Management of massive hemopericardium in the electrophysiology laboratory: The double long sheath technique.

AIM: To describe a simple and useful technique for acute management of massive hemopericardium inside the Electrophysiology (EP) laboratory METHODS AND RESULTS: Five patients from a single center experience were identified, all with blood loss above 1000 ml after initial pericardiocenthesis. Using two long 8.5 F transseptal sheaths inside the pericardium space, with continuous negative pressure, allowed the complete cessation of bleeding or hemodynamic maintenance until definitive surgical repair in all patients CONCLUSION: The use of two long sheaths for blood drainage, instead of conventional pericardiocenthesis, might be helpful to manage massive hemopericardium inside EP lab, avoiding urgent cardiac surgery or maintaining clinical stability until surgical staff is available.

A novel treatment for esophageal lesions following atrial fibrillation ablation.

This study presents a novel technique for the treatment of a deep esophageal ulcer after ablation of paroxysmal atrial fibrillation (AF). Pulmonary vein isolation was performed using a radiofrequency irrigated tip catheter. On Day 5 of follow-up, a deep esophageal ulcer was observed. No significant visual improvement was observed after conventional treatment. Endoscopic negative pressure therapy in the esophagus was then applied for 5 days. A significant decrease in diameter and depth of the lesion was observed, possibly preventing perforation. Endoscopic negative pressure therapy can be used to heal thermal lesions after AF ablation procedures.

Catheter ablation of the parahisian accessory pathways from the aortic cusps-Experience of 20 cases-Improving the mapping strategy for better results.

INTRODUCTION: Catheter ablation of the parahisian accessory pathways (PHAP) has been established as the definitive therapy for this type of arrhythmia. However, the PHAP proximity to the normal atrioventricular conduction system makes the procedure technically challenging. Here, we have reported a case series of 20 patients with PHAP who underwent aortic access ablation to evaluate the safety and efficacy of this approach in the PHAP ablation. METHODS AND RESULTS: The ablation through the aortic cusps was the successful approach in 13 of 20 (65%) of the cases. In 11 patients, the aortic approach was the initial strategy for ablation, and the accessory pathway was eliminated in seven (63.6%) of them. The aortic approach followed a failed right-sided attempt in nine patients. In six (66.7%) patients, the ablation was successful with the aortic approach. The only independent predictor for the successful ablation with each approach was the earliest ventricular activation before delta wave (predelta time) and a right-sided earliest ventricular activation of more than 23 ms had high sensitivity and specificity for right-sided success. Systematically using the two strategies (right and left approaches), the ablation of the PHAP was successful in 18 (90%) patients. CONCLUSION: The aortic approach seems to be a safe and effective strategy for the ablation of PHAP. It can be used when the right-sided approach fails or even considered as an initial strategy when the predelta time is less than 23 ms in the right septal region. When combining the right- and left-sided approaches, the success rate is high. We believe that the retrograde aortic approach remains a key tool for this challenging ablation.

Comparative study of strategies to prevent esophageal and periesophageal injury during atrial fibrillation ablation.

OBJECTIVE: To compare the prevalence of esophageal and periesophageal thermal injury in patients undergoing radiofrequency (RF) atrial fibrillation (AF) ablation using 8 mm tip catheters during three different esophageal protection strategies. METHODS: Forty-five consecutive patients with paroxysmal or persistent AF underwent first ablation procedure, besides esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS) performed before and after the pulmonary vein (PV) isolation. Before the procedure, patients were randomly assigned to one of three esophageal lesion protection strategies: group I-without any protective or monitoring dispositive and limiting RF applications to 30 W for 20 seconds, in left atrium posterior wall (LAPW); group II-power and time of RF delivery, up to 50 W for 20 seconds at LAPW, limited by esophageal temperature monitoring; group III-applications of RF in LAPW with fixed power application of 50 W for 20 seconds during continuous esophageal cooling. RESULTS: Baseline characteristics of patients were similar in all groups. The four PVs were isolated in 14 (93.3%), 13 (86.7%), and 15 (100%) patients, respectively in groups I, II, and III. The mean RF power was significantly higher (P < .001) in the posterior side of PVs in group III. Post-AF ablation EGD and EUS revealed two esophageal wall ulcerations and two periesophageal mediastinal edemas only in the esophageal cooling group (P = .008). CONCLUSION: Esophageal cooling balloon strategy resulted in a higher RF power energy delivery when ablating at the LA posterior wall, using 8 mm nonirrigated tip catheters under temperature mode control. Despite that, patients presented a relatively low incidence of esophageal and periesophaeal injuries.

Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block.

AIMS: Asymptomatic nocturnal long ventricular pauses are usually detected accidentally and it has been suggested that they may lead to sudden death. Identification of predisposing factors could prevent cardiovascular events. METHODS AND RESULTS: We report the case of a patient with frequent asymptomatic nocturnal ventricular pauses of 3-11 s, characteristic of a vagally mediated atrioventricular (AV) block. Echocardiography, treadmill test, thyroid function test levels, and polysomnogram were normal. In an attempt to reduce the risk, it was decided that an atrial vagal denervation induced by radiofrequency (RF) ablation (cardioneuroablation) could be useful. Spectral mapping was used to localize endocardial vagal innervation in the right and left aspects of the inter-atrial septum, responsible for the sinus node and AV node modulation, and RF pulses were applied in those sites only. After finishing the procedure, significant changes were observed in the heart rate (66-90 b.p.m.), atrial-His interval (115-74 ms), Wenckebach cycle length (820-570 ms), and sinus node recovery time (1100-760 ms). Follow-up Holter recording demonstrated that the number of ventricular pauses had reduced from 438 to 0. Heart rate and time domain characteristics were compatible with vagal denervation. CONCLUSION: Ablation of the endocardial vagal innervation sites seems to be safe and efficient in reducing the frequency and the length of the ventricular pauses. It was possible by identifying certain spectral components of the atrial electrogram, resulting in a conservative approach.

Impact of an online course on enhancing the diagnosis of Chagas disease in Latin America.

Objective: Chagas disease poses a public health problem in Latin America, and the electrocardiogram is a crucial tool in the diagnosis and monitoring of this pathology. In this context, the aim of this study was to quantify the change in the ability to detect electrocardiographic patterns among healthcare professionals after completing a virtual course. Materials and Methods: An asynchronous virtual course with seven pre-recorded classes was conducted. Participants answered the same questionnaire at the beginning and end of the training. Based on these responses, pre and post-test results for each participant were compared. Results: The study included 1656 participants from 21 countries; 87.9% were physicians, 5.2% nurses, 4.1% technicians, and 2.8% medical students. Initially, 3.1% answered at least 50% of the pre-test questions correctly, a proportion that increased to 50.4% after the course (p=0.001). Regardless of their baseline characteristics, 82.1% of course attendees improved their answers after completing the course. Conclusions: The implementation of an asynchronous online course on electrocardiography in Chagas disease enhanced the skills of both medical and non-medical personnel to recognize this condition.

Comparison between cryotherapy and radiofrequency energy sources for parahisian accessory pathway percutaneous ablation.

BACKGROUND: Catheter ablation of parahisian accessory pathways (PHAP) are challenging due to their proximity to the normal conduction system. Retrospective studies suggest that cryoablation has a better safety profile but a higher recurrence rate when compared to radiofrequency ablation (RFCA). The objective of this study was to compare the results of parahisian AP ablation performed by electrophysiologists with experience in both technologies. METHODS: Prospective single-center, non-blinded and 1:1 model was used. Patients included had parahisian AP confirmed by an electrophysiological study and referred for radiofrequency or cryotherapy ablation according to current guidelines, under fluoroscopic guidance. No electroanatomic mapping was used. RESULTS: A total of 30 patients (mean age of 25±9.4 years; 90% male) were enrolled between Oct/2018 to Feb/2020. Acute success rate between RFCA and CRYO were similar (93% vs. 87%, p = 0.54). A nonsignificant reduction in short-term recurrence rate for RFCA (14% vs. 30%, p = 0.3) and mechanical trauma (6% vs. 20%; p = 0.28) was observed. Long-term recurrence rate and event-free survival time were similar in both groups after 1-year follow-up (p = 0.286). No persistent complete AV block or conduction disturbance was also observed. CONCLUSION: Considering the limitation of a small sample size and the lack of use of electroanatomic mapping for RFCA, the efficacy and safety profile of parahisian AP ablation with RFCA was not different from CRYO, when performed by experienced electrophysiologists. No cases of permanent complete AV block were reported with either energy modalities.

Long-Term Outcome of Cardiac Denervation Procedures: The Anatomically Guided Septal Approach.

BACKGROUND: Functional bradycardia is a challenging condition that affects a healthy population. Ganglionated plexus ablation has emerged as a therapeutic alternative to avoid a pacemaker. OBJECTIVES: The purpose of this study is to evaluate long-term effects of anatomically guided cardiac denervation. METHODS: This is a prospective longitudinal study that included 36 patients with symptomatic functional bradycardia. Electroanatomic reconstruction of both atria was carried out, and the main septal ganglionated plexi were anatomically located and targeted. RESULTS: Ablation endpoints were: 1) heart rate increment; 2) Wenckebach cycle length shortening; and 3) atrio-Hisian (AH) interval shortening. A sinus node denervation was obtained in all patients with an increment of 21.6% in the mean heart rate. All patients presented a negative atropine test after ablation. Twenty-eight (77.7%) patients presented immediate sings of atrioventricular node denervation, with a shortening of 15.6% of mean Wenckebach cycle length and 15.9% of the mean AH interval. All heart rate variability parameters showed a significant reduction after 12 months, enduring after 18 months. Thirty (83.3%) patients remained free of events after a mean follow-up of 52.1 ± 35.2 months. One patient (2.77%) presented acute sinus node artery occlusion during ablation with persistent sinus dysfunction and had a pacemaker implantation; 3 (8.3%) other patients evolved with sinus tachycardia, and 4 (11.1%) patients presented syncope recurrence during follow-up, 3 (8.3%) of them requiring a pacemaker implantation. No other tachyarrhythmia was observed. CONCLUSIONS: The anatomically guided septal approach is an effective technique for syncope prevention, promoting long-lasting autonomic changes. No significant proarrhythmia effect has been observed during the long-term follow-up.

Outcomes of a combined vs non-combined endo-epicardial ventricular tachycardia ablation strategy.

BACKGROUND: Direct comparisons of combined (C-ABL) and non-combined (NC-ABL) endo-epicardial ventricular tachycardia (VT) ablation outcomes are scarce. We aimed to investigate the long-term clinical efficacy and safety of these 2 strategies in ischemic heart disease (IHD) and non-ischemic cardiomyopathy (NICM) populations. METHODS: Multicentric observational registry included 316 consecutive patients who underwent catheter ablation for drug-resistant VT between January 2008 and July 2019. Primary and secondary efficacy endpoints were defined as VT-free survival and all-cause death after ablation. Safety outcomes were defined by 30-day mortality and procedure-related complications. RESULTS: Most of the patients were male (85%), with IHD (67%) and mean age of 63 ± 13 years. During a mean follow-up of 3 ± 2 years, 117 (37%) patients had VT recurrence and 73 (23%) died. Multivariate survival analysis identified electrical storm (ES) at presentation, IHD, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class III / IV, and C-ABL as independent predictors of VT recurrence. In 135 patients undergoing repeated procedures, only C-ABL and ES were independent predictors of relapse. The identified independent predictors of mortality were C-ABL, ES, LVEF, age, and NYHA class III / IV. C-ABL survival benefit was only seen in patients with a previous ablation (P for interaction = 0.04). Mortality at 30 days was similar between NC-ABL and C-ABL (4% vs. 2%, respectively, P = 0.777), as was complication rate (10.3% vs. 15.1%, respectively, P = 0.336). CONCLUSION: A combined or sequential endo-epicardial VT ablation strategy was associated with lower VT recurrence and lower all-cause death in IHD and NICM patients undergoing repeated procedures. Both approaches seemed equally safe.

Initial experience on cardiac magnetic resonance-aided VT ablation in South America.

BACKGROUND: Cardiac magnetic resonance (CMR) allowed to precisely identify the substrate in scar-related ventricular tachycardia (VT). New software has been developed to define the 3D scar and corridors to help VT ablation by integrating the scar and electroanatomical mapping (EAM). The objective of this study is to evaluate the results of VT ablation aided by the integration of EAM and CMR software processed scar. METHODS: We selected patients that underwent VT ablation with the integration of EAM and CMR processed using ADAS software and imported to the CARTO system using VTK file format. RESULTS: From 2019 to 2021, eight patients (mean age 63 ± 4.4, 62.5% male; EF 47 ± 12%) underwent CMR-aided VT ablation. Mean procedural time was 281 ± 77 min. There was of 9 ± 4.4 epicardial and 7.9 ± 4.3 endocardial bulls eye segments with at least 2 g of border zone or core scar. In a median follow-up time of 532 days (Q1: 284, Q3: 688), three patients (37.5%) presented VT recurrence, all three underwent a second procedure, with no VT recurrence on the follow-up. No patient died in the follow-up. CONCLUSION: CMR aided is ablation is feasible and effective in patients with scar related VT.

Feasibility of Transatrial Access for Epicardial Ablation: Evaluation of 2 Different Techniques in Swine.

BACKGROUND: The subxiphoid pericardial access is technically difficult and has a considerable rate of complications, thus transatrial access may be an alternative. OBJECTIVES: This study sought to assess the feasibility and safety of this strategy regarding periprocedural period and after 1-week follow-up. METHODS: The investigators performed epicardial mapping through transatrial puncture in 20 swine. Animals were divided into group A, in which aspiration of the sheath was performed to maintain negative pressure after the withdraw of the catheters, and group B, in which a device (Konar-MF VSD Occluder) was delivered to occlude the right atrial appendage perforation. Bleeding was investigated immediately and 1 week after. RESULTS: Access was safe in 19 of 20 animals (95%) with small amount of bleeding (6.4 ± 6 mL). In group A (n = 10), 1 animal presented hemopericardium right after the puncture. In the other 9, epicardial ablation was performed and 60.0 ± 28.0 mL of blood was aspirated without events. After 1 week, fibrin-hemorrhagic pericarditis was identified in 3 animals. In group B (n = 10), reaching the epicardial surface was possible in all animals. An adequate position of the prosthesis was obtained in 90% (9 of 10). One death occurred in the immediate postoperative period, secondary to pneumothorax. After 1 week, postmortem analysis showed absence of pericardial bleeding and a normal-appearing pericardium in the 8 animals with adequate prosthesis position. CONCLUSIONS: Transatrial access allows epicardial mapping and ablation. Sheath removal after negative pressure contributes to achieving acute bleeding control but does not prevent its occurrence. The use of the device prevents bleeding and hemorrhagic pericarditis.

Clinical Features, Genetic Findings, and Risk Stratification in Arrhythmogenic Right Ventricular Cardiomyopathy: Data From a Brazilian Cohort.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC), a rare inherited disease, causes ventricular tachycardia, sudden cardiac death, and heart failure (HF). We investigated ARVC clinical features, genetic findings, natural history, and the occurrence of life-threatening arrhythmic events (LTAEs), HF death, or heart transplantation (HF-death/HTx) to identify risk factors. METHODS: The clinical course of 111 consecutive patients with definite ARVC, predictors of LTAE, HF-death/HTx, and combined events were analyzed in the entire cohort and in a subgroup of 40 patients without sustained ventricular arrhythmia before diagnosis. RESULTS: The 5-year cumulative probability of LTAE was 30% and HF-death/HTx was 10%. Predictors of HF-death/HTx were reduced right ventricle ejection fraction (HR: 0.93; P=0.010), HF symptoms (HR: 4.37; P=0.010), epsilon wave (HR: 4.99; P=0.015), and number of leads with low QRS voltage (HR: 1.28; P=0.001). Each additional lead with low QRS voltage increased the risk of HF-death/HTx by 28%. Predictors of LTAE were prior syncope (HR: 1.81; P=0.040), number of leads with T wave inversion (HR: 1.17; P=0.039), low QRS voltage (HR: 1.12; P=0.021), younger age (HR: 0.97; P=0.006), and prior ventricular arrhythmia/ventricular fibrillation (HR: 2.45; P=0.012). Each additional lead with low QRS voltage increased the risk of LTAE by 17%. In patients without ventricular arrhythmia before clinical diagnosis of ARVC, the number of leads with low QRS voltage (HR: 1.68; P=0.023) was independently associated with HF-death/HTx. CONCLUSIONS: Our study demonstrated the characteristics of a specific cohort with a high prevalence of arrhythmic burden at presentation, male predominance, younger age and HF severe outcomes. Our main results suggest that the presence and extension of low QRS voltage can be a risk predictor for HF-death/HTx in ARVC patients, regardless of the arrhythmic risk. This study can contribute to the global ARVC risk stratification, adding new insights to the international current scientific knowledge.

[Update on ablation of ventricular tachyarrhythmias]. / Update Ablation ventrikulärer Tachyarrhythmien.

Catheter ablation of ventricular tachycardia (VT) is performed with increasing frequency in clinical practice. Whereas the reported success rates of idiopathic VT are high, catheter ablation of VT in patients with structural heart disease with its scar-related re-entry mechanism may remain a challenge especially if deep intramyocardial or epicardial portions exist. The integration of modern cardiac imaging, new functional mapping strategies and catheter technologies allow optimized identification and characterization of the critical arrhythmogenic substrate and hence a more targeted VT ablation. The extent to which these innovations will have the potential to improve VT ablation success rates will be determined by future studies.

Sinus Node Artery Occlusion During Cardiac Denervation Procedures.

Cardioneural ablation is a novel treatment for functional bradycardia. However, the risk of acute complications is still unknown. The aim of this case report is to describe acute occlusion of the sinus node artery after cardiac denervation procedures in 2 patients and to encourage measures to prevent it, such as evaluating the aortic angulation in older patients before the procedure and by monitoring signs of sinus failure during ablation in patients with electroanatomical maps showing a constricted aspect of the right atrium. (Level of Difficulty: Advanced.).

Bipolar radiofrequency ablation of septal ventricular tachycardia in a patient with dilated cardiomyopathy using two 8-mm tip catheters-case report.

Septal ventricular tachycardias exhibit high recurrence rates after radiofrequency ablation, which is mainly attributed to the deep intramyocardial circuits and the inability to create transmural lesions with the conventional unipolar ablation. Bipolar radiofrequency ablation is feasible and it has been reported as a valid technique in these cases, leading to deeper lesion formation, high non-inducibility rates, and acceptable recurrence rates during follow-up. Our goal is to report a successful case of bipolar ablation of a septal ventricular tachycardia using a simple bipolar ablation configuration with two 8-mm tip catheters.

Left Atrial Thrombus and Dense Spontaneous Contrast in Direct Oral Anticoagulant Therapy of Atrial Fibrillation: Insights from a Reference Center. / Trombo Atrial Esquerdo e Contraste Espontâneo Denso no Uso de Anticoagulante Oral de Ação Direta em Fibrilação Atrial: Visão de Centro Referenciado.

BACKGROUND: In the treatment of atrial fibrillation (AF), the most frequently sustained arrhythmia, with catheter ablation (CA) or electrical cardioversion (ECV), the periprocedural period is one of the most critical phases. Currently, the use of new direct action oral anticoagulants (DOAC) is increasingly frequent; however, in the real world, there are still few data on studies on the thrombus incidence in the left atrium (TrLA) or dense spontaneous contrast (DSC) on transesophageal echocardiogram (TEE). OBJECTIVE: To evaluate the prevalence of events and association with risk factors in patients using DOACs. Primary objective: to analyze the prevalence of thrombus in the LA by TEE in patients using DOAC undergoing ECV/CA. Second, evaluate the association of comorbidities with the presence of thrombi and DSC. METHODS: Retrospective cohort, single-center study with patients followed at the Arrhythmia Outpatient Unit (InCor-HCFMUSP). Patients indicated for procedures and using DOACs were selected, and their clinical/echocardiographic data were analyzed. A significance level of 5% was considered. RESULTS: 354 patients were included, a total of 400 procedures, from March 2012-March 2018. Thrombus in the LA was found in 11 patients (2.8%), associated with advanced age (p=0.007) and higher CHA2DS2-VASc (p<0.001) score. DSC in the LA before TEE was found in 29 patients (7.3%), with lower LVEF (p<0.038) and greater LA dimension (p<0.0001). CONCLUSION: The incidence of LA thrombus and DSC in patients using DOC in the context of AF ECV/CA, although small, is not negligible. Patients with higher CHA2DS2-VASc scores, especially older and with larger LA diameter, are more prone to these echocardiographic findings.

FUNDAMENTO: No tratamento da fibrilação atrial (FA), a arritmia sustentada mais frequente, com ablação por cateter (ABL) ou cardioversão elétrica (CVE), o período periprocedimento é uma das fases mais críticas. Atualmente, o uso de novos anticoagulantes orais de ação direta (DOAC) é cada vez mais frequente, no entanto, no mundo real, ainda existem poucos dados de estudos sobre a incidência de trombo no átrio esquerdo (TrAE) ou contraste espontâneo denso (CE) no ecocardiograma transesofágico (ETE). OBJETIVO: Analisar a prevalência de TrAE, por ETE, em pacientes em uso de DOAC submetidos à CVE/ABL. Secundariamente: avaliar a associação de comorbidades com a presença de trombos e CE. MÉTODOS: Estudo de coorte retrospectivo, unicêntrico, com pacientes do Ambulatório de Arritmia (InCor-HCFMUSP). Foram selecionados e analisados dados clínicos e ecocardiográficos no prontuário da instituição de pacientes com indicação de procedimentos e em uso de DOACs. Considerado um nível de significância de 5%. RESULTADOS: Foram incluídos 354 pacientes, no total de 400 procedimentos, de março de 2012-março de 2018. TrAE foi encontrado em 11 pacientes (2,8%), associado com idade avançada (p=0,007) e CHA2DS2-VASc maior (p<0,001). Foi encontrado CE no AE no procedimento antes da ETE em 29 pacientes (7,3%), com menor FEVE (p <0,038) e maior dimensão do AE (p <0,0001). CONCLUSÃO: A incidência de TrAE e CE em pacientes em uso de DOAC no contexto de CVE/ABL de FA, embora pequena, não é desprezível. Pacientes com escore CHA2DS2-VASc maior, principalmente mais idosos e com diâmetro do AE maior, são mais propensos a esses achados ecocardiográficos.

Spectral characteristics of atrial electrograms in sinus rhythm correlates with sites of ganglionated plexuses in patients with paroxysmal atrial fibrillation.

AIMS: To verify whether spectral components of atrial electrograms (AE) during sinus rhythm (SR) correlate with cardiac ganglionated plexus (GP) sites. METHODS AND RESULTS: Thirteen patients undergoing atrial fibrillation (AF) ablation were prospectively enrolled. Prior to radio frequency application, endocardial AE were recorded with a sequential point-by-point approach. Electrical stimuli were delivered at 20 Hz, amplitude 100 V, and pulse width of 4 ms. A vagal response was defined as a high-frequency stimulation (HFS) evoked atrioventricular block or a prolongation of RR interval. Spectral analysis was performed on single AE during SR, sampling rate of 1000 Hz, Hanning window. Overall, 1488 SR electrograms were analysed from 186 different left atrium sites, 129 of them corresponding to negative vagal response sites, and 57 to positive response sites. The electrogram duration and the number of deflections were similar in positive and negative response sites. Spectral power density of sites with vagal response was lower between 26 and 83 Hz and higher between 107 and 200 Hz compared with negative response sites. The area between 120 and 170 Hz normalized to the total spectrum area was tested as a diagnostic parameter. Receiver operating characteristic curve analysis demonstrated that an area 120-170/area(total) value >0.14 identified vagal sites with 70.9% sensitivity and 72.1% specificity. CONCLUSION: Spectral analysis of AE during SR in sites that correspond to the anatomical location of the GP is feasible and may be a simpler method of mapping the cardiac autonomic nervous system, compared with the HFS technique.