI determines definite lesion formation most accurately at 3 months post ablation compared to later time points.

AIMS: Neither the long-term development of ablation lesions nor the capability of late gadolinium enhancement (LGE)-MRI to detect ablation-induced fibrosis at late stages of scar formation have been defined. We sought to assess the development of atrial ablation lesions over time using LGE-MRI and invasive electroanatomical mapping (EAM). METHODS AND RESULTS: Ablation lesions and total atrial fibrosis were assessed in serial LGE-MRI scans 3 months and >12 months post pulmonary vein (PV) isolation. High-density EAM performed in subsequent repeat ablation procedures served as a reference. Serial LGE-MRI of 22 patients were analyzed retrospectively. The PV encircling ablation lines displayed an average LGE, indicative of ablation-induced fibrosis, of 91.7% ± 7.0% of the circumference at 3 months, but only 62.8% ± 25.0% at a median of 28 months post ablation (p < 0.0001). EAM performed in 18 patients undergoing a subsequent repeat procedure revealed that the consistent decrease in LGE over time was owed to a reduced detectability of ablation-induced fibrosis by LGE-MRI at time-points > 12 months post ablation. Accordingly, the agreement with EAM regarding detection of ablation-induced fibrosis and functional gaps was good for the LGE-MRI at 3 months (κ .74; p < .0001), but only weak for the LGE-MRI at 28 months post-ablation (κ .29; p < .0001). CONCLUSION: While non-invasive lesion assessment with LGE-MRI 3 months post ablation provides accurate guidance for future redo-procedures, detectability of atrial ablation lesions appears to decrease over time. Thus, it should be considered to perform LGE-MRI 3 months post-ablation rather than at later time-points > 12 months post ablation, like for example, prior to a planned redo-ablation procedure.

Impact of left atrial volume, sphericity, and fibrosis on the outcome of catheter ablation for atrial fibrillation.

INTRODUCTION: To investigate the relation between left atrial (LA) volume, sphericity, and fibrotic content derived from contrast-enhanced cardiac magnetic resonance imaging (CE-CMR) and their impact on the outcome of catheter ablation for atrial fibrillation (AF). METHODS AND RESULTS: In 83 patients undergoing catheter ablation for AF, CE-CMR was used to assess LA volume, sphericity, and fibrosis. There was a significant correlation between LA volume and sphericity (R  =  0.535, P < 0.001) and between LA volume and fibrosis (R  =  0.241, P  =  0.029). Multivariate analyses demonstrated that LA volume was the strongest independent predictor of AF recurrence after catheter ablation (1.019, P  =  0.018). CONCLUSION: LA volume, sphericity, and fibrosis were closely related; however, LA volume was the strongest predictor of AF recurrence after catheter ablation.

ß3 adrenergic agonist treatment in chronic pulmonary hypertension associated with heart failure (SPHERE-HF): a double blind, placebo-controlled, randomized clinical trial.

AIMS: Pulmonary hypertension (PH) associated with left heart disease is an increasingly prevalent problem, orphan of targeted therapies, and related to a poor prognosis, particularly when pre- and post-capillary PH combine. The current study aimed to determine whether treatment with the selective ß3 adrenoreceptor agonist mirabegron improves outcomes in patients with combined pre- and post-capillary PH (CpcPH). METHODS AND RESULTS: The ß3 Adrenergic Agonist Treatment in Chronic Pulmonary Hypertension Secondary to Heart Failure (SPHERE-HF) trial is a multicentre, randomized, parallel, placebo-controlled clinical trial that enrolled stable patients with CpcPH associated with symptomatic heart failure. A total of 80 patients were assigned to receive mirabegron (50 mg daily, titrated till 200 mg daily, n = 39) or placebo (n = 41) for 16 weeks. Of them, 66 patients successfully completed the study protocol and were valid for the main analysis. The primary endpoint was the change in pulmonary vascular resistance (PVR) on right heart catheterization. Secondary outcomes included the change in right ventricular (RV) ejection fraction by cardiac magnetic resonance or computed tomography, other haemodynamic variables, functional class, and quality of life. The trial was negative for the primary outcome (placebo-corrected mean difference of 0.62 Wood units, 95% confidence interval [CI] -0.38, 1.61, p = 0.218). Patients receiving mirabegron presented a significant improvement in RV ejection fraction as compared to placebo (placebo-corrected mean difference of 3.0%, 95% CI 0.4, 5.7%, p = 0.026), without significant differences in other pre-specified secondary outcomes. CONCLUSIONS: SPHERE-HF is the first clinical trial to assess the potential benefit of ß3 adrenergic agonists in PH. The trial was negative since mirabegron did not reduce PVR, the primary endpoint, in patients with CpcPH. On pre-specified secondary outcomes, a significant improvement in RV ejection fraction assessed by advanced cardiac imaging was found, without differences in functional class or quality of life.

Prognosis of Patients With Reduced Left Ventricular Ejection Fraction and Chronic Total Occlusion According to Treatment Applied.

BACKGROUND: Chronic total occlusion (CTO) is common among patients with coronary artery disease. Very few studies have focused on outcomes of patients with CTO and reduced left ventricular ejection fraction (LVEF), according to treatment applied. The aim of our study was to determine the potential influence of the selected treatment on the prognosis in patients with CTO associated with reduced LVEF. METHODS: Between June 2010 and October 2013, all consecutive patients with at least one CTO and reduced LVEF (<40%) were enrolled. Major adverse cardiac events (MACE), defined as the composite of cardiac mortality or myocardial infarction (MI) and its individual components, were compared between three treatment groups: medical therapy (MT), percutaneous coronary intervention (PCI), and coronary bypass graft (CABG). RESULTS: In 256 included patients, the follow-up was 1129 ± 556 days. The incidence of MACE was 40% in the MT group, compared with PCI (20.3%) and CABG (16.7%); p < 0.001. All-cause and cardiac mortality were also higher in the MT group (40.7% and 33.3%, respectively) versus the PCI (21.9% and 15.6%) and CABG (11.9% and 9.5%) groups (p < 0.001 for both endpoints); MI rate did not differ among groups. In the adjusted multivariate analysis, CABG had lower MACE risk, compared with MT (HR = 0.39, 0.17-0.91; p = 0.029); successful PCI also trended toward lower risk of MACE, compared with MT. CONCLUSIONS: Patients with CTO and reduced LVEF treated with MT had a worse prognosis than those treated with revascularization (either CABG or PCI). Patients with an indication for CABG appeared to perform best during long-term follow-up.

Improving the robustness of MOLLI T1 maps with a dedicated motion correction algorithm.

Myocardial tissue T1 constitutes a reliable indicator of several heart diseases related to extracellular changes (e.g. edema, fibrosis) as well as fat, iron and amyloid content. Magnetic resonance (MR) T1-mapping is typically achieved by pixel-wise exponential fitting of a series of inversion or saturation recovery measurements. Good anatomical alignment between these measurements is essential for accurate T1 estimation. Motion correction is recommended to improve alignment. However, in the case of inversion recovery sequences, this correction is compromised by the intrinsic contrast variation between frames. A model-based, non-rigid motion correction method for MOLLI series was implemented and validated on a large database of cardiac clinical cases (n = 186). The method relies on a dedicated similarity metric that accounts for the intensity changes caused by T1 magnetization relaxation. The results were compared to uncorrected series and to the standard motion correction included in the scanner. To automate the quantitative analysis of results, a custom data alignment metric was defined. Qualitative evaluation was performed on a subset of cases to confirm the validity of the new metric. Motion correction caused noticeable (i.e. > 5%) performance degradation in 12% of cases with the standard method, compared to 0.3% with the new dedicated method. The average alignment quality was 85% ± 9% with the default correction and 90% ± 7% with the new method. The results of the qualitative evaluation were found to correlate with the quantitative metric. In conclusion, a dedicated motion correction method for T1 mapping MOLLI series has been evaluated on a large database of clinical cardiac MR cases, confirming its increased robustness with respect to the standard method implemented in the scanner.

Scar channels in cardiac magnetic resonance to predict appropriate therapies in primary prevention.

BACKGROUND: Scar characteristics analyzed by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) are related with ventricular arrhythmias. Current guidelines are based only on the left ventricular ejection fraction to recommend an implantable cardioverter-defibrillator (ICD) in primary prevention. OBJECTIVES: Our study aims to analyze the role of imaging to stratify arrhythmogenic risk in patients with ICD for primary prevention. METHODS: From 2006 to 2017, we included 200 patients with LGE-CMR before ICD implantation for primary prevention. The scar, border zone, core, and conducting channels (CCs) were automatically measured by a dedicated software. RESULTS: The mean age was 60.9 ± 10.9 years; 81.5% (163) were men; 52% (104) had ischemic cardiomyopathy. The mean left ventricular ejection fraction was 29% ± 10.1%. After a follow-up of 4.6 ± 2 years, 46 patients (22%) reached the primary end point (appropriate ICD therapy). Scar mass (36.2 ± 19 g vs 21.7 ± 10 g; P < .001), border zone mass (26.4 ± 12.5 g vs 16.0 ± 9.5 g; P < .001), core mass (9.9 ± 8.6 g vs 5.5 ± 5.7 g; P < .001), and CC mass (3.0 ± 2.6 g vs 1.6 ± 2.3 g; P < .001) were associated with appropriate therapies. Scar mass > 10 g (25.31% vs 5.26%; hazard ratio 4.74; P = .034) and the presence of CCs (34.75% vs 8.93%; hazard ratio 4.07; P = .003) were also strongly associated with the primary end point. However, patients without channels and with scar mass < 10 g had a very low rate of appropriate therapies (2.8%). CONCLUSION: Scar characteristics analyzed by LGE-CMR are strong predictors of appropriate therapies in patients with ICD in primary prevention. The absence of channels and scar mass < 10 g can identify patients at a very low risk of ventricular arrhythmias in this population.

Cardiovascular Imaging in the Electrophysiology Laboratory.

In recent years, rapid technological advances have allowed the development of new electrophysiological procedures that would not have been possible without the parallel development of imaging techniques used to plan and guide these procedures and monitor their outcomes. Ablation of atrial fibrillation is among the interventions with the greatest need for imaging support. Echocardiography allows the appropriate selection of patients and the detection of thrombi that would contraindicate the intervention; cardiac magnetic resonance imaging and computed tomography are also essential in planning this procedure, by allowing a detailed anatomical study of the pulmonary veins. In addition, in cardiac resynchronization therapy, echocardiography plays a central role in both patient selection and, later, in device adjustment and in assessing the effectiveness of the technique. More recently, ablation of ventricular tachycardias has been established as a treatment option; this would not be possible without planning using an imaging study such as cardiac magnetic resonance imaging of myocardial scarring.

Pedagogía crítica para la concienciación en torno a la discriminación de género y la emancipación de las chicas en educación física / Pedagogía crítica para a conscientização em torno a discriminação de gênero e a emancipação das meninas em educação física / Critical pedagogy to raise awareness about gender discrimination and girls' emancipation in physical education

Resumen: Este estudio pone encima de la mesa las posibilidades y limitaciones de la pedagogía crítica como herramienta de concienciación del alumnado de Educación Física en torno a las desigualdades de género. La innovación educativa constaba de 8 sesiones en las que se trabajaba el fútbol a través del aprendizaje cooperativo y los pretextos críticos encaminados a la reflexión. La investigación tomó un cariz etnográfico. Los resultados constataron cambios muy significativos en los chicos y sobretodo en las chicas, en aspectos actitudinales y relacionales. La mayoría de ellas pasaron del conformismo inicial a explicitar sus quejas y tomar las riendas de los grupos cooperativos. Esto nos hace albergar esperanzas sobre el potencial emancipador de la propuesta.

Resumo: No estudo que apresentamos, as possibilidades da pedagogia crítica como uma ferramenta para aumentar a conscientização dos estudantes de Educação Física sobre as desigualdades de gênero são postas na mesa. A inovação educacional consistiu em oito sessões de futebol por meio de aprendizado cooperativo e pretextos críticos voltados à reflexão. A pesquisa leva um olhar etnográfico. Os resultados mostraram mudanças muito significativas nas meninas em aspectos atitudinais e relacionais. Passaram do conformismo inicial para explicitar suas queixas e tomar as rédeas dos grupos cooperativos. Isso nos dá esperança para o potencial emancipador da proposta.

Abstract: This study intends to shed light on critical pedagogy's potential as a tool for raising Physical Education students' awareness about gender inequalities. Eight football lessons were taught using cooperative learning and critical pretexts to encourage reflection. The research used ethnographic techniques. The findings show some changes on girls' attitudinal and relational behaviour. Most of them gave up their initial conformism and started voicing their complaints and taking control of cooperative groups. These facts made us hopeful regarding the emancipatory possibilities of the proposition.

Perfis pedagógicos de professores de educação física em uma escola multicultural / Perfiles pedagógicos del profesorado de educación física en una escuela multicultural / Pedagogical profiles of physical education teachers in a multicultural school

Este artigo apresenta uma classificação dos perfis pedagógicos dos professores de Educação Física de escolas multiculturais a partir de suas próprias percepções, de sua intervenção pedagógica e de sua trajetória profissional. Foi realizado um estudo de casos múltiplos com 12 professores que trabalham em escolas públicas de Barcelona, com mais de 50% de estudantes imigrantes. As técnicas de investigação utilizadas foram entrevistas semiestruturadas e observações não participantes, juntamente com a Análise de Conteúdo correspondente. Os dados recolhidos a partir da ótica intercultural permitiram estabelecer três perfis docentes: o "sensível inclusivo", o "assimilador romântico" e o "queimado-preconceituoso". Essa classificação permite reconhecer a diversidade de posturas existentes nesse coletivo profissional e analisar as necessidades formativas e de suporte mais oportunas em cada caso

Este trabajo presenta una tipificación de los perfiles pedagógicos del profesorado de Educación Física en escuelas multiculturales a partir de sus percepciones, su intervención pedagógica y su trayectoria profesional. Para ello, se ha realizado un estudio de casos múltiple, con doce docentes de escuelas públicas de Barcelona con más del 50% de alumnado inmigrante. Las técnicas de investigación han sido la entrevista semiestructurada y la observación no participante, junto con el correspondiente análisis de contenido. Los datos recogidos, analizados desde la óptica intercultural, han permitido establecer tres perfiles docentes: el "sensible-inclusor", el "romántico-asimilador" y el "quemado-prejuicioso". Esta tipificación permite reconocer la diversidad de posturas existentes entre el colectivo profesional y analizar las necesidades formativas y de apoyo más oportunas en cada caso

This paper presents a categorization of pedagogical profiles of Physical Education teachers in multicultural schools, based on their perceptions, pedagogical interventions and professional histories. A multiple case study was conducted with twelve teachers from public schools in Barcelona where over 50% of students were immigrants. The study used semi-structured interviews and non-participant observation, and then conducted the corresponding content analysis. The data collected were analysed from the cross-cultural point of view, and three teacher profiles were established: "sensitiveinclusive"; "romantic-assimilator"; and "stressed out-prejudiced". This classification allowed us to recognize the diversity of attitudes among these professionals and to analyze the most appropriate training and support needs for each case

Análisis del discurso de género en las matrices curriculares de las ciencias de la actividad física y el deporte / Gender discourse analysis in curriculum materials of the physical activity and sport sciences school / Análise do discurso de gênero nas matrizes curriculares sobre as ciências da atividade física e do desporto

Resumen: En este trabajo se pretende analizar cómo se ha introducido la perspectiva de género en el currículum universitario, y más específicamente, en el grado de Ciencias de la Actividad Física y el Deporte. Para ello se ha realizado un análisis de contenido y de discurso de 763 guías docentes procedentes de 16 universidades españolas. Los resultados ponen de relevancia como la construcción del conocimiento, y las diversas formas como se puede transmitir conlleva distintas implicaciones para la mayor o menor transformación de las relaciones de género. Las aportaciones de este estudio pueden ser útiles para el diseño de propuestas pedagógicas que pretenden incluir la perspectiva de género y fomentar la transformación social desde la formación universitaria. (AU)

Abstract: This paper aims to analyze how gender perspective has been introduced in the higher education curriculum, specifically in the Physical Activity and Sport Sciences degree. Content analysis and discourse analysis of 763 syllabuses from 16 Spanish public universities were carried out. Findings reveal that construction of knowledge and the several ways it can be conveyed have distinct implications on changing gender relations. The article contributes to the design of new pedagogical proposals that aim to include the gender perspective and promote social changes from higher education. (AU)

Resumo: Este trabalho tem como objetivo analisar a introdução da perspectiva de gênero no currículo universitário e, mais especificamente, no grau de Ciências da Atividade Física e do Desporto. Para isso, foi realizada uma análise de conteúdo e discurso de 763 guias de ensino de 16 universidades espanholas. Os resultados mostram como a construção do conhecimento, e as várias maneiras de transmissão trazem implicações diferentes para o grau de transformação das relações de gênero. As contribuições deste estudo podem ser úteis para a concepção de propostas educativas que visam incluir a perspectiva de gênero e promover a transformação social do ensino universitário. (AU)

La educación física y el deporte comoherramientas de inclusión de la población inmigrante en Cataluña: el papel de la escuela y la administración local / Physical education and sports as tools for inclusion of the immigrant population in Catalonia: the role of scholl and local administration

Hay dos instituciones que juegan un papel clave para fomentar la inclusión de la población inmigrante por su proximidad con la ciudadanía: la escuela y la administración local. En este artículo, se exponen las principales actuaciones que se llevan a cabo desde ambos terrenos para aprovechar el potencial socializador del deportey la actividad física en Cataluña. Partiendo del planteamiento político que guían las actuaciones educativas y en ámbito municipal, se describen algunas experiencias en las dos esferas. Fruto de este análisis, se constata la importancia de diseñar las estrategias y propuestas de intervención teniendo en cuenta los principios básicosde participación, transversalidad y continuidad.

There are two institutions which are the most close to citizens with a key role topromote the inclusion of the immigrant population: the school and the local administration. This article sets out the main actions that are carried out from both fields to take advantage of the socializing potential of sport and physical activity in Catalonia. We describe the political approach which guide both institutions and someexperiences and data. From this analysis, we can remark the importance of designing strategies and proposals for intervention taking into account the basic principles of participation, mainstreaming and continuity.