Revascularization of coronary chronic total occlusions in an infarct-related artery and recurrence of ventricular arrhythmias among patients with secondary prevention implantable cardioverter defibrillator.

OBJECTIVES: To evaluate whether the revascularization of a coronary chronic total occlusion in an infarct-related artery (IRACTO) may be associated with lower recurrence of ventricular arrhythmias (VA) among patients with a secondary prevention implantable cardioverter defibrillator (ICD). BACKGROUND: IRACTO is increasingly recognized as an independent predictor of VA. It is unknown whether IRACTO revascularization can reduce the burden of VA. METHODS: Multicenter observational cohort study that included consecutive patients with prior myocardial infarction and secondary prevention ICD. The primary endpoint was any appropriate ICD therapy. RESULTS: Among the 460 patients included, 269 (58%) had at least one IRACTO at the coronary angiogram performed before ICD implantation; of these, 20 (7%) had their IRACTO successfully revascularized (IRACTO-R) afterwards. During a median follow-up of 48 months, 229 patients (49%) had at least one appropriate ICD therapy. Patients with IRACTO not revascularized (IRACTO-NR) had the highest incidence of ICD therapies (65%) while patients with IRACTO-R had the lowest (10%, p < .001). In the entire cohort, IRACTO-NR was an independent predictor of appropriate ICD therapies (HR 2.85, p < .001) and appropriate ICD shocks (HR 2.94, p < .001). Among patients with IRACTO at baseline, IRACTO-R was independently associated with a marked reduction of appropriate ICD therapies (HR 0.12, p = .002) and appropriate ICD shocks (HR 0.21, p = .03). CONCLUSIONS: In patients with prior myocardial infarction and secondary prevention ICD, IRACTO revascularization was independently associated with a markedly lower incidence of appropriate ICD therapies and shocks. These results should be corroborated by larger prospective studies.

Improved prediction of electrical storm in patients with prior myocardial infarction and implantable cardioverter defibrillator.

AIMS: To evaluate predictors of electrical storm (ES), including chronic total occlusion in an infarct-related coronary artery (infarct-related artery CTO, IRACTO), in a cohort of patients with prior myocardial infarction (MI) and implantable cardioverter-defibrillators (ICD). METHODS: Multicenter observational cohort study including 643 consecutive patients with prior MI and a first ICD implanted between 2005 and 2018 at three tertiary hospitals. All the patients included in the study had undergone a diagnostic coronary angiography before ICD implantation. The variable prior ventricular arrhythmias (VA+) was positive in patients with secondary prevention ICDs and in those with at least one appropriate ICD therapy after primary prevention implantation. RESULTS: During a median follow-up of 42 months 59 patients (9%) suffered ES. The presence of at least one IRACTO not revascularized (IRACTO-NR) was associated with a significantly higher cumulative incidence of ES (14.5% vs 4.8%, p < 0.001). IRACTO-NR maintained a significant association with ES after adjustment for potential confounders (HR 2.3, p = 0.005) and was an independent predictor of ES together with VA+ and LVEF. The best cut-off of LVEF to predict ES was ≤38%. A risk-prediction model based on IRACTO-NR, VA+ and LVEF≤38% identified three categories of ES risk (low, intermediate and high), with progressively increasing cumulative incidence of ES (2.2%, 9% and 20%). CONCLUSION: In a cohort of patients with prior MI and ICD, IRACTO-NR is an independent predictor of ES. A new risk-prediction model allowed the identification of three categories of risk, with potentially important clinical implications.

Comparative Study between Subcutaneous and Endovascular Defibrillator Recipients Regarding Tolerance to the Implant Procedure and Perception of Quality of Life. / Estudo Comparativo entre Receptores de Desfibriladores Subcutâneos e Transvenosos em Relação à Tolerância ao Procedimento de Implante e Percepção da Qualidade de Vida.

BACKGROUND: The totally subcutaneous implantable cardioverter-defibrillator (S-ICD) is a safe alternative to the conventional transvenous ICD (TV-ICD) system to prevent sudden death. OBJECTIVE: To compare the impact of the type of ICD system and surgical technique on patients' quality of life, as well as the severity of discomfort and pain, between S-ICD and TV-ICD recipients. METHODS: Consecutively implanted patients with an S-ICD system were matched with patients with a TV-ICD system. In addition, patients undergoing S-ICD implantation after removal of a TV-ICD due to complications were included. Quality of life (measured with the 12-item short-form health survey) and severity of pain and discomfort were evaluated. Statistical significance was defined as p < 0.05. RESULTS: A total of 64 patients implanted with S-ICD or TV-ICD under local anesthesia and conscious sedation were analyzed. Patients with S-ICD and TV-ICD systems did not differ significantly in quality of life scores. S-ICD patients had a higher level of perioperative pain; no differences were found regarding severity of intraoperative pain. The magnitude of aesthetic discomfort and sleep disturbances did not differ between groups. An S-ICD was implanted in 7 additional patients after removal of a TV-ICD. All but one of these patients recommended the S-ICD system. CONCLUSIONS: The type of ICD system and the surgical technique have negligible impact on patients' quality of life. These results suggest that conscious sedation, provided by an experienced electrophysiology team, could be considered as an alternative to general anesthesia to manage patients undergoing S-ICD implantation.

FUNDAMENTO: O cardioversor-desfibrilador implantável subcutâneo (S-CDI) é uma alternativa segura ao sistema convencional do CDI transvenoso (TV-CDI) para evitar morte súbita. OBJETIVO: Comparar o impacto do tipo de sistema de CDI e técnica cirúrgica na qualidade de vida dos pacientes, bem como a gravidade do desconforto e da dor, entre receptores de S-CDI e TV-CDI. MÉTODOS: Pacientes consecutivamente implantados com um sistema S-CDI foram pareados com pacientes com um sistema TV-CDI. Além disso, foram incluídos os pacientes submetidos ao implante de S-CDI após a remoção de um TV-CDI, devido a complicações. Foram avaliadas a qualidade de vida (medida com o questionário de saúde de 12 itens) e a gravidade da dor e desconforto. Significância estatística foi definida como p < 0,05. RESULTADOS: Foram analisados 64 pacientes implantados com S-CDI ou TV-CDI sob anestesia local e sedação consciente. Pacientes com sistemas S-CDI e TV-CDI não diferiram significativamente nos escores de qualidade de vida. Os pacientes com S-CDI apresentaram maior nível de dor peri-operatória; nenhuma diferença foi encontrada em relação à gravidade da dor intra-operatória. A magnitude do desconforto estético e dos distúrbios do sono não diferiu entre os grupos.O S-CDI foi implantado em 7 pacientes adicionais após a remoção de um TV-CDI. Todos exceto um desses pacientes recomendaram o sistema S-CDI. CONCLUSÕES: O tipo de sistema de CDI e a técnica cirúrgica têm impacto insignificante na qualidade de vida dos pacientes. Estes resultados sugerem que a sedação consciente, fornecida por uma equipe experiente de eletrofisiologia, pode ser considerada uma alternativa à anestesia geral para o manejo de pacientes submetidos ao implante de S-CDI.

Estudo Comparativo entre Receptores de Desfibriladores Subcutâneos e Transvenosos em Relação à Tolerância ao Procedimento de Implante e Percepção da Qualidade de Vida / Comparative Study between Subcutaneous and Endovascular Defibrillator Recipients Regarding Tolerance to the Implant Procedure and Perception of Quality of Life

Resumo Fundamento O cardioversor-desfibrilador implantável subcutâneo (S-CDI) é uma alternativa segura ao sistema convencional do CDI transvenoso (TV-CDI) para evitar morte súbita. Objetivo Comparar o impacto do tipo de sistema de CDI e técnica cirúrgica na qualidade de vida dos pacientes, bem como a gravidade do desconforto e da dor, entre receptores de S-CDI e TV-CDI. Métodos Pacientes consecutivamente implantados com um sistema S-CDI foram pareados com pacientes com um sistema TV-CDI. Além disso, foram incluídos os pacientes submetidos ao implante de S-CDI após a remoção de um TV-CDI, devido a complicações. Foram avaliadas a qualidade de vida (medida com o questionário de saúde de 12 itens) e a gravidade da dor e desconforto. Significância estatística foi definida como p < 0,05. Resultados Foram analisados 64 pacientes implantados com S-CDI ou TV-CDI sob anestesia local e sedação consciente. Pacientes com sistemas S-CDI e TV-CDI não diferiram significativamente nos escores de qualidade de vida. Os pacientes com S-CDI apresentaram maior nível de dor peri-operatória; nenhuma diferença foi encontrada em relação à gravidade da dor intra-operatória. A magnitude do desconforto estético e dos distúrbios do sono não diferiu entre os grupos.O S-CDI foi implantado em 7 pacientes adicionais após a remoção de um TV-CDI. Todos exceto um desses pacientes recomendaram o sistema S-CDI. Conclusões O tipo de sistema de CDI e a técnica cirúrgica têm impacto insignificante na qualidade de vida dos pacientes. Estes resultados sugerem que a sedação consciente, fornecida por uma equipe experiente de eletrofisiologia, pode ser considerada uma alternativa à anestesia geral para o manejo de pacientes submetidos ao implante de S-CDI.

Abstract Background The totally subcutaneous implantable cardioverter-defibrillator (S-ICD) is a safe alternative to the conventional transvenous ICD (TV-ICD) system to prevent sudden death. Objective To compare the impact of the type of ICD system and surgical technique on patients' quality of life, as well as the severity of discomfort and pain, between S-ICD and TV-ICD recipients. Methods Consecutively implanted patients with an S-ICD system were matched with patients with a TV-ICD system. In addition, patients undergoing S-ICD implantation after removal of a TV-ICD due to complications were included. Quality of life (measured with the 12-item short-form health survey) and severity of pain and discomfort were evaluated. Statistical significance was defined as p < 0.05. Results A total of 64 patients implanted with S-ICD or TV-ICD under local anesthesia and conscious sedation were analyzed. Patients with S-ICD and TV-ICD systems did not differ significantly in quality of life scores. S-ICD patients had a higher level of perioperative pain; no differences were found regarding severity of intraoperative pain. The magnitude of aesthetic discomfort and sleep disturbances did not differ between groups. An S-ICD was implanted in 7 additional patients after removal of a TV-ICD. All but one of these patients recommended the S-ICD system. Conclusions The type of ICD system and the surgical technique have negligible impact on patients' quality of life. These results suggest that conscious sedation, provided by an experienced electrophysiology team, could be considered as an alternative to general anesthesia to manage patients undergoing S-ICD implantation.

Ola de calor: desencadenante de tormenta arrítmica en un paciente con síndrome de Brugada / Heat wave: a trigger of electrical storm in a patient with brugada syndrome

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Vasoespasmo coronario asintomático y arritmias ventriculares graves / Asymptomatic Coronary Artery Spasm and Severe Ventricular Arrhythmias

El vasoespasmo coronario generalmente evoluciona con episodios de dolor torácico y elevación del ST. No obstante, existen casos de vasoespasmo sin dolor torácico con taquiarritmias ventriculares documentadas. Su incidencia se desconoce y debe incluirse en el diagnóstico diferencial de taquicardia o fibrilación ventricular idiopática. En esta presentación se describe el caso de un paciente con historia de dos cuadros sincopales sin cardiopatía estructural aparente. La monitorización electrocardiográfica continua objetivó episodios de elevación del ST que conducían a taquicardia ventricular polimorfa. Con el diagnóstico de vasoespasmo coronario asintomático se inició tratamiento con calcioantagonistas y se implantó un cardiodesfibrilador automático.

Coronary artery spasm usually results in episodes of chest pain and ST-segment elevation. However, it may occasionally occur in the absence of angina with documented severe ventricular arrhythmias. The incidence of this condition is unknown and should be included in the differential diagnosis of idiopathic ventricular tachycardia or fibrillation. We describe the case of a patient with a history of two episodes of syncope without apparent structural heart disease. Continuous ECG monitoring revealed the presence of episodes of ST-segment elevation leading to polymorphic ventricular tachycardia. Asymptomatic coronary artery spasm was diagnosed and treatment with calcium channel blockers was initiated; an implantable cardioverter defibrillator device was implanted.

Taquicardia de QRS ancho tras la administración de adenosina / Wide QRS-complex tachycardia following administration of adenosine

Las taquicardias regulares de QRS estrecho constituyen una patología frecuente en la práctica de los servicios de urgencia. El diagnóstico diferencial incluye taquicardias por reentrada aurículo-ventricular (intranodal o mediada por vía accesoria) y taquicardia auricular/flutter auricular. El tratamiento con maniobras vagales y adenosina es una práctica habitual ante este tipo de taquicardias. Presentamos el caso de un paciente con antecedentes de fibrilación auricular paroxística, en tratamiento habitual con flecainida, que presentó taquicardia regular de QRS estrecho a 205 lpm. Tras administrar adenosinase enlenteció transitoriamente la frecuencia cardiaca, para posteriormente presentar una taquicardia regular de QRS ancho a la misma frecuencia cardiaca de morfología aparentemente ventricular. Se trataba de un flutter auricular 1C con conducción aurículo-ventricular 1:1 con gran aberrancia de conducción debido al tratamiento con flecainiday favorecida puntualmente por el bloqueo aurículo-ventricular transitorio generado por la adenosina (AU)

Regular tachycardia with a narrow QRS complex is a common presenting complaint in emergency departments. The differential diagnosis includes atrioventricular reentrant tachycardia (intranodal or accessory pathway-mediated) and trial tachycardia (atrial flutter). These types of tachycardia are commonly treated using vagal maneuvers and adenosine.We describe a patient with a history of paroxysmal atrial fibrillation receiving regular treatment with flecainide who presented with a regular narrow QRS-complex tachycardia (205 beats/min). After administration of adenosine the heartrate slowed briefly; there followed regular wide QRS-complex tachycardia at the same rate as before and apparently ventricular in origin. The patient was in class 1C atrial flutter with 1:1 atrioventricular conduction; severe conduction disturbance due to flecainide treatment was intermittently exacerbated by the adenosine-induced atrioventricular block (AU)