Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter.

BACKGROUND: Mitral annular flutter (MAF) is the most common left atrial macro-reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear. METHODS: This single-center, retrospective study sought to compare the acute and long-term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long-term arrhythmia recurrence were compared between the two groups. RESULTS: Between 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17-0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12-0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group. CONCLUSION: In this retrospective study of patients with MAF, a MIL compared to AML was associated with a long-term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.

Pericardial effusion caused by accidently placing a Micra transcatheter pacing system into the coronary sinus.

BACKGROUND: Leadless pacemaker has been acknowledged as a promising pacing strategy to prevent pocket and lead-related complications. Although rare, cardiac perforation remains a major safety concern for implantation of Micra transcatheter pacing system (TPS). CASE PRESENTATION: A 83-year-old female with low body mass index (18.9 kg m-2) on dual anti-platelet therapy, was indicated for Micra TPS implantation due to sinus arrest and paroxysmal atrial flutter. The patient developed mild pericardial effusion during the procedure since the delivery catheter was accidentally placed into the coronary sinus for several times. Cardiac perforation with moderate pericardial effusion and pericardial tamponade was detected 2 h post-procedure. The patient was treated with immediately pericardiocentesis and recovered without further invasive therapy. CONCLUSION: Pericardial effusion caused by accidently placing a delivery catheter into the coronary sinus is rare but should be carefully considered in Micra TPS implantation, especially for those with periprocedural anti-platelet therapy.

Electrophysiological findings in patients with isolated veins after cryoablation for paroxysmal atrial fibrillation.

AIMS: The main cause of atrial fibrillation recurrence after catheter ablation is pulmonary vein reconnection. The purpose of this retrospective study was to analyse the electophysiological findings in patients undergoing repeat procedures after an index cryoballoon ablation (CB-A) and presenting with permanency of pulmonary vein isolation (PVI) in all veins. In addition, we sought to compare the latter with a similar group of patients with reconnected veins at the redo procedure. METHODS: A total of 132 patients (81 men, 60.7 ±â€Š12.4 years) who underwent CB-A for paroxysmal atrial fibrillation (PAF) were enrolled. Indication for the redo procedure was symptomatic PAF in 83 (63%), persistent atrial fibrillation (PerAF) in 32 (24%) or persistent regular atrial tachycardia (RAT) in 17 (13%) patients. RESULTS: Seventy-five (57%) patients presented a pulmonary vein reconnection (pulmonary vein group) during the redo procedure, whereas 57 (43%) had no pulmonary vein reconnection (non-pulmonary vein group). The non-pulmonary vein group exhibited significantly more non-pulmonary vein foci and atrial flutters than the pulmonary vein group after induction protocol (51 vs. 24%, P = 0.002 and 67 vs. 36%, P = 0.003, respectively). Twenty-two (29.3%) patients of the pulmonary vein group and 20 (35%) patients of the non-pulmonary vein group had atrial fibrillation/RAT recurrence after a mean follow-up of 12.5 ±â€Š8 months. The survival analysis demonstrated no statistical significance in recurrence between both groups (log rank P = 0.358). CONCLUSION: Atrial fibrillation/RAT recurrence in patients after CB-A with durable PVI is significantly associated with non-pulmonary vein foci and atrial flutters. No statistically different success rate regarding atrial fibrillation/RAT freedom was detected between the pulmonary vein and non-pulmonary vein groups after redoing RF-CA.

Ablation of Atrial Fibrillation Without Left Atrial Appendage Imaging in Patients Treated With Direct Oral Anticoagulants.

BACKGROUND: Many centers continue to routinely perform transesophageal echocardiograms before atrial fibrillation (AF) ablation procedures in patients treated with direct oral anticoagulants (DOACs). One study suggested that the procedures could be done without transesophageal echocardiogram but used intracardiac echocardiography imaging of the appendage from the right ventricular outflow. This study aimed to assess the safety of ablation for AF without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage in DOAC compliant patients. METHODS: All patients undergoing AF ablation at the Cleveland Clinic (2011-2018) were enrolled in a prospectively maintained data registry. All consecutive patients presenting with AF or atrial flutter on DOAC were included. Periprocedural thromboembolic complications were assessed. RESULTS: A total of 900 patients were included. Their median CHA2DS2-VASc score was 2 (interquartile range 1-3). All were on DOACs (333 rivaroxaban, 285 dabigatran, 281 apixaban, and 1 edoxaban). Thromboembolic complications occurred in 4 patients (0.3%): 2 ischemic strokes, 1 transient ischemic attack without residual deficit, and 1 splenic infarct; all with no further complications. Bleeding complications occurred in 5 patients (0.4%): 2 pericardial effusions (1 intraoperative, 1 after 30 days, both drained), 3 groin hematomas (1 of them due to needing heparin for venous thrombosis, none required interventions). No patients required emergent surgeries. CONCLUSIONS: In DOAC compliant patients who present for ablation in AF/atrial flutter, the procedures could be performed without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage; with low risk of complications.

Flutter Wave Morphology of Peri-Mitral Atrial Flutters Is Mainly Determined by Right Atrial Activation: Insights From High-Resolution Mapping.

BACKGROUND: Peri-mitral atrial flutters frequently develop post-atrial fibrillation ablation or postcardiac surgery. The determinants of the flutter wave morphology on surface ECG have been less studied. METHODS: We retrospectively reviewed 24 patients with peri-mitral atrial flutters who underwent biatrial high-resolution mapping at 3 institutions with LUMIPOINT software. We analyzed the overlap between the right atrial (RA) activation time and flutter wave duration and compared the proportion of the endocardial area that was activated in both atria during the flutter wave duration. Biatrial activation patterns and interatrial conductions were also identified. RESULTS: The mean tachycardia cycle length was 264±60 ms, with RA activation time 155±45 ms (60.8±20.6% of the tachycardia cycle length), and the flutter wave duration 107±31 ms (41.6±11.7% of the tachycardia cycle length). The overlap between the RA activation time and the flutter wave duration was 102±29 ms, which takes 68.5±17.2% of the RA activation time and 95.7±9.1% of the flutter wave duration, respectively. Quantitative analysis also showed that during the flutter wave duration, more percentage of the endocardial area was activated in the RA than in the left atrium (73.0±12.7% versus 45.2±13.0%, P<0.001). We consistently observed that the RA anterior wall rightward activation corresponded to the positive component in V1 in both flutter patterns, and the RA downward activation corresponded to the positive component in the counterclockwise group or the upward activation corresponded to the negative component in the clockwise group in the inferior leads. The passive RA activation patterns were varied with spontaneous atrial scarring or previous linear ablation. CONCLUSIONS: ECG flutter wave morphology of peri-mitral atrial flutters is mainly dependent on RA activation patterns.

Prospective Evaluation of Clinico-Pathological Predictors of Postoperative Atrial Fibrillation: An Ancillary Study From the OPERA Trial.

BACKGROUND: Postoperative atrial fibrillation (POAF) occurs in 30% to 50% of patients undergoing cardiac surgery and is associated with increased morbidity and mortality. Prospective identification of structural/molecular changes in atrial myocardium that correlate with myocardial injury and precede and predict risk of POAF may identify new molecular pathways and targets for prevention of this common morbid complication. METHODS: Right atrial appendage samples were prospectively collected during cardiac surgery from 239 patients enrolled in the OPERA trial (Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation), fixed in 10% buffered formalin, and embedded in paraffin for histology. We assessed general tissue morphology, cardiomyocyte diameters, myocytolysis (perinuclear myofibril loss), accumulation of perinuclear glycogen, interstitial fibrosis, and myocardial gap junction distribution. We also assayed NT-proBNP (N-terminal pro-B-type natriuretic peptide), hs-cTnT, CRP (C-reactive protein), and circulating oxidative stress biomarkers (F2-isoprostanes, F3-isoprostanes, isofurans) in plasma collected before, during, and 48 hours after surgery. POAF was defined as occurrence of postcardiac surgery atrial fibrillation or flutter of at least 30 seconds duration confirmed by rhythm strip or 12-lead ECG. The follow-up period for all arrhythmias was from surgery until hospital discharge or postoperative day 10. RESULTS: Thirty-five percent of patients experienced POAF. Compared with the non-POAF group, they were slightly older and more likely to have chronic obstructive pulmonary disease or heart failure. They also had a higher European System for Cardiac Operative Risk Evaluation and more often underwent valve surgery. No differences in left atrial size were observed between patients with POAF and patients without POAF. The extent of atrial interstitial fibrosis, cardiomyocyte myocytolysis, cardiomyocyte diameter, glycogen score or Cx43 distribution at the time of surgery was not significantly associated with incidence of POAF. None of these histopathologic abnormalities were correlated with levels of NT-proBNP, hs-cTnT, CRP, or oxidative stress biomarkers. CONCLUSIONS: In sinus rhythm patients undergoing cardiac surgery, histopathologic changes in the right atrial appendage do not predict POAF. They also do not correlate with biomarkers of cardiac function, inflammation, and oxidative stress. Graphic Abstract: A graphic abstract is available for this article.

Predictors of zero X ray procedures in supraventricular arrhythmias ablation.

To evaluate predictors of zero-X ray procedures for supraventricular arrhythmias (SVT) using minimally fluoroscopic approach (MFA). Patients referred for RF catheter ablation of SVT were admitted for a MFA with an electro-anatomical navigation system or a conventional fluoroscopic approach (ConvA). Exclusion criterion was the need to perform a transseptal puncture. 206 patients (98 men, age 53 ± 19 years) underwent an EP study, 93 (45%) with an MFA and 113 (55%) with a ConvA. Fifty-five had no inducible arrhythmias (EPS). Fifty-four had AV nodal reentrant tachycardia (AVNRT), 49 patients had typical atrial flutter (AFL), 37 had AV reciprocating tachycardia (AVRT/WPW), 11 had focal atrial tachycardia (AT), and underwent a RF ablation. X-ray was not used at all in 51/93 (58%) procedures (zero X ray). MFA was associated with a significant reduction in total fluoroscopy time (5.5 ± 10 vs 13 ± 18 min, P = 0.01) and operator radiation dose (0.8 ± 2.5 vs 3 ± 8.2 mSV, P < 0.05). The greatest absolute dose reduction was observed in AVNRT (0.1 ± 0.3 vs 5.1 ± 10 mSV, P = 0.01, 98% relative dose reduction) and in AFL (1.3 ± 3.6 vs 11 ± 16 mSV, P = 0.003, 88% relative dose reduction) groups. Both AVNRT or AFL resulted the only statistically significant predictors of zero x ray at multivariate analysis (OR 4.5, 95% CI 1.5-13 and OR 5, 95% CI 1.7-15, P < 0.001, respectively). Success and complication rate was comparable between groups (P = NS). Using MFA for SVT ablation, radiological exposure is significantly reduced. Type of arrhythmia is the strongest predictor of zero X ray procedure.

The mechanisms of recurrent atrial arrhythmias after second-generation cryoballoon ablation.

BACKGROUND: In patients with paroxysmal atrial fibrillation (PAF), 10%-15% of patients require repeat procedures after second-generation cryoballoon pulmonary vein isolation (CB-PVI). We sought to explore the mechanisms of recurrences after cryoballoon ablation. METHODS: The data of 122 PAF patients who underwent second procedures for recurrent arrhythmias 7.0 (4.0-12.0) months after the CB-PVI were analyzed. During second procedures, non-PV AF foci were explored with isoproterenol, adenosine, and repetitive cardioversions. RESULTS: In total, 378/487 (77.6%) PVs remained isolated, and reconnections were not observed in any PVs in 59 (48.4%) patients. PV reconnections were associated with recurrences in 38 (31.1%) patients, of whom 33 (86.8%) had reconnections of at least 1 upper PV. In 6 (4.9%) patients, non-PV AF foci were identified in the upper PV antra where cryoballoons cannot isolate but within the circumferential radiofrequency PVI line. Non-PV AF foci were identified in the superior vena cava, right atrial body, left atrial body, and atrial septum in 28 (23.0%), 18 (14.7%), 4 (3.3%), and 5 (4.1%) patients, respectively. Twelve (9.8%) patients had multiple non-PV AF foci. Four (3.3%), 3 (2.4%), and 8 (6.5%) patients underwent second procedures for atrioventricular nodal reentrant tachycardia, atrial flutter, and atrial tachycardias. During 16.0 (8.0-24.0) months of follow-up, freedom from any atrial arrhythmia at 1 year and 2 years after the second procedure was 79.2% and 60.6%. Nineteen (15.5%) patients had antiarrhythmic drug therapy at the last follow-up. CONCLUSIONS: Our study suggested that improvement in the upper PV PVI durability, eliminating arrhythmogenic superior vena cavae and coexisting atrial arrhythmias, and bonus cryoballoon applications at PV antra might improve the single procedure outcome in cryoballoon ablation.

Cavotricuspid isthmus is constantly a zone of slow conduction: Data from ultra-high-resolution mapping.

BACKGROUND: Whether cavotricuspid isthmus (CTI) is a region of conduction slowing during typical flutter has been discussed with conflicting results in the literature. We aimed to evaluate conduction velocity (CV) along the different portions of the typical flutter circuit with a recently proposed method by means of ultra-high-resolution (UHR) mapping. METHODS: Consecutive patients referred for typical atrial flutter (AFL) ablation underwent UHR mapping (Rhythmia, Boston Scientific). CVs were measured in the CTI as well as laterally and septally, respectively, from its lateral and septal borders. RESULTS: A total of 33 patients (mean age: 65 ± 13 years; right atrial volume: 134 ± 57 mL) were mapped either during ongoing counterclockwise (n = 25), or clockwise (n = 3) AFL (mean cycle length: 264 ± 38 ms), or during coronary sinus pacing at 400 ms (n = 1), 500 ms (n = 1), or 600 ms (n = 3). A total of 13 671 ± 7264 electrograms were acquired in 14 ± 9 min. CTI CV was significantly lower (0.56  ± 0.18 m/s) in comparison with the lateral CV (1.31 ± 0.29 m/s; P < .0001) and the septal border CV of the CTI (1.29 ± 0.31 m/s; P < .0001). CONCLUSION: UHR mapping confirmed that CTI CV was systematically twice lower than atrial conduction velocities outside the CTI.

Management of paroxysmal atrial flutter that occurred in an outpatient prior to dental surgery: a case report.

BACKGROUND: It is essential to accomplish the appropriate emergency care particularly in patients undergoing stressful dento-oral surgical procedures. Atrial flutter may be induced by sympathetic hypertonia due to excessive mental and physical stress. There is no report regarding dental care in patients with atrial flutter. Herein, we describe a rare case of the antiarrhythmic management in an outpatient who presented with an electrocardiographic finding of paroxysmal atrial flutter before the initiation of the dento-oral surgical procedure. CASE PRESENTATION: A 60-year-old male patient was scheduled for a dental extraction. He had a history of angina pectoris, diabetes mellitus, and paroxysmal atrial fibrillation with medication. The preoperative electrocardiogram (ECG) revealed left ventricular hypertrophy and ST-T segment abnormality. Immediately before the dental extraction, II-lead ECG revealed atrial flutter; however, he complained of few subjective symptoms, such as precordial discomfort or palpitation. Observing the vital signs, ECG findings, and the general condition of the patient, low dose diltiazem was immediately administered by continuous infusion in order to control the heart rate and prevent atrial flutter-induced supraventricular tachyarrhythmia. Special attention was paid to prevent any critical cardiovascular condition under a preparation of intravenous disopyramide and verapamil and a defibrillator. The intravenous administration of diltiazem progressively restored the sinus rhythm after converting atrial flutter into atrial fibrillation, resulting in the prevention of tachycardia, and then was found to be appropriate as a prophylactic therapy of tachyarrhythmia. CONCLUSIONS: The present case suggests that it is possible to successfully manage some of such patients using our method during dento-oral surgery which is likely to be associated with mental and physical stress. Therefore, it is essential to accomplish an initial emergency care in parallel to the differential diagnosis of unforeseen serious medical conditions or paroxysmal arrhythmia such as atrial flutter.

From near-zero to zero fluoroscopy catheter ablation procedures.

AIMS: The use of electroanatomical mapping (EAM) systems can reduce radiation exposure (RX) and it can also completely eliminate the use of RX. Radiation exposure related to conventional radiofrequency ablation procedures can have a stochastic and deterministic effect on health. The main aim of this study was to evaluate the safety and feasibility of an entirely nonfluoroscopic approach to catheter ablation (CA) using EAM CARTO3. METHODS: In 2011 we started an RX-minimization programme in all procedures using the CARTO system with the deliberate intention to not resort to the aid of RX unless strictly necessary. We divided procedures into two groups (group 1: from 2011 to 2013; group 2: from 2014 to 2017). The only exclusion criteria were the need for transseptal puncture, and nonidiopathic ventricular tachycardia (VT). RESULTS: From a total of 525 procedures, we performed CA entirely without RX in 78.5% of cases. From 2011 to 2013, we performed CA without RX in 38.5% of cases; from 2014 to 2017, we performed 96.2% of cases with zero RX. The use of RX was significantly reduced in group 2 (group 2: 1.4 ± 19.6 seconds vs group 1: 556.92 ± 520.76 seconds; P < .001). These differences were irrespective of arrhythmia treatment. There were no differences between the two groups in acute success, complications, or duration of procedures. CONCLUSION: CA of supraventricular tachycardia and VT entirely without RX, guided by the CARTO system, is safe, feasible, and effective. After an adequate learning curve, CA can be performed entirely without RX.

Atrial arrhythmias in patients with arrhythmogenic right ventricular cardiomyopathy: Prevalence, echocardiographic predictors, and treatment.

INTRODUCTION: The clinical role of atrial arrhythmias (AA) in arrhythmogenic right ventricular cardiomyopathy (ARVC) and the echocardiographic variables that predict them are not well defined. We describe the prevalence, types, echocardiographic predictors, and management of AA in patients with ARVC. METHODS: We retrospectively evaluated medical records of 117 patients with definite ARVC (2010 Task Force Criteria) from two tertiary care centers. We identified those patients with sustained AA (>30 seconds), including atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT). We collected demographic, genetic, and clinical data. The median follow-up was 3.4 years (interquartile range = 2.0-5.7). RESULTS: Total 26 patients (22%) had one or more types of AA: AF (n = 19), AFL (n = 9), and AT (n = 8). We performed genetic testing on 84 patients with ARVC (71.8%). Two patients with AA (8%) had peripheral emboli, and one patient (4%) suffered inappropriate implantable cardioverter-defibrillator shock. We performed catheter ablation of AA in eight patients (31%), with no procedural complications. Right atrial area and left atrial volume index were independently associated with increased odds of AA; odds ratio (OR), 1.1 (95% confidence interval [CI]:1.02-1.16) (P = .01) and OR, 1.1 (95% CI:1.03-1.15) (P = .003), respectively. An increase in tricuspid annular plane peak systolic excursion was independently associated with reduced odds; OR, 0.3 (95% CI: 0.1-0.94) (P = .003). CONCLUSIONS: Atrial arrhythmias (AA) are common in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Inappropriate shocks and systemic emboli may be associated with AA. Atrial size and right ventricular dysfunction may help identify patients with ARVC at increased odds of AA.

Regional isolation in the right atrium with disruption of intra-atrial conduction after catheter ablation of atrial tachycardia.

BACKGROUND: Ablation of atrial tachycardia (AT) that occurs after cardiac surgery or prior ablation often requires complex lesion sets. In combination with the pre-existing atrial scar, these lesion sets may result in inadvertent intra-atrial conduction block. This study reports the phenomenon of incidental isolation of right atrial (RA) regions that occurs secondary to AT ablation, which in some cases results in profound bradycardia due to sinus exit block. METHODS AND RESULTS: Intracardiac electrograms were examined in consecutive patients who underwent AT ablation in the RA. Cases of localized isolation of the RA were defined as areas that developed electrical dissociation during ablation. Of 132 patients having ablation in both the RA free wall and the cavotricuspid isthmus (CTI), 10 (7.6%) developed unintentional isolation of the lateral RA. Five of these patients had prior mitral valve surgery, comprising 12.2% of all 41 patients with mitral surgery who underwent ablation in the CTI and the RA free wall. All patients with regional isolation had a pre-existing scar in the lateral wall of the RA. In six patients, isolation of the lateral RA resulted in profound bradycardia due to exit block from the peri-sinus node myocardium. CONCLUSIONS: Complex ablation lesions in patients with prior valve surgery, prior ablation, or atrial myopathy may result in unintended localized conduction block in the RA. In some cases, isolation of the lateral RA can result in complete sinus exit block with profound bradycardia requiring pacemaker implantation.

Splenic rupture after elective cardioversion.

Splenic laceration and rupture are common phenomena among patients in a traumatic setting, especially in blunt trauma. Much more unusual, however, is splenic injury without a known insult. Several case reports and studies have been written about spontaneous splenic injury in patients with viral, haematological or malignant processes. Recently, we encountered a patient with a spontaneous splenic rupture and no preceding trauma apart from semielective cardioversion. Operative decision-making was complicated by the fact that he required systemic anticoagulation for atrial fibrillation. He eventually underwent splenectomy and made an uneventful recovery.

Outcome after catheter ablation for left atrial flutter.

Objectives. Left atrial flutter has been reported in up to 10% of patients following pulmonary vein isolation or cardiac surgery. Left atrial flutter is typically highly symptomatic, responds poorly to medical antiarrhythmic treatment, and is often treated by catheter ablation. We aimed to investigate midterm freedom from recurrent arrhythmia after catheter ablation for left atrial flutter. Design. In the National Danish Ablation Registry, we identified consecutive patients, who had undergone catheter ablation for left atrial flutter between 1 January 2014 and 1 April 2017 at our centre. Results. A total of 53 patients (median age 68 years (IQR 60-71) 37 (70%) male) were included. Forty-two patients had prior left atrial catheter ablation procedures (79%), one patient prior ablation for classic atrial flutter (2%), four patients had prior surgery for congenital heart disease (8%), and six patients (11%) had no previous cardiac intervention. Acute procedural success, defined as non-inducibility of any atrial arrhythmia, was achieved in 45 of 53 patients (85%). During midterm follow-up (mean 20 ± 12 months), 26 patients experienced an episode of recurrent atrial arrhythmia. Median EHRA-score was 3 (range 2-4) before catheter ablation and reduced to median 1 (range 1-3) evaluated at follow-up visits after three and twelve months (both p < .001, Wilcoxon rank test). Conclusion. Left atrial flutter is preceded by catheter ablation or cardiac surgery in 89% of patients. Acute procedural success is achieved in majority of patients and ablation reduces symptoms effectively. During midterm follow-up, almost half the patients experience recurrent atrial arrhythmia.

Mechanism, underlying substrate and predictors of atrial tachycardia following atrial fibrillation ablation using the second-generation cryoballoon.

BACKGROUND: Data regarding atrial tachycardia (AT) following second-generation cryoballoon ablation (CBA) of atrial fibrillation (AF) are limited. AIM: To describe the incidence, mechanisms, and clinical predictors of ATs following CBA. METHODS AND RESULTS: In this retrospective single-center study 238 patients undergoing CBA for treatment of paroxysmal (91/238; 38.2%) or persistent AF were analyzed. During a mean follow-up of 11.9 ± 5.5 months recurrence of AF occurred in 49/238 patients (20.6%) and AT in 27/238 (11.3%). Twenty-six patients with AT and 14 with AF only underwent a redo ablation. The prevailing mechanism of AT was macroreentry [typical atrial flutter (AFL) (n = 10), left atrial macroreentry (n = 14), focal left-AT (n = 2)]. Non-cavotricuspid-isthmus-dependent macroreentry right-AT was mapped and ablated in 3 patients after initial AFL ablation. In a multivariate regression model, persistent type of AF (HR = 3.3; CI = 1.2-9.4), cardiomyopathy (HR = 3.5; CI = 1.5-8.4), treatment with beta-blockers (HR = 0.3; CI = 0.1-0.6), and pulmonary vein-abnormality (HR = 4.6; CI = 2.1-10.4) were independent predictors of AT. Substrate analysis revealed a significantly higher number of low voltage areas in the left atrium in patients with left-AT in comparison to patients with AF recurrence only (2.0; IQR=2.0-4.0 vs. 0.5; IQR = 0.0-2.25; p = 0.005). CONCLUSION: In this study, AT after CBA occurred in 11.3% of patients with macroreentry being the prevalent mechanism. All patients with left-AT presented with low voltage areas in the left atrium, suggesting a more progressive underlying fibrotic disease in these patients.

Arritmias e alterações cardíacas no paciente cirrótico / Arrhythmias and cardiac alterations in the cirrhotic patient

No Brasil, a cirrose é um problema de saúde pública, que afeta aproximadamente 2 milhões de pessoas. As causas mais comuns são a doença hepática alcoólica, as hepatites virais e a doença hepática não alcoólica. A relação entre desordens cardíacas e hepatopatias é descrita na literatura, e a mais importante delas é o prolongamento do intervalo QT. A cirrose, independente de sua causa, é uma patologia frequentemente encontrada na população brasileira. Por este motivo, elucidar dados referentes às arritmias cardíacas em pacientes cirróticos é de grande importância dentro do estudo desta subpopulação. O objetivo deste artigo é fazer uma revisão de literatura com as informações referentes a epidemiologia, fisiopatologia, fatores de risco e prognóstico para as arritmias cardíacas em portadores de cirrose. (AU)

In Brazil, cirrhosis is a public health problem affecting approximately 2 million people. The most common causes are alcoholic liver disease, viral hepatitis, and non-alcoholic liver disease. The relationship between cardiac disorders and liver diseases is described in the literature, and the most important one is the QT interval prolongation. Cirrhosis, regardless of its causes, is a pathology that is frequently found in the Brazilian population. For this reason, elucidating data regarding cardiac arrhythmias in cirrhotic patients is of great importance within the study of this subpopulation. The aim of this article is to review the literature with information on the epidemiology, pathophysiology, risk factors, and prognosis for cardiac arrhythmias in patients with cirrhosis. (AU)