RESUMO
Aims: To assess whether obstructive sleep apnea (OSA) was associated with increased rotor burden among atrial fibrillation (AF) patients. Methods and results: We studied 33 consecutive patients who were scheduled for focal impulse and rotor modulation (FIRM) ablation at our institution to describe the mapping, ablation, and outcomes, among patients with and without OSA. Patients underwent biatrial FIRM mapping in AF with ablation of stable rotors in addition to conventional ablation lesion sets. Differences between groups were tested with student's t-tests and Fisher's exact tests, as appropriate. Survival analyses were performed using the Kaplan-Meier method. Twelve of the 33 (36%) patients had OSA and 8 (66%) used continuous positive airway pressure ventilation (CPAP). Obstructive sleep apnea patients had a higher body mass index (BMI) (33.6 vs. 28.8 kg/m2, P = 0.01) and were more commonly on beta blockers (67% vs. 29%, P = 0.03) but were otherwise similar regarding baseline characteristics, medication use, and prior AF treatments, including antiarrhythmic drugs and prior ablation. Focal impulse and rotor modulation mapping demonstrated increased rotor burden in the OSA patients (2.6 ± 0.9 vs. 2.0 ± 1.0, P =0.03). The increased rotor burden was more evident in the right atrium (RA) (1.0 ± 0.7 vs. 0.5 ± 0.7, P =0.04 compared with left atrium (1.7 ± 0.8 vs. 1.4 ± 0.7, P = 0.15). There was no correlation between BMI and total number of rotors (r = 0.0961, P = 0.59). Among the population of patients with OSA, CPAP therapy was associated with a lower number of RA rotors (0.8 ± 0.7 vs. 1.5 ± 0.6, P = 0.05) but no significant difference in overall rotors (P = 0.33). Conclusion: Obstructive sleep apnea patients demonstrate increased rotor prevalence, driven predominantly by an increase in RA rotors. CPAP therapy was associated with fewer RA rotors.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter , Pressão Positiva Contínua nas Vias Aéreas , Sistema de Condução Cardíaco/cirurgia , Frequência Cardíaca , Apneia Obstrutiva do Sono/terapia , Potenciais de Ação , Idoso , Antiarrítmicos/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Polissonografia , Prevalência , Recidiva , Estudos Retrospectivos , Fatores de Risco , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/epidemiologia , Apneia Obstrutiva do Sono/fisiopatologia , Resultado do TratamentoRESUMO
INTRODUCTION: Approximately 10-20% of ICD recipients receive inappropriate device therapies. The purpose of this study was to compare the frequency of inappropriate therapies (IT) between men and women enrolled in MADIT II and MADIT-CRT, and assess for potential adverse outcomes. METHODS: The electrograms for each ICD or CRT-D therapy, defined as either ATP or shock, were reviewed by adjudication committees for both studies. ICD therapy was considered inappropriate if it was delivered for reasons other than VT/VF. The rhythm triggering IT was categorized as atrial fibrillation/flutter, SVT, or inappropriate sensing when possible. RESULTS: One thousand nine hundred and fifty-four men and 556 women received ICD or CRT-D devices. The risk of IT was significantly lower in women than men (9.2% vs. 13.5%, P = 0.006). The most common cause of IT in men was atrial fibrillation (38%) and SVT in women (43%). Inappropriate shock was not associated with increased mortality in either women (HR 0.82 [95% CI 0.11-6.08]; P = NS) or men (HR 1.37 [95% CI 0.75-2.48]; P = NS) by multivariate analysis. Conversely, appropriate shock therapy strongly correlated with increased risk of death during subsequent post-shock follow-up in women (HR 5.99 [95% CI 2.75-13.02]; P < 0.0001) and men (HR 2.61 [95% CI 1.82-3.74]; P < 0.0001). CONCLUSIONS: Women experience significantly less IT than men, partially explained by the increased frequency of atrial fibrillation in men. IT was not associated with increased mortality in either sex. Appropriate shock therapy was a strong predictor of death in both, with women showing a 2-fold higher risk than men during post-shock long-term follow-up.
Assuntos
Dispositivos de Terapia de Ressincronização Cardíaca , Terapia de Ressincronização Cardíaca , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Falha de Prótese , Taquicardia Ventricular/terapia , Fibrilação Ventricular/terapia , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/fisiopatologia , Terapia de Ressincronização Cardíaca/efeitos adversos , Terapia de Ressincronização Cardíaca/mortalidade , Morte Súbita Cardíaca/etiologia , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/mortalidade , Técnicas Eletrofisiológicas Cardíacas , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Fatores Sexuais , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/fisiopatologia , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Resultado do Tratamento , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/mortalidade , Fibrilação Ventricular/fisiopatologiaAssuntos
Eletrofisiologia Cardíaca/educação , Cardiopatias , Ablação por Cateter/métodos , Ablação por Cateter/normas , Competência Clínica , Educação , Cardioversão Elétrica/métodos , Cardioversão Elétrica/normas , Técnicas Eletrofisiológicas Cardíacas/métodos , Técnicas Eletrofisiológicas Cardíacas/normas , Bolsas de Estudo/métodos , Bolsas de Estudo/normas , Diretrizes para o Planejamento em Saúde , Cardiopatias/diagnóstico , Cardiopatias/terapia , HumanosAssuntos
Arritmias Cardíacas , Terapia de Ressincronização Cardíaca/métodos , Cardioversão Elétrica , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/terapia , Desfibriladores Implantáveis/normas , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/métodos , Técnicas Eletrofisiológicas Cardíacas/instrumentação , Técnicas Eletrofisiológicas Cardíacas/métodos , Frequência Cardíaca , Humanos , Teste de Materiais/métodos , Teste de Materiais/normas , Medição de RiscoAssuntos
Arritmias Cardíacas/terapia , Desfibriladores Implantáveis/normas , Cardioversão Elétrica/normas , Técnicas Eletrofisiológicas Cardíacas/normas , Teste de Materiais/normas , Implantação de Prótese/normas , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Consenso , Cardioversão Elétrica/instrumentação , Humanos , Valor Preditivo dos Testes , Desenho de Prótese , Implantação de Prótese/instrumentaçãoAssuntos
Cardiologia/educação , Ablação por Cateter , Educação de Pós-Graduação em Medicina , Cardioversão Elétrica , Técnicas Eletrofisiológicas Cardíacas , Cardiologia/normas , Ablação por Cateter/normas , Competência Clínica , Credenciamento , Currículo , Educação de Pós-Graduação em Medicina/normas , Cardioversão Elétrica/normas , Técnicas Eletrofisiológicas Cardíacas/normas , HumanosRESUMO
OBJECTIVES: We evaluated whether electrophysiologic (EP) inducibility predicts the subsequent occurrence of spontaneous ventricular tachycardia (VT) or ventricular fibrillation (VF) in the Defibrillators in Nonischemic Cardiomyopathy Treatment Evaluation (DEFINITE) trial. BACKGROUND: Inducibility of ventricular arrhythmias has been widely used as a risk marker to select implantable cardioverter defibrillator (ICD) candidates, but is believed not to be predictive in nonischemic cardiomyopathy patients. METHODS: In DEFINITE, patients randomized to the ICD arm, but not the conventional arm, underwent noninvasive EP testing via the ICD shortly after ICD implantation using up to three extrastimuli at three cycle lengths plus burst pacing. Inducibility was defined as monomorphic or polymorphic VT or VF lasting 15 seconds. Patients were followed for a median of 29 +/- 14 months (interquartile range = 2-41). An independent committee, blinded to inducibility status, characterized the rhythm triggering ICD shocks. RESULTS: Inducibility, found in 29 of 204 patients (VT in 13, VF in 16), was associated with diabetes (41.4% vs 20.6%, P = 0.014) and a slightly higher ejection fraction (23.2 +/- 5.9 vs 20.5 +/- 5.7, P = 0.021). In follow-up, 34.5% of the inducible group (10 of 29) experienced ICD therapy for VT or VF or arrhythmic death versus 12.0% (21 of 175) noninducible patients (hazard ratio = 2.60, P = 0.014). CONCLUSIONS: In DEFINITE patients, inducibility of either VT or VF was associated with an increased likelihood of subsequent ICD therapy for VT or VF, and should be one factor considered in risk stratifying nonischemic cardiomyopathy patients.
Assuntos
Estimulação Cardíaca Artificial/estatística & dados numéricos , Cardiomiopatias/diagnóstico , Cardiomiopatias/epidemiologia , Desfibriladores Implantáveis , Técnicas Eletrofisiológicas Cardíacas/métodos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/epidemiologia , Cardiomiopatias/prevenção & controle , Feminino , Humanos , Incidência , Masculino , Isquemia Miocárdica/complicações , Isquemia Miocárdica/diagnóstico , Reprodutibilidade dos Testes , Medição de Risco/métodos , Fatores de Risco , Sensibilidade e Especificidade , Taquicardia Ventricular/prevenção & controle , Estados Unidos/epidemiologiaRESUMO
UNLABELLED: In the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II, implantable cardioverter-defibrillator (ICD)-randomized patients underwent electrophysiologic testing. Both inducible and noninducible patients received an ICD. We correlated inducibility with the occurrence of subsequent ventricular tachycardia (VT) or ventricular fibrillation (VF). Intracardiac ICD electrograms for subsequent events were analyzed to categorize the spontaneous arrhythmia as VT or VF. The two-year Kaplan-Meier event rate for VT in inducible patients was 29.0% versus 19.3% in noninducible patients. However, ICD therapy for spontaneous VF was less common at two years in inducible patients (3.2%) than in noninducible patients (8.6%). In the MADIT II study, inducibility predicted an increased likelihood of VT but decreased VF. OBJECTIVES: We correlated electrophysiologic inducibility with spontaneous ventricular tachycardia (VT) or ventricular fibrillation (VF) in the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II. BACKGROUND: In the MADIT II study, 593 (82%) of 720 implantable cardioverter-defibrillator (ICD) randomized patients underwent electrophysiologic testing. Patients received an ICD whether they were inducible or not. METHODS: A "standard" inducibility definition included sustained monomorphic or polymorphic VT induced with three or fewer extrastimuli or VF induced with two or fewer extrastimuli. We compared a narrow inducibility definition (only monomorphic VT) and a broad definition (standard definition plus VF with three extrastimuli). We used ICD-stored electrograms to categorize spontaneous VT or VF. RESULTS: Inducible patients (standard definition) had a greater likelihood of experiencing ICD therapy for VT than noninducible patients (p = 0.023). Unexpectedly, ICD therapy for spontaneous VF was less common (p = 0.021) in inducible patients than in noninducible patients. The two-year Kaplan-Meier event rate for VT or VF was 29.4% for inducible patients and 25.5% for noninducible patients. Standard inducibility did not predict the combined end point of VT or VF (p = 0.280, by log-rank analysis). The narrow inducibility definition outperformed the standard definition, whereas the broad definition appeared inferior to the standard definition. CONCLUSIONS: In the MADIT II study patients, inducibility was associated with an increased likelihood of VT. Noninducible MADIT II study subjects using this electrophysiologic protocol had a considerable VT event rate and a higher VF event rate than inducible patients. Induction of polymorphic VT or VF, even with double extrastimuli, appears less relevant than induction of monomorphic VT.