RESUMO
BACKGROUND: Catheter ablation is effective for eliminating most drug-refractory ventricular arrhythmias (VA). However, a major reason for procedural failure is arrhythmia originating deep within the myocardium where it is inaccessible to conventional endocardial or epicardial approaches. Affected patients have limited therapeutic options. OBJECTIVES: The objective of this study was to assess the safety and outcome of a novel radiofrequency ablation catheter that used an extendable/retractable 27-g needle capable of targeting deep arrhythmia (intramural) substrate. METHODS: Patients who failed at least one prior catheter ablation procedure for sustained ventricular tachycardia (VT) or nonsustained VA with associated left ventricular dysfunction were enrolled at 3 centers. The target was sustained monomorphic VT in 26 patients, including 8 with recent VT storm or VT requiring intravenous medication, and 5 with incessant VA associated with ventricular dysfunction. RESULTS: Needle ablation was performed in 31 patients (median of 2 failed prior ablation procedures; 71% nonischemic heart disease). After a median of 15 needle lesions/patient, ablation abolished at least 1 inducible VT in 19 of 26 VT patients (73%), and suppressed ambient arrhythmia in 4 of 5 nonsustained arrhythmia patients. At the 6-month follow-up, 48% of patients were free of recurrent arrhythmia and another 19% were improved. Procedure-related complications included a single pericardial effusion treated with percutaneous drainage and a left ventricular pacing lead dislodgement with no deaths. CONCLUSIONS: In patients with recurrent ventricular arrhythmias refractory to medications and conventional catheter ablation, intramural needle radiofrequency ablation offers significant arrhythmia control with an acceptable procedural risk.
Assuntos
Ablação por Cateter/métodos , Técnicas Eletrofisiológicas Cardíacas/métodos , Taquicardia Ventricular , Ablação por Cateter/efeitos adversos , Eletrocardiografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Derrame Pericárdico/etiologia , Derrame Pericárdico/terapia , Retratamento/métodos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/terapiaRESUMO
BACKGROUND: Right ventricular (RV)-scar related ventricular tachycardia (VT) is often due to arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) or cardiac sarcoidosis (CS), but some patients whose clinical course has not been described do not fulfill diagnostic criteria for these diseases. We sought to characterize the electrophysiologic substrate and catheter ablation outcomes of such patients, termed RV cardiomyopathy of unknown source (RCUS). METHODS AND RESULTS: Data of 100 consecutive patients who presented with RV cardiomyopathy and/or RV-related VT for ablation were reviewed (51 ARVC/D, 22 CS; 27 RCUS). Compared to ARVC/D, RCUS patients were older (P = 0.001), less commonly had RV dilatation (P = 0.001) or dysfunction (P = 0.01) and fragmented QRS, parietal block, and T-wave inversion. Compared to CS, R-CUS patients had less severe LV dysfunction. Extent and distribution of endocardial/epicardial scar and inducible VTs in RCUS patients were comparable with ARVC/D and CS patients. At a median follow-up of 23 months, RCUS patients had more favorable VT-free survival (RCUS 71%, ARVC/D 60%, CS 41%, P = 0.03) and survival free of death or cardiac transplant (RCUS 92%, ARVC/D 92%, CS 62%, P = 0.01). No RCUS patients developed new criteria for ARVC/D or CS in follow-up. CONCLUSIONS: Up to one-third of patients with RV scar-related VT are not classifiable as ARVC/D or CS. These patients had a somewhat better prognosis than ARVC/D or sarcoid and did not develop evidence of these diseases during the initial 2 years of follow-up. The extent to which this population comprises mild ARVC/D, CS, or other diseases is not clear.
Assuntos
Cardiomiopatias/complicações , Ablação por Cateter , Frequência Cardíaca , Ventrículos do Coração/cirurgia , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/cirurgia , Função Ventricular Direita , Potenciais de Ação , Adulto , Displasia Arritmogênica Ventricular Direita/diagnóstico , Displasia Arritmogênica Ventricular Direita/fisiopatologia , Cardiomiopatias/diagnóstico , Cardiomiopatias/fisiopatologia , Ablação por Cateter/efeitos adversos , Diagnóstico Diferencial , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Sarcoidose/diagnóstico , Sarcoidose/fisiopatologia , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Noninducibility of sustained monomorphic ventricular tachycardia (SMVT) postablation does not insure absence of later recurrence in patients with ischemic cardiomyopathy. This study aims to determine the relation between inducible nonsustained VT postablation and VT recurrences. METHODS AND RESULTS: One hundred sixty-five consecutive patients (156 male; age 68±9 years) underwent ablation for SMVT because of ischemic cardiomyopathy; 44 patients who did not have induction testing or in whom only ventricular fibrillation was induced after ablation were excluded. In 38 patients (23%), SMVT was inducible (group C). Of the 83 patients without inducible SMVT after ablation, nonsustained VT defined as ≥5 beats lasting for <30 s, was induced in 34 patients (group B, 21%), whereas the remaining 49 patients had no VT induced by the induction test (group A, 30%). Over a median follow-up of 18.7 months, freedom from recurrent VT at 24 months was 60% in group A, 45% in group B (P=0.017 versus group A), and 38% in group C (P=0.005 versus group A). In patients without inducible SMVT, inducible nonsustained VT and left ventricular ejection fraction was independently associated with VT recurrence (hazard ratio, 3.66 and 1.07; 95% CI, 1.3-11.1 and 1.01-1.14). CONCLUSIONS: Inducible nonsustained VT postablation suggests the continued presence of functional arrhythmia substrate. Further trials are needed to assess whether additional ablation would improve outcome in this group.
Assuntos
Cardiomiopatias/cirurgia , Ablação por Cateter/métodos , Taquicardia Ventricular/cirurgia , Idoso , Cardiomiopatias/fisiopatologia , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Humanos , Masculino , Recidiva , Taquicardia Ventricular/fisiopatologiaRESUMO
INTRODUCTION: Substrate-based ablation for scar-related ventricular tachycardia (VT) has gained prominence: however, there is limited data comparing it to ablation guided predominantly by activation and entrainment mapping of inducible and hemodynamically tolerated VTs. We compared the acute procedural efficacy and outcomes of predominantly substrate-based ablation versus ablation guided predominantly by activation and entrainment mapping. METHODS AND RESULTS: Database searches through April 2016 identified 6 eligible studies (enrolling 403 patients, with 1 randomized study) comparing the 2 strategies. The relative risk of VT recurrence at follow-up was assessed as the primary outcome using a random-effects meta-analysis. Secondary endpoints of acute success (based on noninducibility of VT), procedural complications, and mortality were assessed using weighted mean difference with the random effects model. At a median follow-up of 18 months, the relative risk (RR) of VT recurrence was not significantly different with substrate-based versus activation/entrainment guided VT ablation (0.72, 95% confidence interval [CI] 0.44-1.18), P = 0.2). Acute success (RR 1.02, 95% CI 0.95-1.1, P = 0.6), procedural complications (RR 0.8, 95% CI 0.35-1.82, P = 0.5) cardiovascular mortality and total mortality did not differ significantly (RR 0.83, 95% CI 0.38-1.79, P = 0.6 and RR 0.76, 95% CI 0.36-1.59, P = 0.5, respectively). CONCLUSIONS: This meta-analysis demonstrates similar acute procedural efficacy, and complications, VT recurrence and mortality rates when comparing a predominantly substrate-based ablation strategy to a strategy guided predominantly by activation and entrainment mapping of inducible and hemodynamically tolerated VTs.
Assuntos
Ablação por Cateter/métodos , Ventrículos do Coração/cirurgia , Taquicardia Ventricular/cirurgia , Potenciais de Ação , Ablação por Cateter/efeitos adversos , Ablação por Cateter/mortalidade , Distribuição de Qui-Quadrado , Técnicas Eletrofisiológicas Cardíacas , Feminino , Frequência Cardíaca , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Recidiva , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Resultado do TratamentoRESUMO
OBJECTIVE: We have previously demonstrated that the mechanism of nifedipine (NIF)-induced gingival overgrowth is related to the observation that proliferation and cell cycle progression of gingival fibroblasts derived from NIF reactive patient (NIFr) are greater than those from NIF non-reactive patient (NIFn). Gingival overgrowth has also been reported to be a result of inhibited apoptosis of gingival fibroblasts. Apoptosis in fibroblasts is induced by lipopolysaccharide (LPS). Thus, we focused upon evaluating whether there is a difference in LPS-induced apoptosis between NIFn and NIFr. METHODS: Both NIFn and NIFr were arrested in DMEM containing 0.5% FBS, stimulated by LPS, and assayed for apoptosis, cell cycle analysis, Western blotting, and caspase activity. RESULTS: Compared to NIFn, the number of apoptotic cells was significantly decreased and the percentage of cells in S and G(2)/M phase was significantly increased in NIFr. The levels of Bax and cytochrome c proteins in NIFr were not up-regulated by LPS compared with NIFn. Both NIFn and NIFr displayed the following changes in protein expression: increased Bad, decreased Bcl-xL, and unchanged Bcl-2 and p53. Caspase-3 and -9 activities were significantly increased by LPS in NIFn but were unchanged in NIFr. Caspase-2 activity remained constant whilst caspase-8 activity significantly increased upon LPS treatment in both NIFn and NIFr. CONCLUSION: Bad, Bax, cytochrome c, p53, and caspases-2, -3, -8, and -9 are pro-apoptotic proteins. Bcl-2 and Bcl-xL are anti-apoptotic proteins. Thus, the mechanism of NIF-induced gingival overgrowth might be related to decreased apoptosis in NIFr through a reduction of Bax, cytochrome c, and caspase-3 and -9.
Assuntos
Apoptose/efeitos dos fármacos , Fibroblastos/efeitos dos fármacos , Gengiva/efeitos dos fármacos , Crescimento Excessivo da Gengiva/patologia , Lipopolissacarídeos/farmacologia , Nifedipino/efeitos adversos , Vasodilatadores/efeitos adversos , Caspase 2/análise , Caspase 2/efeitos dos fármacos , Caspase 3/análise , Caspase 3/efeitos dos fármacos , Caspase 8/análise , Caspase 8/efeitos dos fármacos , Caspase 9/análise , Caspase 9/efeitos dos fármacos , Técnicas de Cultura de Células , Ciclo Celular/efeitos dos fármacos , Proliferação de Células/efeitos dos fármacos , Cisteína Endopeptidases/análise , Cisteína Endopeptidases/efeitos dos fármacos , Citocromos c/análise , Citocromos c/efeitos dos fármacos , Escherichia coli , Fase G2/efeitos dos fármacos , Gengiva/patologia , Crescimento Excessivo da Gengiva/induzido quimicamente , Humanos , Metáfase/efeitos dos fármacos , Proteínas Proto-Oncogênicas c-bcl-2/análise , Proteínas Proto-Oncogênicas c-bcl-2/efeitos dos fármacos , Fase S/efeitos dos fármacos , Proteína Supressora de Tumor p53/análise , Proteína Supressora de Tumor p53/efeitos dos fármacos , Proteína X Associada a bcl-2/análise , Proteína X Associada a bcl-2/efeitos dos fármacos , Proteína de Morte Celular Associada a bcl/análise , Proteína de Morte Celular Associada a bcl/efeitos dos fármacos , Proteína bcl-X/análise , Proteína bcl-X/efeitos dos fármacosRESUMO
BACKGROUND: We sought to characterize patients with persistent atrial fibrillation (AF) who were successfully treated by ablation targeting the left atrium (LA). METHODS AND RESULTS: Ninety-three patients (58±10 years, 79 male) undergoing ablation of persistent AF were studied. During the first procedure, ablation was performed in the LA and coronary sinus, consisting of pulmonary vein isolation, linear ablation, and electrogram-based ablation. During follow-up after the first procedure, 35 patients (38%) remained free from tachyarrhythmias, 27 patients (29%) had atrial tachycardia, and 31 patients (33%) had AF. Duration of persistent AF according to medical history and whether AF was terminated by ablation were associated with the outcome (P=0.005, P=0.004, respectively). In multivariate analysis, the duration of persistent AF was the only predictor of freedom from AF (sinus rhythm or atrial tachycardia) (odds ratio, 0.80 for a 1-year increase; 95% confidence interval, 0.67 to 0.95; P=0.01). Of 31 patients in whom AF recurred during follow-up, electrogram-based ablation was performed in the right atrium in 26 patients. Sixteen of those patients (62%) remained free from AF during follow-up. Overall, 82% of patients were free from any tachyarrhythmias at 2-year follow-up after a median of 2 procedures. CONCLUSIONS: Patients with shorter duration of persistent AF were more likely to be free from AF by LA ablation. Right atrial ablation may provide incremental efficacy in patients who are refractory to LA ablation.