Cardioneuroablation for the treatment of reflex syncope and functional bradyarrhythmias: A Scientific Statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS) and the Latin American Heart Rhythm Society (LAHRS).

Cardioneuroablation has emerged as a potential alternative to cardiac pacing in selected cases with vasovagal reflex syncope, extrinsic vagally induced sinus bradycardia-arrest or atrioventricular block. The technique was first introduced decades ago, and its use has risen over the past decade. However, as with any intervention, proper patient selection and technique are a prerequisite for a safe and effective use of cardioneuroablation therapy. This document aims to review and interpret available scientific evidence and provide a summary position on the topic.

Evaluation of a new treadmill exercise protocol to unmask type 1 Brugada electrocardiographic pattern: can we improve diagnostic yield?

AIMS: High precordial leads (HPL) on the resting electrocardiogram (ECG) are widely used to improve diagnostic detection of type 1 Brugada ECG pattern (Br1ECGp). A parasympathetic activation marks the initial recovery phase of treadmill stress testing (TET), and this can be useful for detecting the typical ECG pattern. Our study aimed to evaluate the role of a new HPL-treadmill exercise testing (TET) protocol in detecting Br1ECGp fluctuation compared to resting HPL-ECG. METHODS AND RESULTS: 74 out of 163 patients of a Brugada syndrome (BrS) Brazilian cohort (GenBra Registry) underwent exercise testing with HPL-TET protocol. Precordial leads were displayed in strategic positions in the right and left parasternal spaces. The step-by-step analysis included ECG classification (as presence or absence of Br1ECGp) in standard vs. HPL leads placement in the following sequences: resting phase, maximal exercise, and the passive recovery phase (including 'quick lay down'). For heart rate recovery (HRR) measurements and comparisons, a Student's t-test was applied. McNemar tests compared the detection of Br1ECGp. The significance level was defined as P < 0.05. Fifty-seven patients (57/74; 77%) were male, the mean age was 49.0 ± 14, 78.4% had spontaneous BrS, and the mean Shanghai score was 4.5. The HPL-TET protocol increased Br1ECGp detection by 32.4% against resting HPL-ECG (52.7% vs. 20.3%, P = 0.001) alone. CONCLUSION: Stress testing using HPL with the passive recovery phase in the supine position offers an opportunity to unmask the type 1 Br1ECGp, which could increase the diagnostic yield in this population.

Management of massive hemopericardium in the electrophysiology laboratory: The double long sheath technique.

AIM: To describe a simple and useful technique for acute management of massive hemopericardium inside the Electrophysiology (EP) laboratory METHODS AND RESULTS: Five patients from a single center experience were identified, all with blood loss above 1000 ml after initial pericardiocenthesis. Using two long 8.5 F transseptal sheaths inside the pericardium space, with continuous negative pressure, allowed the complete cessation of bleeding or hemodynamic maintenance until definitive surgical repair in all patients CONCLUSION: The use of two long sheaths for blood drainage, instead of conventional pericardiocenthesis, might be helpful to manage massive hemopericardium inside EP lab, avoiding urgent cardiac surgery or maintaining clinical stability until surgical staff is available.

Prognosis of chronic Chagas heart disease and other pending clinical challenges.

In this chapter, the main prognostic markers of Chagas heart disease are addressed, with an emphasis on the most recent findings and questions, establishing the basis for a broad discussion of recommendations and new approaches to managing Chagas cardiopathy. The main biological and genetic markers and the contribution of the electrocardiogram, echocardiogram and cardiac magnetic resonance are presented. We also discuss the most recent therapeutic proposals for heart failure, thromboembolism and arrhythmias, as well as current experience in heart transplantation in patients suffering from severe Chagas cardiomyopathy. The clinical and epidemiological challenges introduced by acute Chagas disease due to oral contamination are discussed. In addition, we highlight the importance of ageing and comorbidities in influencing the outcome of chronic Chagas heart disease. Finally, we discuss the importance of public policies, the vital role of funding agencies, universities, the scientific community and health professionals, and the application of new technologies in finding solutions for better management of Chagas heart disease.

A novel treatment for esophageal lesions following atrial fibrillation ablation.

This study presents a novel technique for the treatment of a deep esophageal ulcer after ablation of paroxysmal atrial fibrillation (AF). Pulmonary vein isolation was performed using a radiofrequency irrigated tip catheter. On Day 5 of follow-up, a deep esophageal ulcer was observed. No significant visual improvement was observed after conventional treatment. Endoscopic negative pressure therapy in the esophagus was then applied for 5 days. A significant decrease in diameter and depth of the lesion was observed, possibly preventing perforation. Endoscopic negative pressure therapy can be used to heal thermal lesions after AF ablation procedures.

Impact of adherence to warfarin therapy during 12 weeks of pharmaceutical care in patients with poor time in the therapeutic range.

Poor adherence to warfarin treatment is a contributor to poor quality of treatment, which increases the risk of bleeding and thromboembolic events. This study aims to evaluate the impact of adherence to warfarin therapy on anticoagulation quality during 12 weeks of pharmaceutical care and after 1 year of follow-up for patients with atrial fibrillation and with poor TTR. The Arrhythmia Unit of tertiary hospital in Brazil. We included 262 patients with AF and poor quality of anticoagulation therapy with warfarin (TTR < 50%). Pharmacist-driven therapy management was performed for 12 weeks and patients were also evaluated 1 year after the end of the follow-up with a pharmacist. Adherence was classified into high adherence, medium adherence and low adherence. Impact of adherence to warfarin therapy after pharmaceutical care. Of the 262 patients, 160 were high adherence, 71 were medium adherence and 31 were low adherence. No statistically significant difference is found between adherence groups in demographic and clinical variables. The TTR basal means were not different among adherence groups (p = 0.386). However, the means of TTR 12 weeks and TTR 1 year after the end of protocol were statistically different among adherence groups (p < 0.001 and p = 0.002, respectively). When we compared TTR values at different times within the adherence group, we observed that there is a statistical difference between the three TTR means (basal versus 12 weeks versus 1 year after) within the adherence group (p < 0.001). Patients with poor anticoagulation control, who adhered to the treatment with warfarin during the pharmaceutical care had better anticoagulation quality compared to those who did not adhere to the therapy with warfarin.

Anatomic guided ablation of the atrial right ganglionated plexi is enough for cardiac autonomic modulation in patients with significant bradyarrhythmias.

INTRODUCTION: Cardiac autonomic system modulation by endocardial ablation targeting atrial ganglionated plexi (GP) is an alternative strategy in selected patients with severe functional bradyarrhythmias, although no consensus exists on the best ablation strategy. The aim of this study was to evaluate if a simplified approach by a purely anatomical guided ablation of just the atrial right GP is enough for the treatment of these patients. METHODS: We prospectively enrolled patients with significant functional bradyarrhythmias and performed endocardial ablation purely guided by 3D electroanatomic mapping directed at the atrial right GP and accessed parameters of parasympathetic modulation and recurrence of bradyarrhythmias. RESULTS: Thirteen patients enrolled (76.9% male, median age 51, 42-63 years). After ablation, a median RR interval shortening of 28.3 (25.6-40.3)% occurred (1111, 937.5-1395.4 ms to 722.9, 652.2-882.4 ms, p = 0.0002). The AH interval also shortened (19, 10.5-35.7%) significantly after the procedure (115, 105-122 ms to 85, 71-105 ms, p = 0.0023) as well as Wenckebach cycle length (11.1, 5.9-17.8% shortening) from 450, 440-510 ms to 430, 400-460 ms, p = 0.0127. On 24-h Holter monitoring there was significant increase in heart rates (HR) of patients after ablation (minimal HR increased from 34 (26-43)bpm to 49 (43-56)bpm, p = 0,0102 and mean HR from 65 (47-72)bpm to 78 (67-87)bpm, p = 0.0004). No patients had recurrence of symptoms or significant bradyarrhythmias during a median follow-up of 8.4 months. CONCLUSIONS: A purely anatomic guided procedure directed only at the atrial right ganglionated plexi seems to be enough as a therapeutic approach for cardioneuroablation in selected patients with significant functional bradyarrhythmias.

Low rate of life-threatening events and limitations in predicting invasive and noninvasive markers of symptoms in a cohort of type 1 Brugada syndrome patients: Data and insights from the GenBra registry.

BACKGROUND: Brugada syndrome (BrS) has diagnostic challenges and controversial risk assessment. We aimed to investigate invasive and noninvasive parameters in symptomatic and asymptomatic patients from a Brazilian cohort of type-1 BrS. METHODS: Patients with spontaneous and drug-induced type-1 BrS were classified into two groups, asymptomatic (n = 116, 84.1%) and symptomatic (n = 22, 15.9%; 13 with arrhythmogenic syncope, 9 with aborted sudden cardiac death). Genetic testing, EPS parameters, and electrocardiogram (ECG) parameters were analyzed. RESULTS: A total of 138 consecutive patients were eligible, 101 men (73.2%), mean 41.4 years, mostly probands (79%). Spontaneous pattern, observed in 77.5% of the patients, was associated with symptoms only if expressed in V1 and V2 standard position (not high precordial leads; p = .014). All symptomatic patients were probands. The presence of right ventricular outflow tract conduction delay (RVOTcd) signs, positive EPS, and SCN5A status was similar between symptomatic and asymptomatic subjects. During the mean 75-month follow-up, eight patients had appropriate therapies. All had spontaneous type-1 ECG pattern and 2/8 (25%) were asymptomatic, with positive EPS. The overall LAE incidence of 1.1% per year dropped to 0.27% in asymptomatic patients. RVOTcd occurred more frequently in SCN5A carriers (QRS-f 33.3% vs. 7.7%; p = .005, AVR sign 58.3% vs. 13.6%; p < .001; deep S in lead I 75% vs. 48.5%, p = .025%), as well as longer HV interval (66 vs. 49 ms; p < .001). CONCLUSIONS: Spontaneous type-1 Brugada pattern in standard leads and proband status were more frequent in symptomatic subjects. RVOTcd, more common in SCN5A carriers, did not predict symptoms in BrS patients. EPS exhibited limited prognostic value for this low-risk population.

Comparative study of strategies to prevent esophageal and periesophageal injury during atrial fibrillation ablation.

OBJECTIVE: To compare the prevalence of esophageal and periesophageal thermal injury in patients undergoing radiofrequency (RF) atrial fibrillation (AF) ablation using 8 mm tip catheters during three different esophageal protection strategies. METHODS: Forty-five consecutive patients with paroxysmal or persistent AF underwent first ablation procedure, besides esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS) performed before and after the pulmonary vein (PV) isolation. Before the procedure, patients were randomly assigned to one of three esophageal lesion protection strategies: group I-without any protective or monitoring dispositive and limiting RF applications to 30 W for 20 seconds, in left atrium posterior wall (LAPW); group II-power and time of RF delivery, up to 50 W for 20 seconds at LAPW, limited by esophageal temperature monitoring; group III-applications of RF in LAPW with fixed power application of 50 W for 20 seconds during continuous esophageal cooling. RESULTS: Baseline characteristics of patients were similar in all groups. The four PVs were isolated in 14 (93.3%), 13 (86.7%), and 15 (100%) patients, respectively in groups I, II, and III. The mean RF power was significantly higher (P < .001) in the posterior side of PVs in group III. Post-AF ablation EGD and EUS revealed two esophageal wall ulcerations and two periesophageal mediastinal edemas only in the esophageal cooling group (P = .008). CONCLUSION: Esophageal cooling balloon strategy resulted in a higher RF power energy delivery when ablating at the LA posterior wall, using 8 mm nonirrigated tip catheters under temperature mode control. Despite that, patients presented a relatively low incidence of esophageal and periesophaeal injuries.

Catheter ablation of the parahisian accessory pathways from the aortic cusps-Experience of 20 cases-Improving the mapping strategy for better results.

INTRODUCTION: Catheter ablation of the parahisian accessory pathways (PHAP) has been established as the definitive therapy for this type of arrhythmia. However, the PHAP proximity to the normal atrioventricular conduction system makes the procedure technically challenging. Here, we have reported a case series of 20 patients with PHAP who underwent aortic access ablation to evaluate the safety and efficacy of this approach in the PHAP ablation. METHODS AND RESULTS: The ablation through the aortic cusps was the successful approach in 13 of 20 (65%) of the cases. In 11 patients, the aortic approach was the initial strategy for ablation, and the accessory pathway was eliminated in seven (63.6%) of them. The aortic approach followed a failed right-sided attempt in nine patients. In six (66.7%) patients, the ablation was successful with the aortic approach. The only independent predictor for the successful ablation with each approach was the earliest ventricular activation before delta wave (predelta time) and a right-sided earliest ventricular activation of more than 23 ms had high sensitivity and specificity for right-sided success. Systematically using the two strategies (right and left approaches), the ablation of the PHAP was successful in 18 (90%) patients. CONCLUSION: The aortic approach seems to be a safe and effective strategy for the ablation of PHAP. It can be used when the right-sided approach fails or even considered as an initial strategy when the predelta time is less than 23 ms in the right septal region. When combining the right- and left-sided approaches, the success rate is high. We believe that the retrograde aortic approach remains a key tool for this challenging ablation.

Accuracy of the pacemaker event recorder versus Holter-ECG to detect both symptomatic and asymptomatic ventricular arrhythmias.

BACKGROUND: Although new pacemakers can register cardiac rhythm, few studies were performed evaluating their accuracy in diagnosing ventricular arrhythmias (VA). This study aimed to assess the correlation and agreement between the pacemaker's monitor and the ambulatory Holter in detecting VA. METHODS AND RESULTS: We studied 129 patients with pacemakers, mean age 68.6 ± 19.1 years, 54.8% female. Once Holter monitoring was connected, the pacemakers' event counters were reset and clocks of both systems were synchronized to register electrocardiograms (ECG) simultaneously. Pacemakers were programmed to detect the lowest ventricular rate and lowest number of sequential beats allowed in their event monitors. After 72 hours, Holter and pacemakers records were analyzed. VA was defined in Holter and event monitor, respectively, as: isolated premature ventricular complexes: "PVC"; pairs: "couplets"; nonsustained ventricular tachycardia (NSVT): "triplets"-3 beats; "runs"-4-8 or > 8 beats, and high ventricular rates ("HVR")-3-4 beats. Spearman correlations evaluated whether pacemaker and Holter identified the same parameters. Intraclass correlation coefficients (ICCs) and respective 95% confidence intervals were calculated to assess the concordance between methods. The agreement between both systems was low, except for "triplet" and three beats NSVT (ICC = 0.984). The correlation for more than 10 PVC/h was moderate (Kappa = 0.483). When the pacemaker was programmed to detect HVR sequences of three beats lower than 140 bpm (< 140/3), the correlation with NSVT was perfect (r = 1) and agreement was also quite high (ICC = 0.800). CONCLUSIONS: Pacemakers' event monitors underestimate the occurrence of ventricular arrhythmias detected by Holter. Standardization of pacemakers' algorithms is required before using this function for patients' clinical follow-up.

Atrial-oesophageal fistula following percutaneous radiofrequency catheter ablation of atrial fibrillation: the risk still persists.

Aims: Atrial-oesophageal fistula is a serious complication related to ablation of atrial fibrillation. As its occurrence is rare, there is a great lack of information about their mechanisms, incidence, presentations, and treatment. The objective of this manuscript is to present a series of cases of atrial-oesophageal fistula in Brazil, focusing on incidence, clinical presentation, and follow-up. Methods and results: This is a retrospective multicentre registry of atrial-oesophageal fistula cases that occurred in eight Brazilian centres from 2003 to 2015. Ten cases (0.113%) of atrial-oesophageal fistula were reported in 8863 ablation procedures in the period. Most of the subjects were male (70%) with age 59.6 ± 9.3 years. Eight centres were reference units in atrial fibrillation ablation with an experience over than 200 procedures at the time of fistula occurrence. Oesophageal temperature monitoring was performed in eight cases using coated sensors in six. The first atrial-oesophageal fistula clinical manifestation was typically fever (in six patients), with a median onset time of 16.5 (12­43) days after ablation. There was a delay of 7.8 ± 3.3 days between the first manifestation and the diagnosis in five patients. The treatment was surgical in six cases, clinical in three and stenting in one. Seven patients died (70%) and two developed permanent neurological sequelae. Conclusion: Atrial-oesophageal fistula remains a serious complication following AF ablation despite the incorporation of protective measures and increased technical experience of the groups. The high morbidity and mortality despite the treatment indicates the need to develop adequate preventive strategies.

Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block.

AIMS: Asymptomatic nocturnal long ventricular pauses are usually detected accidentally and it has been suggested that they may lead to sudden death. Identification of predisposing factors could prevent cardiovascular events. METHODS AND RESULTS: We report the case of a patient with frequent asymptomatic nocturnal ventricular pauses of 3-11 s, characteristic of a vagally mediated atrioventricular (AV) block. Echocardiography, treadmill test, thyroid function test levels, and polysomnogram were normal. In an attempt to reduce the risk, it was decided that an atrial vagal denervation induced by radiofrequency (RF) ablation (cardioneuroablation) could be useful. Spectral mapping was used to localize endocardial vagal innervation in the right and left aspects of the inter-atrial septum, responsible for the sinus node and AV node modulation, and RF pulses were applied in those sites only. After finishing the procedure, significant changes were observed in the heart rate (66-90 b.p.m.), atrial-His interval (115-74 ms), Wenckebach cycle length (820-570 ms), and sinus node recovery time (1100-760 ms). Follow-up Holter recording demonstrated that the number of ventricular pauses had reduced from 438 to 0. Heart rate and time domain characteristics were compatible with vagal denervation. CONCLUSION: Ablation of the endocardial vagal innervation sites seems to be safe and efficient in reducing the frequency and the length of the ventricular pauses. It was possible by identifying certain spectral components of the atrial electrogram, resulting in a conservative approach.

Evaluation of a pharmacogenetic-based warfarin dosing algorithm in patients with low time in therapeutic range - study protocol for a randomized controlled trial.

BACKGROUND: Time in therapeutic range (TTR) is a measurement of quality of warfarin therapy and lower TTR values (<50%) are associated with greater risk of thromboembolic and bleeding events. Recently, we developed a pharmacogenetic-based warfarin dosing algorithm specifically calibrated for a Brazilian patient sample. The aims of this study are: to evaluate the impact of a genetic-based algorithm, compared to traditional anticoagulation, in the time to achieve the therapeutic target and in TTR percentage; and to assess the cost-effectiveness of genotype-guided warfarin dosing in a specific cohort of patients with low TTR (<50%) from a tertiary cardiovascular hospital. METHODS/DESIGN: This study is a randomized controlled trial in patients (n = 300) with atrial fibrillation with TTR < 50%, based on the last three INR values. At the first consultation, patients will be randomized into two groups: TA group (traditional anticoagulation) and PA group (pharmacogenetic anticoagulation). For the first group, the physician will adjust the dose according to current INR value and, for the second group, a pharmacogenetic algorithm will be used. At the second, third, fourth and fifth consultations (with an interval of 7 days each) INR will be measured and, if necessary, the dose will be adjusted based on guidelines. Afterwards, patients who are INR stable will begin measuring their INR in 30 day intervals; if the patient's INR is not stable, the patient will return in 7 days for a new measurement of the INR. Outcomes measures will include the time to achieve the therapeutic target and the percentage of TTR at 4 and 12 weeks. In addition, as a secondary end-point, pharmacoeconomic analysis will be carried out. Ethical approval was granted by the Ethics Committee for Medical Research on Human Beings of the Clinical Hospital of the University of São Paulo Medical School. DISCUSSION: This randomized study will include patients with low TTR and it will evaluate whether a population-specific genetic algorithm might be more effective than traditional anticoagulation for a selected group of poorly anticoagulated patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02592980 . Registered on 29 October 2015.

The morphology of the coronary sinus in patients with congenitally corrected transposition: implications for cardiac catheterisation and re-synchronisation therapy.

Patients with congenitally corrected transposition frequently benefit from re-synchronisation therapy or ablation procedures. This is likely to require catheterisation of the coronary sinus. Its anatomy, however, is not always appreciated, despite being well-described. With this caveat in mind, we have evaluated its location and structure in hearts with congenitally corrected transposition in order to reinforce the guidance needed by the cardiac interventionist. We dissected and inspected the coronary sinus, the oblique vein of the left atrium, and the left-sided-circumflex venous channel in eight heart specimens with corrected transposition and eight controls, measuring the orifice and length of the sinus and the atrioventricular valves. In two-thirds of the malformed hearts, the sinus deviated from its anticipated course in the atrioventricular groove, ascending obliquely on the left atrial inferior wall to meet the left oblique vein. The maximal deviation coincided in all hearts with the point where the left oblique vein joined the left-sided-circumflex vein to form the coronary sinus. We describe a circumflex vein, rather than the great cardiac vein, as the latter venous channel is right-sided in the setting of corrected transposition. The length of the sinus correlated positively with the diameter of the tricuspid valve (p=0.02). Compared with controls, the left oblique vein in the malformed hearts joined the circumflex venous channel significantly closer to the mouth of the sinus. The unexpected course of the coronary sinus in corrected transposition and the naming of the cardiac veins have important implications for venous cannulation and interpretation of images.

Differential diagnosis of wide QRS tachycardias: comparison of two electrocardiographic algorithms.

AIMS: This study's aim is to compare the ability of two ECG criteria to differentiate ventricular (VT) from supraventricular tachycardia (SVT): Brugada et al. [horizontal plane (HP) leads] and Vereckei et al. [frontal plane (FP), specifically aVR lead], having electrophysiological study (EPS) as gold standard. After comparing, suggestions for better diagnosis of wide QRS-complex tachycardia (WCT) in emergency situations were made. METHODS AND RESULTS: Fifty-one consecutive patients with 12-lead ECG registered during EPS-induced regular WCT were selected. Each ECG was split into two parts: HP (V1-V6) and FP (D1-D3, aVR, aVL, and aVF), randomly distributed to three observers, blinded for EPS diagnosis and complementary ECG plane, resulting in total 306 ECG analyses. Observers followed the four steps of both algorithms, counting time-to-diagnosis. Global sensitivity, specificity, percentage of incorrect diagnoses, and step-by-step positive/negative likelihood ratios (+LR and -LR) were calculated. Kaplan-Meier curve was plotted for final time-to-diagnosis. Inter-observer agreement was assessed with kappa-statistic. Global sensitivity was similarly high in FP and HP algorithms (89.2 vs. 90.1%), and incorrect classifications were 27.4 vs. 24.7%. Forty-eight correct analyses by Vereckei criteria took 9.13 s to diagnose VT in the first step, showing that first step was fast, with high +LR, generating nearly conclusive pre- (72.6%) to post-test (98.0%) changes for VT probability. CONCLUSION: Both algorithms as a whole are similar for diagnosis of WTC; however, the first step of Vereckei (initial R in aVR) is a simple, reproducible, accurate, and fast tool to use. The negativity of this step requires a 'holistic' approach to distinguish VT from SVT.