ABSTRACT
Embolic cerebral protection devices are not routinely used in clinical practice during electrophysiological interventions. We report a case series of patients with intracardiac thrombosis undergoing a percutaneous left atrial appendage (LAA) closure and a ventricular tachycardia (VT) catheter ablation supported by TriGuard 3 Cerebral Embolic Protection Device.
Subject(s)
Atrial Appendage , Atrial Fibrillation , Embolic Protection Devices , Heart Diseases , Thrombosis , Humans , Atrial Fibrillation/surgery , Treatment Outcome , Atrial Appendage/surgery , Thrombosis/surgeryABSTRACT
Pulmonary vein isolation and left atrial posterior wall ablation using the Farapulse system, followed by left atrial appendage occlusion, have been achieved as single combined procedure to treat long-standing persistent atrial fibrillation in a patient at high hemorrhagic risk.
ABSTRACT
The rate of post-vaccine myocarditis is being studied from the beginning of the massive vaccination campaign against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although a direct cause-effect relationship has been described, in most cases, the vaccine pathophysiological role is doubtful. Moreover, it is not quite as clear as having had a previous myocarditis could be a risk factor for a post-vaccine disease relapse. A 27-year-old man presented to the emergency department for palpitations and pericardial chest pain radiated to the upper left limb, on the 4th day after the third dose of BNT162b2 vaccine. He experienced a previous myocarditis 3 years before, with full recovery and no other comorbidities. Electrocardiogram showed normal atrioventricular conduction, incomplete right bundle branch block, and diffuse ST-segment elevation. A cardiac echo showed lateral wall hypokinesis with preserved ejection fraction. Troponin-T was elevated (160 ng/L), chest X-ray was normal, and the SARS-CoV-2 molecular buffer was negative. High-dose anti-inflammatory therapy with ibuprofen and colchicine was started; in the 3rd day high-sensitivity Troponin I reached a peak of 23000 ng/L. No heart failure or arrhythmias were observed. A cardiac magnetic resonance was performed showing normal biventricular systolic function and abnormal tissue characterization suggestive for acute non-ischaemic myocardial injury (increased native T1 and T2 values, increased signal intensity at T2-weighted images and late gadolinium enhancement, all findings with matched subepicardial distribution) at the level of mid to apical septal, anterior, and anterolateral walls. A left ventricular electroanatomic voltage mapping was negative (both unipolar and bipolar), while the endomyocardial biopsy showed a picture consistent with active myocarditis. The patient was discharged in good clinical condition, on bisoprolol 1.25 mg, ramipril 2.5 mg, ibuprofen 600 mg three times a day, colchicine 0.5 mg twice a day. We presented the case of a young man with history of previous myocarditis, admitted with a non-complicated acute myopericarditis relapse occurred 4 days after SARS-CoV-2 vaccination (3rd dose). Despite the observed very low incidence of cardiac complications following BNT162b2 administration, and the lack of a clear proof of a direct cause-effect relationship, we think that in our patient this link can be more than likely. In the probable need for additional SARS-CoV-2 vaccine doses in the next future, studies addressing the risk-benefit balance of this subset of patient are warranted. We described a multidisciplinary management of a case of myocarditis recurrence after the third dose of SARS-CoV-2 BNT162b2 vaccine.
ABSTRACT
BACKGROUND: Electroanatomic voltage mapping (EVM) is a promising modality for guiding endomyocardial biopsies (EMBs). However, few data support its feasibility and safety. We now report the largest cohort of patients undergoing EVM-guided EMBs to show its diagnostic yield and to compare it with a cardiac magnetic resonance (CMR)-guided approach. METHODS: We included 162 consecutive patients undergoing EMB at our institution from 2010 to 2019. EMB was performed in pathological areas identified at EVM and CMR. CMR and EVM sensitivity and specificity regarding the identification of pathological substrates of myocardium were evaluated according to EMB results. RESULTS: Preoperative CMR showed late gadolinium enhancement in 70% of the patients, whereas EVM identified areas of low voltage in 61%. Right (73%), left (19%), or both ventricles (8%) underwent sampling. EVM proved to have sensitivity similar to CMR (74% versus 77%), with specificity being 70% and 47%, respectively. In 12 patients with EMB-proven cardiomyopathy, EVM identified pathological areas that had been undetected at CMR evaluation. Sensitivity of pooled EVM and CMR was as high as 95%. EMB analysis allowed us to reach a new diagnosis, different from the suspected clinical diagnosis, in 39% of patients. The complications rate was low, mostly related to vascular access, with no patients requiring urgent management. CONCLUSIONS: EVM proved to be a promising tool for targeted EMB because of its sensitivity and specificity for identification of myocardial pathological substrates. EVM was demonstrated to have accuracy similar to CMR. EVM and CMR together conferred a positive predictive value of 89% on EMB.
Subject(s)
Contrast Media/administration & dosage , Electrophysiologic Techniques, Cardiac , Gadolinium/administration & dosage , Heart Ventricles , Magnetic Resonance Imaging , Myocardium , Adult , Biopsy , Female , Heart Ventricles/diagnostic imaging , Heart Ventricles/physiopathology , Humans , Male , Middle AgedABSTRACT
AIMS: Radiofrequency catheter ablation (RFCA) represents an effective option for idiopathic premature ventricular contractions (PVCs) treatment. Ablation Index (AI) is a novel ablation marker incorporating RF power, contact force, and time of delivery into a single weighted formula. Data regarding AI-guided PVCs RFCA are currently lacking. Aim of the study was to compare AI-guided and standard RFCA outcomes in patients with PVCs originating from the right ventricle outflow tract (RVOT). METHODS AND RESULTS: Consecutive patients undergoing AI-guided RFCA of RVOT idiopathic PVCs were prospectively enrolled. Radiofrequency catheter ablation was performed following per-protocol target cut-offs of AI, depending on targeted area (RVOT free wall AI cut-off: 590; RVOT septum AI cut-off: 610). A multi-centre cohort of propensity-matched (age, sex, ejection fraction, and PVC site) patients undergoing standard PVCs RFCA was used as a comparator. Sixty AI-guided patients (44.2 ± 18.0 years old, 58% male, left ventricular ejection fraction 56.2 ± 3.8%) were enrolled; 34 (57%) were ablated in RVOT septum and 26 (43%) patients in the RVOT free wall area. Propensity match with 60 non-AI-guided patients was performed. Acute outcomes and complications resulted comparable. At 6 months, arrhythmic recurrence was more common in non-AI-guided patients whether in general (28% vs. 7% P = 0.003) or by ablated area (RVOT free wall: 27% vs. 4%, P = 0.06; RVOT septum 29% vs. 9% P = 0.05). Ablation Index guidance was associated with improved survival from arrhythmic recurrence [overall odds ratio 6.61 (1.95-22.35), P = 0.001; RVOT septum 5.99 (1.21-29.65), P = 0.028; RVOT free wall 11.86 (1.12-124.78), P = 0.039]. CONCLUSION: Ablation Index-guidance in idiopathic PVCs ablation was associated with better arrhythmic outcomes at 6 months of follow-up.
Subject(s)
Catheter Ablation , Ventricular Premature Complexes , Adult , Catheter Ablation/adverse effects , Electrocardiography , Female , Heart Ventricles/diagnostic imaging , Heart Ventricles/surgery , Humans , Male , Middle Aged , Proof of Concept Study , Prospective Studies , Stroke Volume , Treatment Outcome , Ventricular Function, Left , Ventricular Premature Complexes/diagnosis , Ventricular Premature Complexes/surgeryABSTRACT
AIMS: To provide long-term outcome data on arrhythmogenic cardiomyopathy (ACM) patients with non-classical forms [left dominant ACM (LD-ACM) and biventricular ACM (Bi-ACM)] and an external validation of a recently proposed algorithm for ventricular arrhythmia (VA) prediction in ACM patients. METHODS AND RESULTS: Demographic, clinical, and outcome data were retrieved from all ACM patients encountered at our institution. Patients were classified according to disease phenotype (R-ACM; Bi-ACM; LD-ACM). Overall and by phenotype long-term survival were calculated; the novel Cadrin-Tourigny et al. algorithm was used to calculate the a priori predicted VA risk, and it was compared with the observed outcome to test its reliability. One hundred and one patients were enrolled; three subgroups were defined (R-ACM, n = 68; Bi-ACM, n = 14; LD-ACM, n = 19). Over a median of 5.41 (2.59-8.37) years, the non-classical form cohort experienced higher rates of VAs than the classical form [5-year freedom from VAs: 0.58 (0.43-0.78) vs. 0.76 (0.66-0.89), P = 0.04]. The Cadrin-Tourigny et al. predictive model adequately described the overall cohort risk [mean observed-predicted risk difference (O-PRD): +6.7 (-4.3, +17.7) %, P = 0.19]; strafing by subgroup, excellent goodness-of-fit was demonstrated for the R-ACM subgroup (mean O-PRD, P = 0.99), while in the Bi-ACM and LD-ACM ones the real observed risk appeared to be underestimated [mean O-PRD: -20.0 (-1.1, -38.9) %, P < 0.0001; -22.6 (-7.8, -37.5) %, P < 0.0001, respectively]. CONCLUSION: Non-classical ACM forms appear more prone to VAs than classical forms. The novel prediction model effectively predicted arrhythmic risk in the classical R-ACM cohort, but seemed to underestimate it in non-classical forms.
Subject(s)
Arrhythmogenic Right Ventricular Dysplasia , Follow-Up Studies , Humans , Phenotype , Reproducibility of Results , Risk FactorsABSTRACT
Cryoballoon ablation was developed as a new treatment for pulmonary vein (PV) isolation and has demonstrated high procedural success and comforting long-term clinical outcome. However, some improvements are necessary for real-time visualization of PV signals that appeared important to increase the efficacy and reduce ineffective cryoapplications. We report, for the first time, a cryoablation procedure using the fourth-generation cryoballoon, describing betterment in vein signal recording and acute procedural success.
Subject(s)
Atrial Fibrillation/surgery , Cryosurgery/instrumentation , Pulmonary Veins/surgery , Atrial Fibrillation/diagnostic imaging , Equipment Design , Humans , Male , Middle Aged , Operative Time , Tomography, X-Ray ComputedABSTRACT
BACKGROUND: The novel fourth-generation cryoballoon (CB4) potentially allows for enhanced catheter maneuverability and more frequent capture of pulmonary vein (PV) potentials which can be used to monitor real-time PV isolation (PVI). The aim of our study is to compare the acute procedural endpoints between the CB4 and second-generation cryoballoon (CB2). METHODS: A single-center retrospective chart review was used to examine 50 consecutive patients with drug-refractory atrial fibrillation undergoing CB4-based PVI. Procedural data and acute success of these patients were compared to 50 propensity-matched controls who underwent cryoballoon ablation procedure using CB2. RESULTS: Procedures performed with the CB4 showed significant shorter fluoroscopy time (14.8 ± 5.5 vs 18.0 ± 6.5 minutes, P = .04), shorter procedure time (58.3 ± 15.7 vs 65.3 ± 21 minutes, P = .13), and shorter total ablation time (10.8 ± 1.5 vs 13.8 ± 1.9 minutes, P = .42). The real-time PVI visualization rate was 33.3% in the CB2 group and 74.7% in the CB4 group (P < .001). CB4 was correlated to significant increase of acute real-time recordings with regard to all the single PV (left superior PV: 58% vs 84%, P = .02; left inferior PV: 26% vs 71%, P = .001; right superior PV 29% vs 61%, P = .01; and right inferior PV 19% vs 58%, P = .002). CONCLUSION: The CB4 was more often able to capture real-time recordings of PV potentials and the subsequent acute PV isolation.
Subject(s)
Atrial Fibrillation/surgery , Balloon Occlusion/instrumentation , Cryosurgery/instrumentation , Pulmonary Veins/surgery , Female , Fluoroscopy , Humans , Male , Middle Aged , Operative Time , Propensity Score , Retrospective StudiesABSTRACT
OBJECTIVE: Pregnancy can trigger maternal tachycardias, and the onset of recurrent or incessant focal atrial tachycardia (AT) can lead to tachycardia-induced cardiomyopathy. Medical interventions are commonly employed, but they carry potential fetal and maternal risks. Catheter ablation (CA), particularly with non-fluoroscopic navigation systems, may be considered as an alternative. This systematic review aims to explore the feasibility and outcomes of CA for focal AT during pregnancy. METHODS: A thorough literature search was conducted until September 30th, 2023, on PubMed, Embase, and Cochrane databases. Included articles described maternal focal ATs diagnosed through electrophysiological studies and treated with CA. Data derived from these studies were organized into tables and subsequently analyzed. RESULTS: Out of 278 papers reviewed, 15 articles involving 24 patients were retrieved. CA, utilizing radiofrequency energy achieved acute success in 95.8% of cases. Sixteen patients (66.7%) underwent complete fluoroless procedures, with two adverse events directly related to the procedure reported. Long-term follow-up revealed minimal AT recurrences, with a 0.06% arrhythmia burden in one case. CONCLUSION: Focal ATs during pregnancy can be incessant and refractory to medical intervention, precipitating an acute decline in left ventricular ejection fraction. In this setting, CA emerges as an efficacious treatment modality, particularly in cases of tachycardia-induced cardiomyopathies. Whenever feasible, it is advisable to perform these procedures with minimal or no fluoroscopy guidance. Larger studies are needed to establish the safety and the efficacy of CA for focal ATs during pregnancy, as current research consists of case reports or small case series.
ABSTRACT
BACKGROUND: A new intracardiac leadless pacemaker (ILP) has been developed to ensure atrioventricular (AV) synchrony (AVS) during ventricular pacing (VP). Recent studies have shown the feasibility and safety of accelerometer-based atrial sensing and an improvement in AVS among patients with atrioventricular block implanted with the Micra AV ILP (Medtronic Inc., Minneapolis, MN, USA). However, no data exists about the benefits of a VDD ILP in patients wearing a still working VVI Nanostim ILP (St Jude Medical, St Paul, MN, USA). We describe the feasibility of the procedure and the absence of device-related adverse events in the short-term follow-up. CASE SUMMARY: We present the case of a 72-year-old man implanted with a VVI ILP (Nanostim, St Jude Medical, St Paul, MN, USA) on May 2014, who has developed symptomatic high percentage of VVI asynchronous pacing and was treated with an upgrade to synchronous AV pacemaker (PM) ILP-Micra AV (Medtronic Inc., Minneapolis, MN, USA), which has improved symptoms and functional class. DISCUSSION: Intracardiac leadless pacemakers represent the best current option for patients requiring PM implantation who are at high risk of infection and bleeding. Our case shows that the new AVS ILP is a good alternative to VVI ILP in patients with sinus rhythm and a strong need for VP.
ABSTRACT
OBJECTIVES: This study aimed to assess the long-term outcomes of minimally fluoroscopic approach (MFA) compared with conventional fluoroscopic ablation (ConvA) in terms of recurrences of arrhythmia and long-term complications. BACKGROUND: Catheter ablation (CA) of supraventricular tachycardia (SVT) with an MFA, under the guidance of electroanatomic mapping (EAM) systems, results in a significant reduction in exposure to ionizing radiations without impairing acute procedural success and complication rate. However, data regarding long-term outcomes of MFA compared with ConvA are lacking. METHODS: This is a retrospective observational study. All patients undergoing MFA CA of SVT (atrioventricular nodal re-entrant tachycardia and atrioventricular re-entrant tachycardia) between 2010 and 2015 were enrolled and were compared with matched subjects (1 MFA: 2 ConvA) undergoing ConvA during the same period. The 2 co-primary outcomes were recurrence of arrhythmias and long-term complications. RESULTS: A total of 618 patients (mean age 38 ± 15 years, 60% female) were enrolled. MFA included 206 patients, whereas 412 were treated with ConvA. Acute success (99% vs. 97%; p = 0.10) and acute complications (2.4% vs. 5.3%; p = 0.14) were similar in the 2 groups. During a median follow-up of 4.4 years, 5.9% of patients experienced recurrence of arrhythmias. At multivariate analysis, ConvA (hazard ratio [HR]: 3.03) and procedural success (HR: 0.10) were independently associated with recurrence of arrhythmias. Late complications (i.e., advance atrioventricular block and need for pacemaker implantation) occurred more frequently in ConvA (3.4% vs. 0.5%; p = 0.03) compared with MFA. CONCLUSIONS: CA guided by EAM systems with MFA provided better long-term results and reduced risk of complications compared with ConvA.
Subject(s)
Catheter Ablation , Tachycardia, Supraventricular , Tachycardia, Ventricular , Adult , Female , Fluoroscopy , Humans , Male , Middle Aged , Tachycardia, Supraventricular/surgery , Treatment Outcome , Young AdultABSTRACT
PURPOSE: Catheter ablation (CA) procedures are characterized by exposure to ionizing radiations (IR). IR can cause DNA damage and may lead to carcinogenesis if not efficiently repaired. The primary endpoint of this study is to investigate whether intravenous administration of N-acetylcysteine prior to CA procedure may prevent systemic oxidative stress and genomic DNA damage induced by exposure to IR. METHODS: The "Cardiac Arrhythmia catheter ablation procedures guided by x-Ray imaging: N-Acetylcysteine Protection Against radiation induced Cellular damagE" (CARAPACE) study is a prospective, randomized, single-blinded, parallel-arm monocenter study enrolling 550 consecutive patients undergoing CA at the Arrhythmology Unit of Centro Cardiologico Monzino (CCM). Inclusion criteria are age ≥ 18, indication for CA procedure guided by IR imaging, and written informed consent. IR levels will be measured via fluoroscopy time, effective dose, and dose area product. Glutathione and glutathione disulfide concentrations will be measured, and urinary levels of 8-iso-prostaglandin-F2α and 8-hydroxy-2-deoxyguanosine will be quantified. The enrolled patients will be randomized 1:1 to the N-acetylcysteine group or to the control group. RESULTS: We expect that pre-operative administration of N-acetylcysteine will prevent IR-induced systemic oxidative stress. The study will provide data on oxidative DNA damage assessed by urinary 8-hydroxy-2-deoxyguanosine levels and direct evidence of genomic DNA damage in blood cells by comet assay. CONCLUSION: Catheter ablation procedures can lead to IR exposure and subsequent DNA damage. N-acetylcysteine administration prior to the procedure may prevent them and therefore lead to less possible complications. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT04154982).
Subject(s)
Acetylcysteine , Catheter Ablation , Adolescent , Adult , Arrhythmias, Cardiac , Fluoroscopy , Humans , Prospective Studies , X-RaysABSTRACT
BACKGROUND: We aim to evaluate the value of Cardiac magnetic resonance (CMR) feature tracking (CMR-FT) in addition to Task Force Criteria(TFC) in patients with (arrhythmogenic cardiomyopathy) AC biopsy-proved. METHODS: Thirty-five patients with AC histologically proven who performed CMR with late gadolinium enhancement (LGE) acquisition were enrolled. The study population was divided in Group1 (negative CMR TFC and LV ejection fraction≥55%) and Group2 (positive CMR TFC and/or LVEF<55%) and compared to an age and gender-matched control group. CMR datasets of all patients were analyzed to calculate LV indexed end-diastolic (LVEDi) and end-systolic (LVESi) volumes and RV indexed end-diastolic (RVEDi) and end-systolic (RVESi) volumes, both LV ejection fraction (LVEF) and RV ejection fraction (RVEF). Moreover, LV and RV global longitudinal (GLS), circumferential (GCS) and radial (GRS) strain were measured. RESULTS: The AC patients showed both higher LVEDi (p:0.002) and RVEDi (p:0.017) and lower LVEF (p: 0.016) as compared to control patients. Moreover, AC patients showed impaired LV-GLS (p < 0.001), LV-GRS (p < 0.001), LV-GCS (p < 0.001) and RV-GRS (p:0.026) as compared to control subjects. Group1 patients showed a significant reduction of LV-GRS (p < 0.05) and LV-GCS p < 0.01) as compared to control subjects. At univariate analysis LV-GCS was the most discriminatory parameter between Group1 vs heathy subjects with an optimal cut-off of -15.8 (Sensitivity: 74%; Specificity: 10%). CONCLUSIONS: In patients with AC biopsy-proven, CMR-FT could improve the diagnostic yield in the subset of patients who results negative for imaging TFC criteria resulting as useful gatekeeper for indication of myocardial biopsy in case of equivocal clinical and imaging presentation.
Subject(s)
Cardiomyopathies , Contrast Media , Biopsy , Gadolinium , Humans , Magnetic Resonance Imaging, Cine , Magnetic Resonance Spectroscopy , Predictive Value of Tests , Stroke Volume , Ventricular Function, LeftABSTRACT
PURPOSE: Since the introduction of catheter ablation as a mainstream treatment for atrial fibrillation (AF), several technical improvements have been put forward. In this contest, Ablation Index (AI) is an accurate ablation quality marker by incorporating power, delivery time, contact force (CF), and catheter stability in a weighted formula. The aim of our study is to evaluate the efficacy of AI-guided AF ablation over 24 month follow-up. METHODS: We evaluated 72 consecutive patients with drug-refractory paroxysmal (66.7%) and early-persistent AF (33.3%) undergoing AI-guided ablation, compared to 72 propensity-matched control patients who underwent CF-guided procedure. All procedures were performed by three skilled operators. Data concerning procedural characteristics and long-term freedom from AF recurrence were analyzed. RESULTS: At 24-month follow-up, Kaplan-Meier curves of AF recurrence were significantly lower in AI group than in CF group (15.5% vs. 30.6%; p 0.042). These findings were confirmed in a sub analysis regardless of the continued use of antiarrhythmic drugs in the follow-up (42.2% in AI-guided group and 66.7% in CF-guided group, p 0.004). At 24-month follow-up, a positive trend in the decrease of arrhythmia recurrences was observed in AI-guided ablation for all operators. CONCLUSIONS: AI-guided ablation results more effective than CF-guided ablation as demonstrated by a lower incidence of AF recurrences regardless of the use of antiarrhythmic drugs in the follow-up. Each operator seems to improve the long-term success using an AI-guided ablation, thus showing both the efficacy and the reproducibility of this approach.
Subject(s)
Atrial Fibrillation/surgery , Catheter Ablation/standards , Quality Improvement , Quality Indicators, Health Care , Female , Humans , Male , Middle Aged , Propensity Score , Prospective Studies , Reproducibility of ResultsABSTRACT
BACKGROUND: Arrhythmogenic left ventricular cardiomyopathy (ALVC) is an under-characterized phenotype of arrhythmogenic cardiomyopathy involving the LV ab initio. ALVC was not included in the 2010 International Task Force Criteria for arrhythmogenic right ventricular cardiomyopathy diagnosis and data regarding this phenotype are scarce. METHODS: Clinical characteristics were reported from all consecutive patients diagnosed with ALVC, defined as a LV isolated late gadolinium enhancement and fibro-fatty replacement at cardiac magnetic resonance plus genetic variants associated with arrhythmogenic right ventricular cardiomyopathy and of an endomyocardial biopsy showing fibro-fatty replacement complying with the 2010 International Task Force Criteria in the LV. RESULTS: Twenty-five patients ALVC (53 [48-59] years, 60% male) were enrolled. T wave inversion in infero-lateral and left precordial leads were the most common ECG abnormalities. Overall arrhythmic burden at study inclusion was 56%. Cardiac magnetic resonance showed LV late gadolinium enhancement in the LV lateral and posterior basal segments in all patients. In 72% of the patients an invasive evaluation was performed, in which electroanatomical voltage mapping and electroanatomical voltage mapping-guided endomyocardial biopsy showed low endocardial voltages and fibro-fatty replacement in areas of late gadolinium enhancement presence. Genetic variants in desmosomal genes (desmoplakin and desmoglein-2) were identified in 12/25 of the cohort presenting pathogenic/likely pathogenic variants. A definite/borderline 2010 International Task Force Criteria arrhythmogenic right ventricular cardiomyopathy diagnosis was reached only in 11/25 patients. CONCLUSIONS: ALVC presents with a preferential involvement of the lateral and postero-lateral basal LV and is associated mostly with variants in desmoplakin and desmoglein-2 genes. An amendment to the current International Task Force Criteria is reasonable to better diagnose patients with ALVC.
Subject(s)
Arrhythmogenic Right Ventricular Dysplasia/diagnosis , Desmoglein 2/genetics , Desmoplakins/genetics , Genetic Variation , Heart Rate , Myocardium/pathology , Arrhythmogenic Right Ventricular Dysplasia/genetics , Arrhythmogenic Right Ventricular Dysplasia/pathology , Arrhythmogenic Right Ventricular Dysplasia/physiopathology , Biopsy , Electrocardiography , Electrophysiologic Techniques, Cardiac , Female , Genetic Predisposition to Disease , Genetic Testing , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Phenotype , Predictive Value of Tests , RegistriesABSTRACT
BACKGROUND: Nowadays, transvenous lead extraction (TLE) is considered an essential technique in lead management strategy. Since 2011, a multidisciplinary approach was undertaken in our centre involving electrophysiologists, cardiac surgeons and anaesthesiologists to improve cross- unit cooperation and minimize complications and mortality. The present paper reports procedural outcomes and complications of our lead extraction experience. METHODS: We retrospectively collected and analysed data from all consecutive patients undergoing cardiac implantable electronic device leads TLE at the IRCCS Centro Cardiologico Monzino between January 2011 and November 2017. RESULTS: One-hundred fifty patients (111 males, 68⯱â¯13â¯years) underwent extraction procedures. The most common extraction indication were infections (86.7%) and TLE was carried out by laser-based approach in 88 (58.6%) patients, by mechanical dilating sheaths in 58 (38.7%) patients and by a combined approach (TLEâ¯+â¯open surgical intervention) in 4 (2.7%) patients. Procedural success was obtained in 146 (97.3%) cases with only 3 (2.0%) major complications with 2 cases of structural injury with tamponade requiring emergent median sternotomy. Open surgery extraction was required in 4 patients, after an attempt to TLE, due to leads strict adhesion to cardiac or vascular structures, whereas in 5 (3.3%) cases, the treatment of choice was a combined approach consisting in transvenous leads extraction followed by planned surgery. CONCLUSIONS: TLE is a complex procedure that sometimes leads to fatal complications. In our single center experience, a multidisciplinary approach involving electrophysiologist, cardiac surgeon, anaesthesiologist in an operating room allows a safer approach and major complications treatment.
Subject(s)
Cardiac Electrophysiology/methods , Defibrillators, Implantable/adverse effects , Device Removal/methods , Intraoperative Care/methods , Patient Care Team , Surgeons , Aged , Aged, 80 and over , Cardiac Electrophysiology/standards , Device Removal/standards , Female , Humans , Intraoperative Care/standards , Male , Middle Aged , Patient Care Team/standards , Retrospective Studies , Surgeons/standardsABSTRACT
PURPOSE: Previous studies indicate force time integral (FTI) as a radiofrequency (RF) lesion quality marker, while not considering power supply. Tacticath™ Quartz catheter provides Lesion index (LSI), a lesion quality marker derived by contact force (CF), power supply, and RF time combined. Our aim is to assess LSI and FTI correlation and a LSI-related cutoff of atrial fibrillation (AF) recurrences 12 months after pulmonary vein isolation (PVI). METHODS: We retrospectively enrolled 37 patients who underwent RF ablation using Tacticath™ Quartz catheter. AF recurrence rate was evaluated 3, 6, and 12 months after PVI procedure. RESULTS: AF recurrence was detected in 32% of patients. FTI mean value was significantly lower in left superior pulmonary vein (LSPV: 256 ± 86 gs vs 329 ± 117 gs, p = 0.05) and right inferior pulmonary vein (RIPV: 253 ± 128 gs vs 394 ± 123 gs p = 0.006) in patients with AF recurrences; no significant differences were found in right superior pulmonary vein (RSPV) and left inferior pulmonary vein (LIPV). LSI instead was significantly higher for all veins in patients without AF recurrences: LSPV (5.2 ± 0.7 vs 4.6 ± 0.8, p = 0.03), LIPV (5.0 ± 0.8 vs 4.5 ± 0.6, p = 0.04), RSPV (5.5 ± 0.6 vs 5.1 ± 0.6, p = 0.05), and RIPV (5.5 ± 0.7 vs 4.7 ± 0.8, p = 0.006). Receiver operator characteristic curve suggests 5.3 as LSI overall cutoff value predicting freedom from disease at 1-year follow-up. CONCLUSIONS: Our preliminary data suggest that a LSI mean value higher than 5.3 can be considered a good predictor of AF freedom at 1-year follow-up.
Subject(s)
Atrial Fibrillation/surgery , Pulmonary Veins/surgery , Radiofrequency Ablation/instrumentation , Echocardiography , Electrocardiography , Epicardial Mapping , Female , Humans , Male , Middle Aged , Recurrence , Retrospective StudiesABSTRACT
BACKGROUND: A lot of studies have shown a positive effect of transcatheter aortic valve implantation (TAVI) on left ventricular ejection fraction (LVEF). OBJECTIVES: We aimed to investigate the effect of TAVI on left ventricular function and correlate this phenomenon with hypertrophy degree in an early follow-up. MATERIALS AND METHODS: Between August 2015 and July 2016, 250 consecutive patients with symptomatic severe aortic stenosis (AS) underwent TAVI in our institution. Given the aim of this analysis, only patients with an LVEF <50%, no more than moderate mitral valve regurgitation, successful valve implantation, and 1-month follow-up available were included in the study (n = 46). Patients were enrolled in a prospective database, with clinical and echocardiographic evaluations at 1 month after TAVI. RESULTS: All patients had severe symptomatic AS (mean transaortic pressure gradients: 44.1 ± 13.8 mmHg and mean aortic valve area: 0.66 ± 0.19 cm2). Mean baseline LVEF was 39.3 ± 8.8%. Significant hemodynamic improvement was observed after TAVI. Mean transvalvular aortic gradient decreased significantly from 44.1 ± 13.8 mmHg to 8.9 ± 4.2 mmHg (P < 0.005). A statistically significant improvement in LVEF compared to baseline was observed in the 1st month of follow-up (39.3 ± 8.8% vs. 44.1 ± 10.1%, P < 0.019). Overall, 52.2% of patients showed an increase in LVEF, 32.6% had no change, while only 2.2% had a decrease in LVEF. Interestingly, we found a significant reverse correlation between LVEF improvement and ventricular hypertrophy measured as diastolic interventricular septum thickness (Pearson index r = -0.42). Patients showing greater improvement in LVEF were those with less than moderate hypertrophy. CONCLUSIONS: Patients with depressed systolic function show a consistent and early LVEF recovery after TAVI. An impaired LVEF recovery is most likely among patients with more than moderate hypertrophy, probably responsible of left ventricular fibrosis that irremediably compromises systolic function.
ABSTRACT
Background Long-term data on durability of currently available transcatheter heart valves are sparse. We sought to assess the incidence of long-term (8-year) structural valve dysfunction and bioprosthetic valve failure in a cohort of patients with transcatheter aortic valve replacement ( TAVR ) who reached at least 5-year follow-up. Methods and Results Consecutive patients with at least 5-year follow-up available undergoing TAVR from June 4, 2007 to March 30, 2012 were included. Structural valve dysfunction and bioprosthetic valve failure were defined according to newly standardized European Association of Percutaneous Cardiovascular Interventions/ European Society of Cardiology/European Association for Cardio-Thoracic Surgery criteria and reported as cumulative incidence function to account for the competing risk of death. A total of 288 consecutive patients with a mean age of 80.7±5.3 years and with a mean Society of Thoracic Surgery mortality score of 8.1±5.1% were analyzed. Survival rate at 8 years was 29.8%. Mean pressure gradients decreased from 53.3±15.9 mm Hg (pre- TAVR ) to 10.5±4.5 mm Hg (in-hospital post- TAVR ) ( P<0.001). There was a small, not significant, increase in the transaortic gradient throughout follow-up. Bioprosthetic valve failure was observed in a total of 11 patients (8-year cumulative incidence function: 4.51%; 95% confidence interval , 1.95%-8.76%). Severe and moderate structural valve dysfunctions were reported in 7 patients (8-year cumulative incidence function: 2.39%; 95% confidence interval, 0.77%-5.71%) and 13 patients (8-year cumulative incidence function: 5.87%; 95% confidence interval , 3.06%-9.96%), respectively. Aortic valve reintervention (redo TAVR ) was successfully performed in 2 patients (0.7%) presenting with symptomatic severe restenosis and intraprosthetic regurgitation subsequent to endocarditis. Conclusions In an aged population of patients with symptomatic severe aortic stenosis treated with first-generation bioprostheses, TAVR was associated with a survival rate of 30% but low rates of bioprosthetic valve failure and structural valve dysfunction at 8 years.
Subject(s)
Aortic Valve Stenosis/surgery , Bioprosthesis , Heart Valve Prosthesis , Prosthesis Failure , Transcatheter Aortic Valve Replacement , Aged , Aged, 80 and over , Aortic Valve , Female , Humans , Incidence , Male , Postoperative Complications/epidemiology , Recurrence , Reoperation , Severity of Illness IndexABSTRACT
AIMS: Long-term data on the durability of currently available transcatheter heart valves are limited. We sought to assess four-year clinical and echocardiographic outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) with the CoreValve prosthesis. METHODS AND RESULTS: Between June 2007 and February 2014, 450 consecutive patients with symptomatic severe aortic stenosis underwent TAVI in our institution. For the purposes of this study, we included only those patients undergoing successful TAVI with the CoreValve prosthesis who had a minimum follow-up of four years (n=125). Survival rates at one, two, three and four years were 83.2, 76.8, 73.6 and 66.3%, respectively. Aortic regurgitation was a common finding after the procedure, especially due to paravalvular regurgitation (PVR), which was observed in the majority of patients (71.5%), mostly mild (52.0%). Progression from mild acute PVR to moderate PVR at four-year follow-up was reported in three patients. No cases of severe PVR were observed. Prosthetic valve failure was reported in four patients (3.2%). CONCLUSIONS: Our study demonstrates that favourable outcomes after successful TAVI are associated with sustained clinical and functional cardiovascular beneï¬ts up to four-year follow-up. Signs of moderate prosthetic valve failure are present only in a small percentage of patients.