RESUMEN
AIMS: Radiofrequency catheter ablation of typical atrial flutter is one of the most frequent indications for catheter ablation in electrophysiology laboratories today. Clinical utility of electroanatomic mapping systems on treatment results and resource utilization compared with conventional ablation has not been systematically investigated in a prospective multicenter study. METHODS AND RESULTS: In this prospective, randomized multicenter study, the results of catheter ablation to cure typical atrial flutter using conventional ablation strategy were compared with electroanatomically guided mapping and ablation (Carto). Primary endpoints of the study were procedure duration and fluoroscopy exposure time, secondary endpoints were acute success rate, recurrence rate, and resource utilization. A total of 210 patients (169 men, 41 women, mean age 63 +/- 10 years) with documented typical atrial flutter were included in the study. Acute ablation success, that is, demonstration of bidirectional isthmus block, was achieved in 99 of 105 patients (94%) in the electroanatomically guided ablation group and in 102 of 105 patients (97%) in the conventional ablation group (P > 0.05). Total procedure duration was comparable between both study groups (99 +/- 57 minutes vs 88 +/- 54 minutes, P > 0.05). Fluoroscopy exposure time was significantly shorter in the electroanatomically guided ablation group (7.7 +/- 7.3 minutes vs 14.8 +/- 11.9 minutes; P < 0.05). Total recurrence rate of typical atrial flutter at 6 months of follow-up was comparable between the 2 groups (respectively for the CARTO and conventional group 6.6% vs 5.7%, P > 0.05). The material costs per procedure in the electroanatomically guided and conventional groups (NaviStar DS vs Celsius DS) was 3035 euro (USD 3,870) and 2133 euro (USD 2,720), respectively. CONCLUSIONS: This multicenter study documented that cavotricuspid isthmus ablation to cure typical atrial flutter was highly effective and safe, both in the conventional and the electroanatomically guided ablation group. The use of electroanatomical mapping system significantly reduced the fluoroscopy exposure time by almost 50%, however, at the expense of increased cost of the procedure.
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Aleteo Atrial/cirugía , Ablación por Catéter/estadística & datos numéricos , Recursos en Salud/estadística & datos numéricos , Magnetismo , Radiografía Intervencional/estadística & datos numéricos , Cirugía Asistida por Computador , Anciano , Aleteo Atrial/diagnóstico , Aleteo Atrial/diagnóstico por imagen , Aleteo Atrial/economía , Ablación por Catéter/efectos adversos , Ablación por Catéter/economía , Ablación por Catéter/métodos , Análisis Costo-Beneficio , Europa (Continente) , Femenino , Fluoroscopía/estadística & datos numéricos , Costos de la Atención en Salud , Recursos en Salud/economía , Humanos , Magnetismo/economía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Dosis de Radiación , Radiografía Intervencional/efectos adversos , Radiografía Intervencional/economía , Recurrencia , Cirugía Asistida por Computador/economía , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Predictors for recurrence of syncope are lacking in patients with vasovagal syncope. The aim of this study was to identify risk factors for recurrence of syncope and develop a simple prognostic risk score of clinical value. METHODS: Two hundred seventy-six patients with a history of vasovagal syncope were prospectively followed for 2 years. Diagnosis of vasovagal syncope was based on clinical history and negative standard work-up. Inclusion in the study was independent from the result of the head-up tilt test, which was performed in all cases. Risk factors for syncope recurrence were evaluated by the Cox proportional hazards regression model and implemented in a risk score, which was validated with the log-rank test and an internal cross-validation. RESULTS: The Cox-regression analysis identified the number of previous syncopal events, history of bronchial asthma, and female gender as predictors for syncope recurrence (all P < 0.05). In contrast, head-up tilt test response had no predictive value (P = 0.881). Developing a risk score, study patients were identified as having high (recurrence rate during 2 years of follow-up: 37.2%), intermediate (24.8%), and low (6.5%) risk for syncope recurrence (receiver operating characteristic [ROC] of score 0.83, P < 0.01; Log-rank test for event-free survival, P < 0.005). CONCLUSIONS: In patients with vasovagal syncope, risk of recurrence can be stratified and is predictable based on a simple risk score.
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Síncope Vasovagal/diagnóstico , Adulto , Anciano , Asma/complicaciones , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Curva ROC , Recurrencia , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Síncope Vasovagal/etiología , Síncope Vasovagal/terapia , Pruebas de Mesa Inclinada , Factores de TiempoRESUMEN
BACKGROUND: Insights gained from noncontact mapping of ventricular tachycardia (VT) have not been systematically applied to contact maps. This study sought to unify both techniques for an individualized approach to the patient with multiple ischemic VTs irrespective of cycle length. METHODS AND RESULTS: For 12 consecutive patients with chronic myocardial infarction and recurrent VT, bipolar contact maps were acquired during sinus or paced rhythm. Additional noncontact maps were obtained during 48 induced VTs (cycle length 192 to 579 ms). Endocardial exit sites were superimposed on contact maps and verified by pace-mapping. Radiofrequency lesions were extended for critical borders defined by multiple neighboring exits and followed the isovoltage contour line of contact maps. Nine critical borders were identified in 8 patients and constituted the substrate for 31 VTs. The voltage at exit sites was 0.8 mV (range 0.1 to 2.3). Noncontact maps revealed 23+/-18% of isthmus conduction. Thirty-seven (77%) of all and 83% of clinically documented VTs were rendered noninducible irrespective of cycle length by application of 27 radiofrequency lesions (range 18 to 56). Spontaneous transitions between distinct VTs along critical borders were demonstrated in 4 patients. Pace-mapping reproduced the QRS morphology of 81% of VTs and was associated with successful ablation (P<0.01). Noninducibility of any sustained VT was reached for 8 (67%) patients. During 15 months (range 5 to 28) of follow-up, 8 patients remained without recurrence, and VT episodes were reduced in the other 4 patients (P<0.01). VT cycle length was not predictive for acute or long-term success. CONCLUSIONS: The combined approach of contact and noncontact mapping effectively defines critical borders as the substrate of multiple VTs without limitation for unstable VTs.
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Ablación por Catéter , Electrocardiografía/métodos , Infarto del Miocardio , Taquicardia Ventricular/terapia , Anciano , Mapeo del Potencial de Superficie Corporal/métodos , Estimulación Cardíaca Artificial , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Resultado del TratamientoRESUMEN
OBJECTIVE: Catheter ablation of ventricular tachycardia (VT) after myocardial infarction (MI) can be complex and time-consuming. We only targeted the previously documented VTs and those with similar or longer cycle lengths. METHODS: 30 patients with VTs after MI were included in the study. Voltage mapping was performed using an electro-anatomic mapping system (CARTOT). Stable VTs were mapped during tachycardia and unstable VTs during sinus rhythm. RESULTS: Clinical VTs were stable in 16 (53%) and unstable in 14 (47%) patients, and ablation was successful in 11 (69%) and 9 patients (64%), respectively (p = 0.42). During follow-up (14 +/- 6 months), 4 patients (25%) treated for stable and 6 (43%) for unstable VTs had recurrences (p = 0.82); ablation was successful in none and 2 (33%) of them, respectively. Non-target VTs were inducible in 11 (55%) of 20 patients after successful ablation and non-inducible in 9 (45%). During follow-up, inducibility of non-target VTs did not predict recurrences (9 vs. 11%, p = 0.88). CONCLUSIONS: Catheter ablation of VTs after MI can be successfully performed. Acute success rates seem to be similar for stable and unstable VTs. VTs faster than those documented clinically exert a minor effect on VT recurrences during follow-up.
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Ablación por Catéter/métodos , Taquicardia Ventricular/terapia , Anciano , Ablación por Catéter/efectos adversos , Técnicas Electrofisiológicas Cardíacas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Taquicardia Ventricular/diagnóstico , Resultado del TratamientoRESUMEN
BACKGROUND: External cardioversion is effective to terminate persistent atrial flutter. Biphasic shocks have been shown to be superior to monophasic shocks for ventricular defibrillation and atrial fibrillation cardioversion. The purpose of this trial was to compare the efficacy of rectilinear biphasic versus standard damped sine wave monophasic shocks in symptomatic patients with typical atrial flutter. METHODS: 135 consecutive patients were screened, 95 (70 males, mean age 62 +/- 13 years) were included. Patients were randomly assigned to a monophasic or biphasic cardioversion protocol. Forty-seven patients randomized to the monophasic protocol received sequential shocks of 100, 150, 200, 300 and 360 J. Forty-eight patients with the biphasic protocol received 50, 75, 100, 150 or 200 J. RESULTS: First-shock efficacy with 50-Joule, biphasic shocks (23/48 patients, 48%) was significantly greater than with the 100-Joule, monophasic waveform (13/47 patients, 28%, p = 0.04). The cumulative second-shock efficacy with the 50- and 75-Joule, biphasic waveform (39/48 patients, 81%) was significantly greater than with the 100- and 150-Joule, monophasic waveform (25/47 patients, 53%, p < 0.05). The cumulative efficacy for the higher energy levels showed naturally no significant difference between the two groups. The amount of the mean delivered energy was significantly lower in the biphasic group (76 +/- 39 J) compared to the monophasic one (177 +/- 78 J, p < 0.05). CONCLUSIONS: For transthoracic cardioversion of typical atrial flutter, biphasic shocks have greater efficacy and the mean delivered current is lower than for monophasic shocks. Therefore, biphasic cardioversion with lower starting energies should be recommended.
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Aleteo Atrial/terapia , Cardioversión Eléctrica/instrumentación , Anciano , Cardioversión Eléctrica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Atrial myocytes that lack t-tubules appear to have two functionally separate sarcoplasmic Ca2+ stores: a peripheral store associated with plasmalemmal L-type calcium channels and a central store with no apparent proximity to L-type calcium channels. Here we describe a set of calcium sparks and waves that are triggered by puffing of pressurized (200-400 mmH2O) bathing solutions onto resting isolated rat atrial myocytes. Puffing of pressurized (200 mmH2O) solutions, identical to those bathing the myocytes from distances of approximately 150 microm onto the surface of a single myocyte triggered or enhanced spontaneously occurring peripheral sparks by five- to six-fold and central Ca2+ sparks by two- to three-fold, without altering the unitary spark properties. Exposure to higher pressure flows (400 mmH2O) often triggered longitudinally spreading Ca2+ waves. These results suggest that pressurized flows may directly modulate Ca2+ signaling of atrial myocytes by activating the intracellular Ca2+ release sites.
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Señalización del Calcio , Calcio/metabolismo , Atrios Cardíacos/metabolismo , Células Musculares/metabolismo , Animales , Función Atrial , Membrana Celular , Células Cultivadas , Atrios Cardíacos/citología , Procesamiento de Imagen Asistido por Computador , Masculino , Microscopía Confocal , Presión , Ratas , Ratas WistarRESUMEN
BACKGROUND: Neutrophils and monocytes are centrally linked to vascular inflammatory disease, and leukocyte-derived myeloperoxidase (MPO) has emerged as an important mechanistic participant in impaired vasomotor function. MPO binds to and transcytoses endothelial cells in a glycosaminoglycan-dependent manner, and MPO binding to the vessel wall is a prerequisite for MPO-dependent oxidation of endothelium-derived nitric oxide (NO) and impairment of endothelial function in animal models. In the present study, we investigated whether heparin mobilizes MPO from vascular compartments in humans and defined whether this translates into increased vascular NO bioavailability and function. METHODS AND RESULTS: Plasma MPO levels before and after heparin administration were assessed by ELISA in 109 patients undergoing coronary angiography. Whereas baseline plasma MPO levels did not differ between patients with or without angiographically detectable coronary artery disease (CAD), the increase in MPO plasma content on bolus heparin administration was higher in patients with CAD (P=0.01). Heparin treatment also improved endothelial NO bioavailability, as evidenced by flow-mediated dilation (P<0.01) and by acetylcholine-induced changes in forearm blood flow (P<0.01). The extent of heparin-induced MPO release was correlated with improvement in endothelial function (r=0.69, P<0.01). Moreover, and consistent with this tenet, ex vivo heparin treatment of extracellular matrix proteins, cultured endothelial cells, and saphenous vein graft specimens from CAD patients decreased MPO burden. CONCLUSIONS: Mobilization of vessel-associated MPO may represent an important mechanism by which heparins exert antiinflammatory effects and increase vascular NO bioavailability. These data add to the growing body of evidence for a causal role of MPO in compromised vascular NO signaling in humans.
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Antiinflamatorios/farmacología , Endotelio Vascular/metabolismo , Heparina/farmacología , Óxido Nítrico/metabolismo , Peroxidasa/metabolismo , Anciano , Disponibilidad Biológica , Vasos Sanguíneos/efectos de los fármacos , Vasos Sanguíneos/enzimología , Estudios de Casos y Controles , Células Cultivadas , Células Endoteliales/efectos de los fármacos , Células Endoteliales/enzimología , Endotelio Vascular/efectos de los fármacos , Femenino , Humanos , Técnicas In Vitro , Masculino , Persona de Mediana Edad , Elastasa Pancreática/sangre , Peroxidasa/sangreRESUMEN
BACKGROUND: The accuracy of three-dimensional mapping systems is affected by cardiac contraction and respiration. OBJECTIVE: The study sought to determine relative motion of cardiac and thoracic structures to assess positional errors and guide the choice of an optimized spatial reference. METHODS: Motion of catheters placed at the coronary sinus (CS), pulmonary vein (PV) ostia, left atrial (LA) isthmus and roof, cavotricuspid isthmus (CTI), and right atrial appendage (RAA) were recorded for 30 patients using Ensite-NavX. The right subclavian vein, left brachiocephalic vein, azygos vein, pulmonary arteries, and a static reference were included. The displacement from a mean position was calculated for each pair of sites. Respiration effects were assessed by the shift of the motion curve during in- and expiration phases. RESULTS: The PVs showed a mean interpair displacement of 4.1 +/- 0.2 mm and a shift of 5.0 +/- 0.5 mm. Proximal CS references for all LA structures (4.0 +/- 1.1 mm) were superior to the static reference (4.9 +/- 0.7 mm; P = .01). In addition, the shift due to respiration was less pronounced at 3.5 +/- 0.8 mm versus 4.9 +/- 0.5 mm (P = .004), respectively. Motion of extracardiac vessels was influenced by a mean shift of 6.8 +/- 1 mm. The remote subclavian and brachiocephalic veins were more affected (7.6 +/- 0.7 mm) than the pulmonary arteries (5.9 +/- 0.4 mm; P = .002). For the CTI, a minimized mean displacement of less than 4.6 +/- 2.0 mm relative to the proximal CS, RAA, and azygos vein was found. CONCLUSION: Respiration is the major source of relative motion, which increases with distance from the heart. For LA procedures, a proximal CS reference position is superior to a static reference position.
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Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Mapeo del Potencial de Superficie Corporal , Ablación por Catéter , Procesamiento de Imagen Asistido por Computador , Movimiento (Física) , Respiración , Anciano , Análisis de Varianza , Venas Braquiocefálicas/fisiopatología , Vasos Coronarios/fisiopatología , Femenino , Atrios Cardíacos/fisiopatología , Sistema de Conducción Cardíaco/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Arteria Pulmonar/fisiopatología , Venas Pulmonares/fisiopatología , Proyectos de Investigación , Resultado del Tratamiento , Válvula Tricúspide/fisiopatologíaAsunto(s)
Algoritmos , Fibrilación Atrial/cirugía , Ablación por Catéter , Medios de Contraste/administración & dosificación , Criocirugía , Técnicas de Apoyo para la Decisión , Espectroscopía Dieléctrica , Venas Pulmonares/cirugía , Anciano , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Criocirugía/efectos adversos , Femenino , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/fisiopatología , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Experimental data of simultaneous acquired activation and motion (AM) propagation from human subjects are not available. OBJECTIVES: The purpose of this study was to demonstrate the feasibility of a novel mapping technique allowing combined analysis of AM timing in vivo and to delineate the influence of chronically ischemic tissue on cardiac AM propagation. METHODS: Ten patients with remote myocardial infarction and 4 control patients were studied during sinus rhythm using electroanatomic mapping (CARTO). Maps of the left ventricle were obtained via the retrograde aortic approach. Real-time catheter positions were extracted using custom-made software. Catheter motion was analyzed along a static line connecting the catheter tip with the apex. Tissue Doppler measurements in all patients provided data for validation. RESULTS: Four shapes of catheter motion curves were identified and correlated to healthy tissue with variable degrees of preloading, scar tissue and dyskinetic regions, e.g. aneurysms. An analysis of the AM-delay revealed areas of delayed activation in 7, and slow motion onset in 4 patients. Tissue Doppler data correlated well with local onset of motion (correlation coefficient 0,99). CONCLUSION: Activation delays as well as long AM-intervals that can be differentiated with the described mapping technique are responsible for asynchronous contraction in the ischemic heart. Myocardial wall motion abnormalities can be derived from catheter motion curves.
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Mapeo del Potencial de Superficie Corporal , Frecuencia Cardíaca/fisiología , Contracción Miocárdica/fisiología , Isquemia Miocárdica/fisiopatología , Adulto , Anciano , Cateterismo Cardíaco , Enfermedad Crónica , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/diagnóstico por imagenRESUMEN
It has been suggested that the multiplicity of Ca(2+) signaling pathways in atrial myocytes may contribute to the variability of its function. This article reports on a novel Ca(2+) signaling cascade initiated by mechanical forces induced by "puffing" of solution onto the myocytes. Ca(i) transients were measured in fura-2 acetoxymethyl (AM) loaded cells using alternating 340- and 410-nm excitation waves at 1.2 kHz. Pressurized puffs of bathing solutions, applied by an electronically controlled micro-barrel system, activated slowly (approximately 300 ms) developing Ca(i) transients that lasted 1,693 +/- 68 ms at room temperature. Subsequent second and third puffs, applied at approximately 20 s intervals activated significantly smaller or no Ca(i) transients. Puff-triggered Ca(i) transients could be reactivated once again following caffeine (10 mM)-induced release of Ca(2+) from sarcoplasmic reticulum (SR). Puff-triggered Ca(i) transients were independent of [Ca(2+)](o), and activation of voltage-gated Ca(2+) or cationic stretch channels or influx of Ca(2+) on Na(+)/Ca(2+)exchanger, because puffing solution containing no Ca(2+), 10 microM diltiazem, 1 mM Cd(2+), 5 mM Ni(2+), or 100 microM Gd(3+) failed to suppress them. Puff-triggered Ca(i) transients were enhanced in paced compared to quiescent myocytes. Electrically activated Ca(i) transients triggered during the time course of puff-induced transients were unaltered, suggesting functionally separate Ca(2+) pools. Contribution of inositol 1,4,5-triphosphate (IP(3))-gated or mitochondrial Ca(2+) pools or modulation of SR stores by nitric oxide/nitric oxide synthase (NO/NOS) signaling were evaluated using 0.5 to 500 microM 2-aminoethoxydiphenyl borate (2-APB) and 0.1 to 1 microM carbonylcyanide-p-trifluoromethoxyphenylhydrazone (FCCP), and 1 mM Nomega-Nitro-L-arginine methyl ester (L-NAME) and 7-nitroindizole, respectively. Only FCCP appeared to significantly suppress the puff-triggered Ca(i) transients. It was concluded that neither Ca(2+) influx nor depolarization was required for activation of this signaling pathway. These studies suggest that pressurized puffs of solutions activate a mechanically sensitive receptor, which signals in turn the release of Ca(2+) from a limited Ca(2+) store of mitochondria. How mechanical forces are sensed and transmitted to mitochondria to induce Ca(2+) release and what role such a Ca(2+) signaling pathway plays in the physiology or pathophysiology of the heart remain to be worked out.
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Señalización del Calcio/fisiología , Atrios Cardíacos/metabolismo , Miocitos Cardíacos/metabolismo , Animales , Señalización del Calcio/efectos de los fármacos , Inhibidores Enzimáticos/farmacología , Atrios Cardíacos/citología , Miocitos Cardíacos/efectos de los fármacos , Estimulación Física/métodos , Ratas , Estrés Mecánico , Desacopladores/farmacologíaAsunto(s)
Fibrilación Atrial/cirugía , Criocirugía/instrumentación , Imagenología Tridimensional/instrumentación , Venas Pulmonares/cirugía , Cirugía Asistida por Computador/instrumentación , Anciano , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/fisiopatología , Criocirugía/efectos adversos , Estudios de Factibilidad , Femenino , Humanos , Interpretación de Imagen Asistida por Computador , Imagenología Tridimensional/efectos adversos , Masculino , Persona de Mediana Edad , Venas Pulmonares/fisiopatología , Cirugía Asistida por Computador/efectos adversos , Resultado del TratamientoRESUMEN
The most widely accepted criterion for successful radiofrequency catheter (RFC) ablation of typical atrial flutter is the development of bi-directional isthmus block. In a subset of patients, conventional RFC ablation fails to achieve this endpoint because deeper and wider lesions are required. We investigated the efficacy of a long 8-mm tip catheter in these cases. One hundred and seventy-four consecutive patients (137 male; 61 +/- 9 years) with recurrent typical atrial flutter underwent conventional RFC ablation first with a standard 4 mm tip catheter. In resistant cases (n = 52), ablation was continued using a large tip 8-mm catheter when the 4-mm tip catheter failed. Resistant atrial flutter was identified when 21 RFC pulses failed to reach the selected endpoint of bi-directional isthmus block or in cases of transient bi- directional block (at least 3 episodes). In 122 of the 174 patients (70%) conventional atrial flutter ablation was successfully performed with 13 +/- 5 RFC applications. In the remaining 52 subjects (30%), the ablation procedure was completed using the large tip electrode catheter. In 30 of these 52 patients (58%), the catheter was changed because of persistent intra-atrial conduction after 21 RFC pulses and in 22 (42%) because of intermittent conduction block after 11 +/- 5 applications. Using the large tip electrode catheter, the selected endpoint was achieved in all patients of both groups with 3 +/- 2 RFC pulses (power output of 50-60 W, pulse duration of 60 sec). No post-procedure complications were observed. After 15 +/- 5 months of follow-up, 16 patients (9%) had recurrence of atrial flutter. Five of the patients had been in the resistant group. In patients with atrial flutter resistant to conventional ablation therapy, the long tip (8-mm) catheter appears to be a safe and effective alternative to use of the conventional 4-mm tip catheter.
Asunto(s)
Aleteo Atrial/cirugía , Ablación por Catéter/instrumentación , Electrodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Isolation of arrhythmogenic pulmonary veins (PVs) by radiofrequency current (RF) application has been introduced as a curative treatment for patients (pts) with paroxysmal atrial fibrillation (AF). The present study sought to investigate the feasibility and efficacy of this approach guided by conventional and electroanatomical mapping (CARTO). METHODS: Twenty pts (13 male; 57 +/- 8 years) with recurrent documented focally triggered idiopathic AF refractory to multiple antiarrhythmic drugs were prospectively included. Atrial premature beats were present at baseline in 9 pts and could be provoked in further 8 pts. Empirical ablation of both superior PVs was performed in 3 pts with no focal activity. After transseptal puncture selective angiography of all PVs was obtained. Thirty-six PVs (left superior: n = 18, right superior: n = 10, left inferior: n = 8) were targeted for RF ablation. A complete left atrial CARTO-map including the left atrial (LA) to pulmonary vein (PV) junction was obtained during sinus rhythm and/or coronary sinus pacing. RF was initially applied at the PV-LA junction at areas with the shortest left atrial- to PV potential interval (target 50 degrees C, max. 30 W, duration 60 sec). Isolation was confirmed by the complete disappearance of specific PV potentials. RF lesions were analyzed with respect to the number of segment-quarters covering the PV ostium. RESULTS: Functional isolation could be achieved in 35 out of 36 PVs following 10 +/- 5 RF applications for each PV. RF applications covered 2 or less quarter segments of the overall PV circumference in 29 (80%) PVs. Total session duration was 6.5 +/- 1.6 h with a mean fluoro-time of 54 +/- 18 minutes. For CARTO mapping and ablation a mean fluoro time of 34 +/- 6 min was required. During a mean follow up period of 8.3 +/- 2.5 months AF relapsed in 9 pts (46%). A second approach was performed in 5 pts. and demonstrated either new foci (n = 2) or recurrence of previously isolated PV (n = 8). The second RF ablation procedure led to stable sinus rhythm in 3 out 5 pts. Thus, the overall success rate including the second procedure was 70%. CONCLUSIONS: CARTO guided functional isolation of presumed arrhythmogenic PVs by RF lesions covering 2 or less segments of the PV ostium in most patients is feasible. However, repeat procedures are often warranted to permanently treat paroxysmal atrial fibrillation.
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Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Electrocardiografía , Angiografía por Resonancia Magnética , Venas Pulmonares/fisiopatología , Adulto , Anciano , Fibrilación Atrial/diagnóstico , Ablación por Catéter/instrumentación , Técnicas Electrofisiológicas Cardíacas , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Venas Pulmonares/diagnóstico por imagen , Radiografía , Recurrencia , Sensibilidad y Especificidad , Taquicardia Paroxística/diagnóstico , Taquicardia Paroxística/cirugía , Resultado del TratamientoRESUMEN
A pilot study was performed to determine the efficacy of low energy biphasic external cardioversion in common type atrial flutter. In the majority of patients (70%) successful cardioversion was achieved with low energy levels of 20 or 30 J; however a considerable number of patients (15%) were initially cardioverted to atrial fibrillation, needing an additional cardioversion with an even higher energy level.
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Aleteo Atrial/metabolismo , Aleteo Atrial/terapia , Cardioversión Eléctrica , Metabolismo Energético/fisiología , Anciano , Aleteo Atrial/fisiopatología , Cardioversión Eléctrica/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios ProspectivosRESUMEN
External cardioversion is an established and very important tool to terminate symptomatic atrial flutter. The superiority of the biphasic waveform has been demonstrated for atrial flutter, but whether electrode position affects the efficacy of cardioversion in this population is not known. The aim of this trial was to evaluate whether anterior-lateral (A-L) compared with anterior-posterior (A-P) electrode position improves cardioversion results. Of 130 screened patients, 96 (72 men, mean age 62 +/- 12 years) were included and randomly assigned to a cardioversion protocol with either A-L or A-P electrode position. In each group, 48 patients received sequential biphasic waveform shocks using a step-up protocol consisting of 50, 75, 100, 150, or 200 J. The mean energy (65 +/- 13 J for A-L vs 77 +/- 13 J for A-P, p = 0.001) and mean number of shocks (1.48 +/- 1.01 for A-L vs 1.96 +/- 1.00 for A-P, p = 0.001) required for successful cardioversion were significantly lower in the A-L group. The efficacy of the first shock with 50 J in the A-L electrode position (35 of 48 patients [73%]) was also highly significantly greater than the first shock with 50 J in the A-P electrode position (18 of 48 patients [36%]) (p = 0.001). In conclusion, the A-L electrode position increases efficacy and requires fewer energy and shocks in external electrical cardioversion of common atrial flutter. Therefore, A-L electrode positioning should be recommended for the external cardioversion of common atrial flutter.
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Aleteo Atrial/terapia , Cardioversión Eléctrica/métodos , Anciano , Algoritmos , Cardioversión Eléctrica/instrumentación , Electrodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
This case report describes a female patient with a cluster of four supraventricular tachycardias during the third trimester of pregnancy. The patient was surgically corrected with a Senning operation at the age of 15. Due to numerous monomorphic atrial tachycardias at the age of 28 an ablation using the noncontact mapping system EnSite 3000 was successfully performed. She remained free of tachycardias for 2 years until the third trimester of pregnancy, where 4 electrical cardioversions and eventually a caesarean section were performed. Subsequently, the patient was free of tachycardias during a 36 month follow-up and the child is healthy.
Asunto(s)
Fibrilación Atrial/diagnóstico , Cardioversión Eléctrica , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Resultado del Embarazo , Taquicardia por Reentrada en el Nodo Atrioventricular/cirugía , Taquicardia Supraventricular/diagnóstico , Adulto , Fibrilación Atrial/terapia , Procedimientos Quirúrgicos Cardíacos/métodos , Ablación por Catéter/métodos , Cesárea , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Embarazo , Tercer Trimestre del Embarazo , Taquicardia por Reentrada en el Nodo Atrioventricular/diagnóstico , Taquicardia Supraventricular/terapia , Transposición de los Grandes Vasos/diagnóstico , Transposición de los Grandes Vasos/cirugíaRESUMEN
AIMS: In the setting of right ventricular outflow tract-tachycardia (RVOT-T), data about long-term follow-up (FU) with respect to the therapeutic strategies are missing. All patients (pts) referred to our institution during the last 20 years for the treatment of RVOT-T were studied in a retrospective analysis to assess mortality and efficacy of treatment. METHODS AND RESULTS: One hundred and thirty-three patients (77 female; 39+/-13 years) with sustained RVOT-T were included in this study. At the time of first presentation, diagnosis of RVOT-T was made by complete invasive and non-invasive diagnostic assessment, including electrophysiology study and two-dimensional echocardiography. After 135+/-68 months (median 136, range 29-248), patients were invited to undergo clinical assessment. Of the 133 pts, 127 (95%) survived and six (5%) died from non-cardiac disease. Anti-arrhythmic (AA) drugs were given to 62 of the 133 pts (47%); of them 32 (52%) had recurrences during follow-up. The mean time to recurrence was 10.02 years (95% CI 7.46-12.59). The other 71 study patients (53%) underwent catheter ablation. The procedure was successful in 58 pts (82%). During follow-up, 30 (52%) of the 58 successfully treated patients had recurrences of RVOT-T. The mean time to recurrence was 6.28 years (95% CI 4.96-7.6). RVOT-T recurrences were similar in morphology to those treated previously in 33% and different in 67% of cases. CONCLUSIONS: Long-term follow-up in patients with RVOT-T is favourable. Catheter ablation is effective in this setting. However, late recurrences with similar or different morphology may arise in half of the patients after initially successful treatment. AA drug therapy is a valid initial therapeutic option, since it is effective in about half of the patients.
Asunto(s)
Antiarrítmicos/uso terapéutico , Ablación por Catéter , Taquicardia Ventricular/terapia , Adulto , Electrofisiología Cardíaca , Angiografía Coronaria , Ecocardiografía , Prueba de Esfuerzo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Recurrencia , Estudios Retrospectivos , Taquicardia Ventricular/mortalidad , Taquicardia Ventricular/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Currently, definition of success following atrial fibrillation (AF) ablation is commonly based on the lack of symptoms. The purpose of this study was to evaluate the correlation between symptoms and the underlying rhythm after AF ablation. METHODS AND RESULTS: Eighty consecutive patients (pts) were treated for paroxysmal episodes of AF by segmental ostial ablation of all pulmonary veins and right atrial isthmus ablation. For 6 months pts transmitted transtelephonic (T-) ECG recordings in combination with comments daily or in the event of symptoms. Eligible comments were classified as: (1) asymptomatic, (2) symptomatic. Analysis was performed at 1-month intervals, defining an acute (first month) and chronic period (second to sixth month) after ablation. Overall 6,835 T-ECGs were analyzed. Of these 5,437 (79.5%) showed sinus rhythm (SR) and 1,398 (20.5%) showed AF. Pts in SR reported symptoms for 593 (10.9%) episodes, whereas 4,844 (89.1%) episodes were asymptomatic. During AF, 646 (46.2%) episodes were associated with symptoms, and 752 (53.8%) episodes remained asymptomatic. Exclusively asymptomatic were 7 (8.8%) pts. In 30 (52.6%) of 57 pts with AF, arrhythmic events were confined to the acute phase. Of the remaining 27 pts 14 (52%) reported an improvement, 12 (44%) the same, and 1 (4%) worsened symptoms after 3 months. A significant change (P < 0.01) toward more asymptomatic episodes from the acute (43.5%) to the chronic (57.5 +/- 4.5%) period was evident. CONCLUSION: Assessment of success after AF ablation cannot be based on the absence of symptoms due to a high prevalence of asymptomatic episodes.
Asunto(s)
Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter , Electrocardiografía , Fibrilación Atrial/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Telemetría , Resultado del TratamientoRESUMEN
AIMS: To investigate the effectiveness of additional substrate modification (SM) by left atrial (LA) linear lesions as compared with pulmonary vein isolation (PVI) alone in patients with persistent atrial fibrillation (AF) in a prospective randomized study. Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF. The benefit of PVI alone and additional linear lesions has not been validated in a randomized study so far. METHODS AND RESULTS: Sixty-two patients with persistent AF (median duration 7, range 1-18 months) were randomly assigned to either PVI alone (n = 30) or additional SM (n =32) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus. Procedures including SM were performed using a three-dimensional mapping system (EnSite NavX, St Jude Medical, St Paul, MN, USA). Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups. Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient's symptoms. PVI was successful in 98% of all targeted veins in both groups. Additional SM did not increase fluoroscopy time (72.1+/-18.7 vs. 72.9+/-17.3 min, P=0.92) because of the use of three-dimensional navigation in the PVI+SM group. AF recurrences within the first 4 weeks following ablation were more common after PVI alone (77%) than additional SM (44%, P=0.002). After a follow-up time of 487 (429-570) days, only 20% of patients undergoing stand alone PVI remained in sinus rhythm when compared with 69% following PVI combined with SM (P=0.0001). Two patients assigned to PVI+SM experienced procedure-related complications (cardiac tamponade and minor stroke) which resolved without sequelae. CONCLUSION: PVI alone is insufficient in the treatment of persistent AF. However, additional left linear lesions increase the success rate significantly. Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM.