Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC-endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society.

Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.

Lack of Anticoagulant Use in Patients with Atrial Fibrillation and Increased Risk of Thromboembolic Events According to Sex: Insights from a Multicentric Brazilian Study. / Falta de Uso de Anticoagulantes em Pacientes com Fibrilação Atrial e Risco Aumentado de Eventos Tromboembólicos de Acordo com o Sexo: Insights de um Estudo Multicêntrico Brasileiro.

BACKGROUND: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, and its presentation differs according to age and sex. Recent studies have revealed differences in AF among various demographic groups, including the Latin American population. OBJECTIVES: To better understand potential disparities in AF prevalence and treatment strategies in the Brazilian population through data from a large multicentric prospective registry. METHODS: The Rede D'Or AF registry is a multicenter prospective observational study including patients aged ≥ 18 years with AF who were seen in the emergency department of 32 tertiary hospitals in Brazil. Patients were characterized according to sex and other baseline characteristics and were classified according to previous anticoagulant use. The lack of anticoagulant use in patients with previous indications was analyzed. Statistical significance was set at 5%. RESULTS: The study data were from a total of 1955 patients enrolled. Male sex was more prevalent, and men were younger than the women. Due to an increased prevalence of previous AF episode and a higher CHA2DS2-VASc score, more women had indications for anticoagulant therapy; however, a significant proportion was not receiving this treatment. From 29 in-hospital deaths, 15 patients had previous indication for anticoagulation, but only 3 were using anticoagulants. CONCLUSION: This study revealed sex-related differences in the Brazilian population of patients with AF that are consistent with trends in high-income countries. The promotion of better implementation of anticoagulant and antithrombotic therapies to reduce the risk of death and thromboembolic events among women with AF in Brazil is crucial.

FUNDAMENTO: A fibrilação atrial (FA) é a arritmia cardíaca mais prevalente e sua apresentação difere de acordo com a idade e o sexo. Estudos recentes revelaram diferenças na FA entre vários grupos demográficos, incluindo a população latino-americana. OBJETIVOS: Melhor compreender as possíveis disparidades na prevalência da FA e nas estratégias de tratamento na população brasileira por meio de dados de um registro prospectivo multicêntrico de grande escala. MÉTODOS: O registro de FA da Rede D'Or é um estudo observacional prospectivo multicêntrico que incluiu pacientes com idade ≥ 18 anos com FA atendidos no pronto-socorro de 32 hospitais terciários no Brasil. Os pacientes foram caracterizados de acordo com o sexo e outras características basais e classificados de acordo com o uso prévio de anticoagulantes. Foi analisada a falta de uso de anticoagulantes em pacientes com indicações prévias. A significância estatística foi estabelecida em 5%. RESULTADOS: Os dados do estudo foram provenientes de um total de 1.955 pacientes inscritos. O sexo masculino foi mais prevalente e os homens eram mais jovens que as mulheres. Devido ao aumento da prevalência de episódios anteriores de FA e a um escore CHA2DS2-VASc mais elevado, mais mulheres tiveram indicação de terapia anticoagulante; no entanto, uma proporção significativa não estava recebendo esse tratamento. Dos 29 óbitos intra-hospitalares, 15 pacientes tinham indicação prévia para anticoagulação, mas apenas 3 estavam em uso de anticoagulantes. CONCLUSÃO: O presente estudo revelou diferenças relacionadas ao sexo na população brasileira de pacientes com FA que são consistentes com tendências em países de alta renda. A promoção de uma melhor implementação de terapias anticoagulantes e antitrombóticas para reduzir o risco de óbito e eventos tromboembólicos entre mulheres com FA no Brasil é crucial.

Falta de Uso de Anticoagulantes em Pacientes com Fibrilação Atrial e Risco Aumentado de Eventos Tromboembólicos de Acordo com o Sexo: Insights de um Estudo Multicêntrico Brasileiro / Lack of Anticoagulant Use in Patients with Atrial Fibrillation and Increased Risk of Thromboembolic Events According to Sex: Insights from a Multicentric Brazilian Study

Resumo Fundamento A fibrilação atrial (FA) é a arritmia cardíaca mais prevalente e sua apresentação difere de acordo com a idade e o sexo. Estudos recentes revelaram diferenças na FA entre vários grupos demográficos, incluindo a população latino-americana. Objetivos Melhor compreender as possíveis disparidades na prevalência da FA e nas estratégias de tratamento na população brasileira por meio de dados de um registro prospectivo multicêntrico de grande escala. Métodos O registro de FA da Rede D'Or é um estudo observacional prospectivo multicêntrico que incluiu pacientes com idade ≥ 18 anos com FA atendidos no pronto-socorro de 32 hospitais terciários no Brasil. Os pacientes foram caracterizados de acordo com o sexo e outras características basais e classificados de acordo com o uso prévio de anticoagulantes. Foi analisada a falta de uso de anticoagulantes em pacientes com indicações prévias. A significância estatística foi estabelecida em 5%. Resultados Os dados do estudo foram provenientes de um total de 1.955 pacientes inscritos. O sexo masculino foi mais prevalente e os homens eram mais jovens que as mulheres. Devido ao aumento da prevalência de episódios anteriores de FA e a um escore CHA2DS2-VASc mais elevado, mais mulheres tiveram indicação de terapia anticoagulante; no entanto, uma proporção significativa não estava recebendo esse tratamento. Dos 29 óbitos intra-hospitalares, 15 pacientes tinham indicação prévia para anticoagulação, mas apenas 3 estavam em uso de anticoagulantes. Conclusão O presente estudo revelou diferenças relacionadas ao sexo na população brasileira de pacientes com FA que são consistentes com tendências em países de alta renda. A promoção de uma melhor implementação de terapias anticoagulantes e antitrombóticas para reduzir o risco de óbito e eventos tromboembólicos entre mulheres com FA no Brasil é crucial.

Abstract Background Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, and its presentation differs according to age and sex. Recent studies have revealed differences in AF among various demographic groups, including the Latin American population. Objectives To better understand potential disparities in AF prevalence and treatment strategies in the Brazilian population through data from a large multicentric prospective registry. Methods The Rede D'Or AF registry is a multicenter prospective observational study including patients aged ≥ 18 years with AF who were seen in the emergency department of 32 tertiary hospitals in Brazil. Patients were characterized according to sex and other baseline characteristics and were classified according to previous anticoagulant use. The lack of anticoagulant use in patients with previous indications was analyzed. Statistical significance was set at 5%. Results The study data were from a total of 1955 patients enrolled. Male sex was more prevalent, and men were younger than the women. Due to an increased prevalence of previous AF episode and a higher CHA2DS2-VASc score, more women had indications for anticoagulant therapy; however, a significant proportion was not receiving this treatment. From 29 in-hospital deaths, 15 patients had previous indication for anticoagulation, but only 3 were using anticoagulants. Conclusion This study revealed sex-related differences in the Brazilian population of patients with AF that are consistent with trends in high-income countries. The promotion of better implementation of anticoagulant and antithrombotic therapies to reduce the risk of death and thromboembolic events among women with AF in Brazil is crucial.

Impact of atrial fibrillation ablation on left ventricular filling pressure and left atrial remodeling.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is associated with new-onset atrial fibrillation (AF), and the estimation of elevated LV filling pressures by E/e' ratio is related to worse outcomes in patients with AF. However, it is unknown if restoring sinus rhythm reverses this process. OBJECTIVE: To evaluate the impact of AF ablation on estimated LV filling pressure. METHODS: A total of 141 patients underwent radiofrequency (RF) ablation to treat drug-refractory AF. Transthoracic echocardiography was performed 30 days before and 12 months after ablation. LV functional parameters, left atrial volume index (LAVind), and transmitral pulsed and mitral annulus tissue Doppler (e' and E/e') were assessed. Paroxysmal AF was present in 18 patients, persistent AF was present in 102 patients, and long-standing persistent AF in 21 patients. Follow-up included electrocardiographic examination and 24-h Holter monitoring at 3, 6, and 12 months after ablation. RESULTS: One hundred seventeen patients (82.9%) were free of AF during the follow-up (average, 18 ± 5 months). LAVind reduced in the successful group (30.2 mL/m(2) ± 10.6 mL/m(2) to 22.6 mL/m(2) ± 1.1 mL/m(2), p < 0.001) compared to the non-successful group (37.7 mL/m(2) ± 14.3 mL/m(2) to 37.5 mL/m(2) ± 14.5 mL/m(2), p = ns). Improvement of LV filling pressure assessed by a reduction in the E/e' ratio was observed only after successful ablation (11.5 ± 4.5 vs. 7.1 ± 3.7, p < 0.001) but not in patients with recurrent AF (12.7 ± 4.4 vs. 12 ± 3.3, p = ns). The success rate was lower in the long-standing persistent AF patient group (57% vs. 87%, p = 0.001). CONCLUSION: Successful AF ablation is associated with LA reverse remodeling and an improvement in LV filling pressure.

Estimulação cardíaca provisória com eletrodo de marcapasso definitivo: Uma alternativa segura? / Temporary cardiac pacing using permanent pacing leads: a safe alternative?

Introdução: A estimulação cardíaca temporária eventualmente é necessária por mais de 15 dias. Este contexto clínico está associado a complicações como o deslocamento de eletrodo e perfuração cardíaca, havendo a necessidade de reposicionamento ou troca de eletrodo. Além disto, os eletrodos e geradores convencionais para estimulação cardíaca temporária impõem ao paciente a restrição ao leito e suas consequências. Objetivo: avaliar um método previamente estudado de estimulação temporária relacionado à menor incidência de complicações e que permite a deambulação do paciente. Método: foram estudados 24 pacientes, entre janeiro de 2015 e dezembro de 2017, submetidos a implante de marcapasso provisório com o uso de eletrodo de fixação ativa. Resultados: a média de idade foi de 68,9 anos, e predominantemente do sexo masculino. O tempo médio de uso do marcapasso (MP) provisório foi de 9,7 dias, variando de dois a 28 dias. Durante um tempo total de 233 pacientes/ dia, não houve deslocamento de eletrodos, falhas de estimulação ou necessidade de revisão do sistema. Conclusão: a estimulação provisória utilizando eletrodos de MP definitivo de fixação ativa foi segura e impactou positivamente na qualidade de vida dos pacientes

Introduction: Temporary cardiac pacing is eventually required for more than 15 days. This clinical context is associated with complications such as electrode displacement and cardiac perforation, requiring repositioning or electrode replacement. In addition, conventional electrodes and generators for temporary cardiac stimulation force patients to stay in bed with its consequences. Objective: to evaluate a previously studied method of temporary stimulation related to a lower incidence of complications which allows patient to walk. Method: 24 patients were studied between January 2015 and December 2017, who underwent temporary PM implantation with the use of an active fixation electrode. Results: mean age was 68.9 years, and patients were predominantly male. The mean time of use of the temporary pacemaker (PM) was 9.7 days, ranging from two to 28 days. During a total time of 233 patients/ day, there was no electrode displacement, no stimulation failures or a need for system revision. Conclusion: Temporary stimulation using definitive PM fixation active electrodes was safe and had a positive impact on patients' quality of life

Simultaneous epicardial and endocardial substrate mapping and radiofrequency catheter ablation as first-line treatment for ventricular tachycardia and frequent ICD shocks in chronic chagasic cardiomyopathy.

BACKGROUND AND AIMS: Slow conduction scarred areas are related with ventricular tachycardia (VT) arrhythmogenesis in nonischemic cardiomyopathy. The purpose of this study was to characterize the substrate in both epicardial and endocardial surfaces of the left ventricle and to evaluate the effectiveness of substrate mapping and ablation for VT in Chagas cardiomyopathy. METHODS AND RESULTS: Seventeen patients were evaluated prospectively using a simultaneous epicardial and endocardial electroanatomical substrate mapping and ablation. With a mean of 201 +/- 94 epicardial and 169 +/- 77 endocardial points, the epicardial voltage areas < or =0.5 mV were 56.8 +/- 40.6 (range 4.4 to 154.8 cm(2)) as compared to 22.5 +/- 15.8 cm(2) (range 5.4 to 61.0 cm(2); p = 0.004) in the endocardium. Analyzing the epicardial surface, there was a strong correlation between the bipolar voltage electrograms and the electrogram duration at the epicardium during sinus rhythm (r = 0.897, p < 0.0001). Acute success was obtained in 83.3% of patients with no serious complications. At the end of follow-up from 14 patients with acute success, 11 (78.6%) had been event-free based on implantable cardioverter defibrillator (ICD) interrogation logs. CONCLUSION: Chronic Chagas cardiomyopathy patients have larger epicardial as compared to endocardial substrate areas. Combined epicardial endocardial substrate mapping and ablation during sinus rhythm proves effective in preventing VT recurrences and appropriate ICD therapies.

Impact of Atrial Fibrillation Ablation on Left Ventricular Filling Pressure and Left Atrial Remodeling / Impacto da Ablação da Fibrilação Atrial na Pressão de Enchimento Ventricular Esquerdo e Remodelamento Atrial Esquerdo

Background: Left ventricular (LV) diastolic dysfunction is associated with new-onset atrial fibrillation (AF), and the estimation of elevated LV filling pressures by E/e' ratio is related to worse outcomes in patients with AF. However, it is unknown if restoring sinus rhythm reverses this process. Objective: To evaluate the impact of AF ablation on estimated LV filling pressure. Methods: A total of 141 patients underwent radiofrequency (RF) ablation to treat drug-refractory AF. Transthoracic echocardiography was performed 30 days before and 12 months after ablation. LV functional parameters, left atrial volume index (LAVind), and transmitral pulsed and mitral annulus tissue Doppler (e' and E/e') were assessed. Paroxysmal AF was present in 18 patients, persistent AF was present in 102 patients, and long-standing persistent AF in 21 patients. Follow-up included electrocardiographic examination and 24-h Holter monitoring at 3, 6, and 12 months after ablation. Results: One hundred seventeen patients (82.9%) were free of AF during the follow-up (average, 18 ± 5 months). LAVind reduced in the successful group (30.2 mL/m2 ± 10.6 mL/m2 to 22.6 mL/m2 ± 1.1 mL/m2, p < 0.001) compared to the non-successful group (37.7 mL/m2 ± 14.3 mL/m2 to 37.5 mL/m2 ± 14.5 mL/m2, p = ns). Improvement of LV filling pressure assessed by a reduction in the E/e' ratio was observed only after successful ablation (11.5 ± 4.5 vs. 7.1 ± 3.7, p < 0.001) but not in patients with recurrent AF (12.7 ± 4.4 vs. 12 ± 3.3, p = ns). The success rate was lower in the long-standing persistent AF patient group (57% vs. 87%, p = 0.001). Conclusion: Successful AF ablation is associated with LA reverse remodeling and an improvement in LV filling pressure. .

Fundamento: A disfunção diastólica do ventrículo esquerdo (VE) está associada a novos episódios de fibrilação atrial (FA), e a estimativa das pressões de enchimento do VE através da razão E/e' está relacionada a um pior prognóstico em pacientes com FA. Entretanto, não se sabe se a restauração do ritmo sinusal pode reverter este processo. Objetivo: Avaliar o impacto da ablação da FA na estimativa da pressão de enchimento do VE. Métodos: Um total de 141 pacientes foi submetido à ablação por radiofrequência (RF) para o tratamento da FA refratária a drogas. Foi realizado ecocardiograma transtorácico 30 dias antes e 12 meses após a ablação. Foram avaliados os parâmetros funcionais do VE, volume do átrio esquerdo indexado (VAEi) e Doppler transmitral pulsado e Doppler tecidual do anel mitral (e' e E/e'). Dezoito pacientes apresentavam FA paroxística, 102 persistente e 21 pacientes FA persistente de longa duração. O acompanhamento incluiu ECG e monitoramento pelo sistema Holter 24h, 3, 6 e 12 meses após a ablação. Resultados: Cento e dezessete pacientes (82,9%) não apresentaram FA durante o acompanhamento (média de 18 meses ± 5 meses). O VAEi apresentou redução significativa no grupo com sucesso (30,2 mL/m2 ± 10,6 mL/m2 para 22,6 mL/m2 ± 1,1 mL/m2, p < 0,001) em comparação ao grupo sem sucesso (37,7 mL/m2 ± 14,3 mL/m2 para 37,5 mL/m2 ± 14,5 mL/m2, p = ns). A melhora da estimativa da pressão de enchimento do VE, avaliada através da redução na razão E/e', foi observada apenas após ablação com sucesso (11,5 ± 4,5 vs. 7,1 ± 3,7, p < 0,001), não sendo observada em pacientes com FA recorrente (12,7 ± 4,4 vs. 12 ± 3,3, p = ns). A taxa de ...

Mapeamento endocárdico e epicárdico para a ablação do substrato arritmogênico de pacientes com cardiomiopatia chagásica e taquicardia ventricular refratária ao tratamento farmacológico / Epicardial and endocardial mapping for arrhythmogenic substrate catheter ablation in patients with Chagas cardiomyopathy and refractory ventricular tachycardia

Objetivo: Avaliar a segurança e a eficácia da ablação por cateter de substrato endocárdico e epicárdico de pacientes com cardiomiopatia chagásica e taquicardia ventricular refratária ao tratamento farmacológico. Método: 34 pacientes foram incluídos no estudo. Durante o ritmo sinusal, foi realizado o mapeamento eletroanatômico (CARTO-XP) endoepicárdico de voltagem utilizando critérios padronizados (cicatriz < 1,5 mV). A estimulação programada foi usada para a indução de taquicardia ventricular e as arritmias estáveis foram submetidas a mapeamento de ativação e encarrilhamento. Nas arritmias instáveis, a saída do circuito foi definida pela estimulação e o mapeamento (pace mapping) na borda da cicatriz. A ablação foi realizada após definição do circuito e do substrato pelas técnicas descritas. Resultados: Foram realizados 34 procedimentos, com sucesso imediato de 79 por cento. Foi encontrada cicatriz epicárdica em 88 por cento dos pacientes. Não houve tamponamento cardíaco ou qualquer outra complicação grave relacionada ao procedimento. No seguimento de 12 meses, a taxa de recorrência foi de 15 por cento sem indução de taquicardia ventricular e três pacientes morreram devido a progressão da falência cardíaca. Conclusão: A ablação endocárdica e epicárdica foi segura e efetiva para o controle da taquicardia ventricular em pacientes com doença de Chagas.

Objective: Assess the safety and efficacy of endocardial and epicardial substrate catheter mapping and ablation of refractory ventricular tachycardia in patients with Chagas Disease. Patients and Methods: 34 patients were included in this study. During sinus rhythm, patients underwent epicardial and endocardial voltage electroanatomic mapping (CARTO) using standardized criteria (scar < 1.5 mV). Programmed ventricular stimulation was used to induce ventricular tachycardia and stable rhythms were submitted to activation and entrainment mapping. Exit of unstable arrhythmias was defined by stimulation and mapping (pace-mapping) in the scar border zone. Ablation was performed after definition of the circuit and substrate by the reported techniques. Results: 34 procedures were performed and immediate success was achieved in 79 percent. Epicardial scar was observed in 88 percent. There was no cardiac tamponade or major complications related to the procedure. During the 12 month follow-up the recurrence rate was 15 percent in the patients without ventricular tachycardia induction and three patients died due to progressive heart failure. Conclusion: In the study population, catheter ablation using epicardial and endocardial approach was safe and effective in ventricular tachycardia control in chagasic patients.