RESUMO
AIMS: Ventricular tachycardia (VT) non-inducibility in response to programmed ventricular stimulation (PVS) is a widely used procedural endpoint for VT ablation despite inconclusive evidence with respect to clinical outcomes in high-risk patients. The aim is to determine the utility of acute post-ablation VT inducibility as a predictor of VT recurrence, mortality, or mortality equivalent in high-risk patients. METHODS AND RESULTS: We conducted a retrospective analysis of high-risk patients (defined as PAINESD > 17) who underwent scar-related VT ablation at our institution between July 2010 and July 2022. Patients' response to PVS (post-procedure) was categorized into three groups: Group A, no clinical VT or VT with cycle length > 240 ms inducible; Group B, only non-clinical VT with cycle length > 240 ms induced; and Group C, all other outcomes (including cases where no PVS was performed). The combined primary endpoint included death, durable left ventricular assist device placement, and cardiac transplant (Cox analysis). Ventricular tachycardia recurrence was considered a secondary endpoint (competing risk analysis). Of the 1677 VT ablation cases, 123 cases met the inclusion criteria for analysis. During a 19-month median follow-up time (interquartile range 4-43 months), 82 (66.7%) patients experienced the composite primary endpoint. There was no difference between Groups A and C with respect to the primary [hazard ratio (HR) = 1.21 (0.94-1.57), P = 0.145] or secondary [HR = 1.18 (0.91-1.54), P = 0.210] outcomes. These findings persisted after multivariate adjustments. The size of Group B (n = 13) did not permit meaningful statistical analysis. CONCLUSION: The results of post-ablation PVS do not significantly correlate with long-term outcomes in high-risk (PAINESD > 17) VT ablation patients.
Assuntos
Ablação por Cateter , Cicatriz , Recidiva , Taquicardia Ventricular , Humanos , Taquicardia Ventricular/fisiopatologia , Taquicardia Ventricular/cirurgia , Taquicardia Ventricular/etiologia , Taquicardia Ventricular/diagnóstico , Masculino , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Cicatriz/fisiopatologia , Cicatriz/etiologia , Idoso , Medição de Risco , Resultado do Tratamento , Fatores de RiscoRESUMO
BACKGROUND: Data are lacking on patient-reported outcomes (PRO) following cryoballoon ablation (CBA) versus radiofrequency ablation (RFA). We sought to evaluate QoL and clinical outcomes of cryoballoon pulmonary vein isolation only (CRYO-PVI-ONLY) versus RFA with PVI and posterior wall isolation (RF-PVI+PWI) in a large prospective PRO registry. METHODS: Patients who underwent AF ablation (2013-2016) at our institution were enrolled in an automated, prospectively maintained PRO registry. CRYO-PVI-ONLY patients were matched (1:1) with RF-PVI+PWI patients based on age, gender, and type of AF (paroxysmal vs. persistent). QoL and clinical outcomes were assessed using PRO surveys at baseline and at 1-year. The atrial fibrillation symptom severity scale (AFSSS) was the measure for QoL. Additionally, we assessed patient-reported clinical improvement, arrhythmia recurrence, and AF burden (as indicated by AF frequency and duration scores). RESULTS: A total of 296 patients were included (148 in each group, 72% paroxysmal). By PRO, a significant improvement in QoL was observed in the overall study population and was comparable between CRYO-PVI-ONLY and RF-PVI+PWI (baseline median AFSSS of 11.5 and 11; reduced to 2 and 4 at 1 year, respectively; p = 0.44). Similarly, the proportion of patients who reported improvement in their overall QoL and AF related symptoms was high and similar between the study groups [92% (CRYO-PVI-ONLY) vs. 92.8% (RF-PVI+PWI); p = 0.88]. Arrhythmia recurrence was significantly more common in the CRYO-PVI-ONLY group (39.7%) compared to RF-PVI+PWI (27.7 %); p = 0.03. Comparable results were observed in paroxysmal and persistent AF. CONCLUSION: CRYO-PVI-ONLY and RF-PVI+PWI resulted in comparable improvements in patient reported outcomes including QoL and AF burden; with RF-PVI+PWI being more effective at reducing recurrences.
Assuntos
Fibrilação Atrial , Criocirurgia , Medidas de Resultados Relatados pelo Paciente , Veias Pulmonares , Humanos , Veias Pulmonares/cirurgia , Masculino , Feminino , Criocirurgia/métodos , Fibrilação Atrial/cirurgia , Pessoa de Meia-Idade , Estudos Prospectivos , Átrios do Coração/cirurgia , Ablação por Cateter/métodos , Sistema de Registros , Qualidade de Vida , Idoso , Ablação por Radiofrequência/métodosRESUMO
INTRODUCTION: Catheter ablation for atrial fibrillation (AF) is frequently used for the purpose of rhythm control and improved quality of life (QoL). Although success rates are high, a significant proportion of patients require redo ablation. Data are scarce on patient-centered outcomes and QoL in patients undergoing redo AF ablation. We aimed to assess QoL and clinical outcomes using a large prospectively maintained patient-reported outcomes (PRO) registry. METHODS: All patients undergoing redo AF ablation (2013-2016) at our center were enrolled in a prospective registry for outcomes and assessed for QoL using automated PRO surveys (baseline, 3 and 6 months after ablation, every 6 months thereafter). Data were collected over 3 years of follow-up. The atrial fibrillation symptom severity scale (AFSSS) was used as the main measure for QoL. Additional variables included patient-reported improvement, AF burden, and AF-related healthcare utilization including emergency room (ER) visits and hospitalizations. RESULTS: A total of 848 patients were included (28% females, mean age 63.8, 51% persistent AF). By automated PRO, significant improvement in QoL was noted (baseline median AFSSS of 12 [5-18] and ranged between 2 and 4 on subsequent assessments; p < .0001), with ≥70%of patients reported remarkable improvement in their AF-related symptoms. The proportion of patients in AF at the time of baseline survey was 36%, and this decreased to <8% across all time points during follow-up (p < .0001). AF burden was significantly reduced (including frequency and duration of episodes; p < .0001), with an associated decrease in healthcare utilization after 6 months from the time of ablation (including ER visits and hospitalizations; p < .0001). The proportion of patients on anticoagulants or antiarrhythmics decreased on follow-up across all time points (p < .0001 for all variables). CONCLUSION: Most patients derive significant QoL benefit from redo AF ablation; with reduction of both AF burden and healthcare utilization.
Assuntos
Fibrilação Atrial , Ablação por Cateter , Feminino , Humanos , Pessoa de Meia-Idade , Masculino , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Qualidade de Vida , Resultado do Tratamento , Antiarrítmicos/uso terapêutico , Ablação por Cateter/efeitos adversos , Medidas de Resultados Relatados pelo PacienteRESUMO
INTRODUCTION: Obesity is a well-known risk factor for atrial fibrillation (AF). We aim to evaluate the effect of baseline obesity on procedural complications, AF recurrence, and symptoms following catheter ablation (CA). METHODS: All consecutive patients undergoing AF ablation (2013-2021) at our center were enrolled in a prospective registry. The study included all consecutive patients with available data on body mass index (BMI). Primary endpoint was AF recurrence based on electrocardiographic documentation. Patients were categorized into five groups according to their baseline BMI. Patients survey at baseline and at follow-up were used to calculate AF symptom severity score (AFSS) as well as AF burden (mean of AF duration score and AF frequency score; scale 0: no AF to 10: continuous and 9 frequencies/durations in between). Patients were scheduled for follow-up visits with 12-lead electrocardiogram at 3, 6, and 12 months after ablation, and every 6 months thereafter. RESULTS: A total of 5841 patients were included (17% normal weight, 34% overweight, 27% Class I, 13% Class II, and 9% Class III obesity). Major procedural complications were low (1.5%) among all BMI subgroups. At 3 years AF recurrence was the highest in Class III obesity patients (48%) followed by Class II (43%), whereas Class I, normal, and overweight had similar results with lower recurrence (35%). In multivariable analyses, Class III obesity (BMI ≥ 40) was independently associated with increased risk for AF recurrence (hazard ratio, 1.30; confidence interval, 1.06-1.60; p = .01), whereas other groups had similar risk in comparison to normal weight. Baseline AFSS was lowest in normal weight, and highest in Obesity-III, median (interquartile range) 10 (5-16) versus 15 (10-21). In all groups, CA resulted in a significant improvement in their AFSS with a similar magnitude among the groups. At follow-up, AF burden was minimal and did not differ significantly between the groups. CONCLUSION: AF ablation is safe with a low complication rate across all BMI groups. Morbid obesity (BMI ≥ 40) was significantly associated with reduced AF ablation success. However, ablation resulted in improvement in QoL including reduction of the AFSS, and AF burden regardless of BMI.
Assuntos
Fibrilação Atrial , Ablação por Cateter , Humanos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Qualidade de Vida , Sobrepeso/diagnóstico , Recidiva , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Obesidade/complicações , Obesidade/diagnóstico , Resultado do TratamentoRESUMO
INTRODUCTION: Pulmonary venous (PV) electrical recovery underlies most arrhythmia recurrences after atrial fibrillation (AF) ablation. Little is known about procedural profiles and outcomes of patients with electrically silent PVs upon redo ablation for AF. METHODS: In a prospectively maintained registry, we enrolled 838 consecutive patients (2013-2016) undergoing redo ablation procedures. Ablation procedures targeted the PVs, the PV antra, and non-PV sites at operators' discretion. Procedural profiles and clinical outcomes were assessed. The primary outcome was freedom from AF after a 3-month blanking period. The secondary outcome was improvement in quality of life. RESULTS: Most patients undergoing redo AF ablation (n = 684, 82%) had PV reconnection while the remaining 154 (18%) had electrically silent PVs. Patients with recurrent AF and electrically silent PVs were older (66 vs. 64 years, p = .02), had more prior ablation procedures (median 2 IQR 1-3 vs 1 IQR 1-2 p = .001), were more likely to have non-paroxysmal AF (62% vs. 49%, p = .004) and atrial flutter (48% vs. 29%, p = .001) and had significantly larger left atrial volumes (89 vs. 81 ml, p = .003). Patients with silent PVs underwent a more extensive non-PV ablation strategies with antral extension of prior ablation sets in addition to ablation of the roof, appendage, inferior to the right PVs, peri-mitral flutter lines, cavotricuspid isthmus lines and ablation in the coronary sinus. Upon one year of follow-up, patients with electrically silent PVs were less likely to remain free from recurrent atrial arrhythmias (64% vs. 76%, p = .008). Regardless of PV reconnection status, redo ablation resulted in improvement in quality of life. CONCLUSION: Rhythm control with extensive ablation allowed maintenance of sinus rhythm in about two thirds of patients with silent PVs during redo AF ablation procedures. Regardless of PV reconnection status, redo ablation resulted in improvement in quality of life. This remains a challenging group of patients, highlighting the need to better understand non-PV mediated AF.
Assuntos
Fibrilação Atrial , Ablação por Cateter , Veias Pulmonares , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/etiologia , Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Humanos , Veias Pulmonares/cirurgia , Qualidade de Vida , Recidiva , Resultado do TratamentoRESUMO
BACKGROUND: Activation maps of scar-related atrial tachycardias (AT) can be challenging to interpret due to difficulty in inaccurate annotation of electrograms, and an arbitrarily predefined mapping window. A novel mapping software integrating vector data and applying an algorithmic solution taking into consideration global activation pattern has been recently described (Coherent™, Biosense Webster "Investigational"). OBJECTIVE: We aimed to assess the investigational algorithm to determine the mechanism of AT compared with the standard algorithm. METHODS: This study included patients who underwent ablation of scar-related AT using the Carto 3 and the standard activation algorithm. The mapping data were analyzed retrospectively using the investigational algorithm, and the mechanisms were evaluated by two independent electrophysiologists. RESULTS: A total of 77 scar-related AT activation maps were analyzed (89.6% left atrium, median tachycardia cycle length of 273 ms). Of those, 67 cases with a confirmed mechanism of arrhythmia were used to compare the activation software. The actual mechanism of the arrhythmia was more likely to be identified with the investigational algorithm (67.2% vs. 44.8%, p = .009). In five patients with dual-loop circuits, 3/5 (60%) were correctly identified by the investigational algorithm compared to 0/5 (0%) with the standard software. The reduced atrial voltage was prone to lead to less capable identification of mechanism (p for trend: .05). The investigational algorithm showed higher inter-reviewer agreement (Cohen's kappa .62 vs. .47). CONCLUSIONS: In patients with scar-related ATs, activation mapping algorithms integrating vector data and "best-fit" propagation solution may help in identifying the mechanism and the successful site of termination.
Assuntos
Ablação por Cateter , Cicatriz , Algoritmos , Cicatriz/diagnóstico , Técnicas Eletrofisiológicas Cardíacas , Humanos , Estudos Prospectivos , Estudos Retrospectivos , TaquicardiaRESUMO
OBJECTIVES: To develop a protocol for using a pre-existing, permanent pacemaker or defibrillator device for rapid ventricular pacing during transcatheter valve procedures and demonstrate feasibility. BACKGROUND: Placement of a passive fixation, temporary pacemaker wire is considered routine during most transcatheter valve procedures to facilitate controlled or rapid ventricular pacing at the time of balloon expansion or valve deployment. Many patients presenting for such procedures have a pre-existing, permanent pacemaker or defibrillator device which could be used for the same function, obviating the need for temporary pacemaker wire placement. METHODS: We developed a strategy for rapid pacing from the pre-existing device using a programmer during transcatheter valve procedures in consecutive patients over a 3-month period. Complications and clinical outcomes were recorded. RESULTS: There were 135 transcatheter valve procedures performed during the study. Of these, 28 (20.7%) had pre-existing devices (17 transcatheter aortic valve replacement, 3 aortic valve-in-valve, 2 mitral valve-in-valve, and 6 balloon aortic valvuloplasty). All patients underwent rapid ventricular pacing using a commercially available device programmer. There were no adverse events related to device pacing and no patients required placement of a temporary pacemaker wire during the procedure. At 30-days follow-up, there were no deaths, one major vascular complication related to arterial access, and one patient with renal failure requiring dialysis. CONCLUSION: Pacing from a commercially available device programmer is safe, feasible, and may reduce both procedural cost and complications such as cardiac tamponade by avoiding placement of a temporary pacemaker lead during transcatheter valve procedures.
Assuntos
Valva Aórtica/cirurgia , Estimulação Cardíaca Artificial , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Doenças das Valvas Cardíacas/cirurgia , Cuidados Intraoperatórios/instrumentação , Marca-Passo Artificial , Cirurgia Assistida por Computador/instrumentação , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/fisiopatologia , Estimulação Cardíaca Artificial/efeitos adversos , Cardioversão Elétrica/efeitos adversos , Estudos de Viabilidade , Feminino , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/fisiopatologia , Humanos , Cuidados Intraoperatórios/efeitos adversos , Masculino , Cirurgia Assistida por Computador/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Programmed long AV delays and intrinsic long first degree AV block may increase risk for competitive atrial pacing (CAP) in devices without CAP avoidance algorithms. METHODS: Patients identified with CAP-induced mode switch episodes were followed clinically from September 2013 to August 2019. Attempts to avoid CAP included shortening of postventricular atrial refractory period (PVARP) or postventricular atrial blanking period (PVAB), or change to AAI or DDI modes. After observing associations with sensor-driven pacing, rate response was inactivated in a subset. RESULTS: Among 23 patients identified with CAP (22 St Jude Medical [Abbott]; one Boston Scientific Corporation devices), atrial fibrillation (AF) was induced in 12 (52%), lasting 10 seconds to 28 hours and 32 minutes. In one patient with an ICD CAP-induced AF with rapid ventricular rates that triggered a shock, inducing ventricular fibrillation, syncope, and another shock. Changing AV delays and shortening of PVARP failed to resolve CAP. After noting that all had CAP during sensor-driven pacing, rate response was inactivated in seven, resolving further device-induced AF in the three of seven that had prior CAP-induced AF. In two patients with intact AV conduction, AAI(R) pacing resolved further documentation of CAP. CONCLUSIONS: CAP predominantly occurs during sensor-driven atrial pacing that competes with intrinsic atrial events falling in PVARP. Inactivation of the activity sensor or change to atrial-based pacing modes (AAI/R) appears to effectively prevent induction of device-induced atrial proarrhythmia. Ultimately, a corrective algorithm is needed to avoid CAP-induced proarrhythmia.
Assuntos
Algoritmos , Fibrilação Atrial/fisiopatologia , Estimulação Cardíaca Artificial/métodos , Desfibriladores Implantáveis , Átrios do Coração/fisiopatologia , Ventrículos do Coração/fisiopatologia , Marca-Passo Artificial , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Advancement of digital technology now allows patients to have access to data from their cardiac implantable electronic devices (CIEDs). However, patients' understanding regarding CIED data and perceived personal usability remain unclear. The present study is a prospective survey to examine patients' understanding of their CIEDs and their perception of what is important. METHODS: We screened 400 patients between July and December 2018 who presented to our outpatient clinic for a CIED interrogation. Patients received a one-page questionnaire asking baseline demographics, their perception about their own knowledge about their device, and multiple-choice questions in seven basic categories: type of CIED, original indication, functionality, manufacturer, number of active leads, estimated battery life, and number of shocks received. We compared these answers to their interrogation reports to assess accuracy. We also asked participants what they would like to be aware of regarding their CIED. RESULTS: From this cohort, 344 of 400 (86%) (62.9 ± 12.8 years and 64 % males) agreed to take the survey and were included in the analysis. At baseline, 63.2% agreed or strongly agreed that they were knowledgeable about their devices. The overwhelming majority of patients demonstrated CIED knowledge deficits in at least one content area (n = 294, 86%), or more than two content areas (n = 176, 51%). Patients agreed or strongly agreed that they had a desire to have information regarding each of the following: battery life (84%), activity level (79%), heart rate trend (75%), and ventricular arrhythmias (74%). CONCLUSION: There is a large discrepancy in patients' level of knowledge regarding their CIEDs and their wish to know more details. Future technologies should satisfy providers' goals to educate their patients with basic information and fulfill patients' desire to obtain more data from their CIEDs.
Assuntos
Acesso à Informação , Atitude Frente a Saúde , Desfibriladores Implantáveis/psicologia , Marca-Passo Artificial/psicologia , Pacientes/psicologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Management of persistent atrial fibrillation (PersAF) remains challenging, and many patients are left on medical therapy after a failed first ablation. In patients with recurrent symptomatic arrhythmias after PersAF ablation, we aimed to compare outcomes of repeat ablation and medical therapy versus medical therapy alone. METHODS AND RESULTS: All 682 consecutive patients with recurrent symptomatic arrhythmia after a first ablation for PersAF at our institution (2005-2012) were included. Repeat ablation with continuation of medical therapy was performed in 364 patients (Group 1) and 318 were only medically managed (Group 2). The outcome of interest was freedom from arrhythmia recurrence beyond a 3-month blanking period. Separate analyses were performed to assess this endpoint totally off antiarrhythmics (primary endpoint) or alternatively with/without use of antiarrhythmics (secondary endpoint). Over a median follow-up of 26 months, 41.5% of Group 1 patients met the primary endpoint and remained free from arrhythmia recurrence off antiarrhythmics (vs. 14.5% in Group 2, P < 0.0001). At last follow-up, antiarrhythmics continued to be required for rhythm control in 40.1% and 46.2% of patients in Groups 1 and 2, respectively (P < 0.0001). The secondary endpoint was met in 60.2% versus 32.1% of patients in Groups 1 and 2, respectively (P < 0.0001). In multivariable Cox analyses, repeat ablation was associated with significant reduction in arrhythmia recurrences compared to medical therapy alone (HR 0.48, 95% CI 0.35-0.65, P < 0.0001). CONCLUSION: In patients with recurrent symptomatic arrhythmia after ablation of PersAF, repeat ablation was associated with significant reduction in arrhythmia recurrences compared to routine medical therapy alone.
Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/cirurgia , Ablação por Cateter , Reoperação , Potenciais de Ação , Idoso , Antiarrítmicos/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Terapia Combinada , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Intervalo Livre de Progressão , Recidiva , Sistema de Registros , Reoperação/efeitos adversos , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND: Limited medical options are available for rhythm control in patients with atrial fibrillation (AF) and hypertrophic cardiomyopathy (HCM). There are no published reports of dofetilide use in this population. METHODS: A retrospective chart review was conducted on 1,404 patients loaded on dofetilide for AF suppression at the Cleveland Clinic from 2008 to 2012, 25 of whom were found to have HCM. RESULTS: The HCM cohort was 32% female, 76% with persistent AF, mean age of 59 ± 10 years, and mean ejection fraction of 54 ± 9 %. Of the 25 patients, 21 were discharged on dofetilide, three discontinued during loading due to QTc prolongation, and one due to inefficacy. There were no adverse events during loading. Of those discharged on dofetilide, 11/21 (52%) were still on it at a median follow-up of 396 (198, 699) days at the time of the chart review. For those in whom it was discontinued, the median time on the drug was 301 (111, 738) days. Of the 10 patients who discontinued dofetilide during follow-up, six were due to inefficacy, one postablation, one postheart transplant, one due to death secondary to lung cancer, and one due to worsening edema. CONCLUSIONS: Dofetilide was well tolerated in this group of patients with AF and HCM and it facilitated management of AF in 21/25 (84%) patients. Further research is needed to assess the safety and efficacy of dofetilide in order to develop evidence-based guidelines for the pharmacological management of AF in this population.
Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Cardiomiopatia Hipertrófica/tratamento farmacológico , Fenetilaminas/uso terapêutico , Sulfonamidas/uso terapêutico , Fibrilação Atrial/complicações , Cardiomiopatia Hipertrófica/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Arrhythmia recurrences remain common after ablation of persistent atrial fibrillation (PersAF). Contact force (CF)-sensing catheters have been introduced for objective assessment of contact during radiofrequency application and have been suggested to improve outcomes in ablation of paroxysmal AF, but little is known about their role in PersAF ablation. We aimed to compare the procedural profiles and outcomes of (PersAF) ablation with or without using CF-sensing catheters. METHODS: All consecutive patients undergoing first time ablation for PersAF between April 2014 and January 2015 at the Cleveland Clinic were included. Substrate modification was performed in addition to isolation of the pulmonary veins. Success rates were determined off antiarrhythmics over 1 year of follow-up. RESULTS: The study included 174 patients (77 CF and 97 non-CF). Ablation with CF-sensing catheters resulted in shorter procedures (median 204 vs. 216 minutes, P = 0.04) and shorter fluoroscopy time (36 vs. 48 minutes, P = 0.0005), without statistical difference in radiation dose (225 vs. 270 milligrays, P = 0.1). Arrhythmia recurrences were less likely to be observed in the CF-sensing group (27.6% vs. 46.4%, P = 0.01, log-rank P = 0.004). In multivariable Cox analyses, the use of CF-sensing catheters was associated with a lower risk of arrhythmia recurrence (hazard ratio 0.49, 95% confidence interval 0.27-0.85, P = 0.01). CONCLUSIONS: Compared to non-CF sensing, the use of CF-sensing catheters for PersAF ablation is associated with shorter procedures, shorter fluoroscopy time, and reduction in arrhythmia recurrences.
Assuntos
Fibrilação Atrial/cirurgia , Cateteres Cardíacos , Ablação por Cateter/instrumentação , Veias Pulmonares/cirurgia , Transdutores de Pressão , Potenciais de Ação , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Distribuição de Qui-Quadrado , Feminino , Fluoroscopia , Frequência Cardíaca , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ohio , Duração da Cirurgia , Modelos de Riscos Proporcionais , Veias Pulmonares/fisiopatologia , Radiografia Intervencionista/métodos , Recidiva , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
The space that exists between the visceral and parietal pericardium has a small amount of fluid under physiologic conditions. The pericardial layers and this fluid in combination have a protective role and also offer fluidity of motion and shock absorbance. The pericardium and the fluid can often be involved in pathologies involving the myocardium or sometimes be independently involved in primary diseases of the pericardium with secondary hemodynamic effects. In physiologic and pathologic conditions, invasion of this space by surgical and percutaneous interventions can provide a unique and precious opportunity to enhance patient management in such situations from a diagnostic and therapeutic aspect. This field of "interventional pericardiology" is the focus of this chapter.
Assuntos
Cardiomiopatias/cirurgia , Ablação por Cateter/métodos , Pericardiocentese/métodos , Mapeamento Epicárdico/métodos , Fluoroscopia/métodos , Humanos , Técnicas de Janela Pericárdica , Pericárdio/anatomia & histologia , Radiografia Intervencionista/métodos , Ultrassonografia de Intervenção/métodosRESUMO
BACKGROUND: There are limited and conflicting data regarding the prevalence of tricuspid regurgitation (TR) after cardiac device implantation (implantable cardioverter defibrillator [ICD]; permanent pacemaker [PPM]). OBJECTIVE: The goal of this study was to assess the prevalence of TR after cardiac device implantation and determine its clinical significance. METHODS: A total of 1,596 patients, who had cardiac devices implanted between 2005 and 2011 at the Cleveland Clinic and had at least one preimplantation echocardiogram and at least one postimplantation echocardiogram were included in this study. A total of 3,566 postimplantation echocardiograms were available for the 1,596 patients (median follow-up 10 months). The primary end point was postimplantation TR and the secondary end point was all-cause mortality after implantation. We have used a cumulative logistic nonlinear mixed-effects model to assess the temporal trend of TR prevalence and a parametric multiphase hazard model to assess survival. RESULTS: Of the 1,596 patients (mean age: 60 ± 10 years, 61% of patients were men), 985 (62%) had ICDs (including 334 patients with cardiac resynchronization therapy defibrillator) and 611 (38%) had PPMs. The prevalence of grade 3 or 4+ TR increased from 27% to 31% by 1 month and to 35% at 4 years. Accordingly, prevalence of grade 0/1+ TR decreased from 46% preimplantation to 37% at 1 month and to 32% at 4 years. Device type (ICD vs PPM) and the number of leads placed did not have an effect on postimplantation TR (P > 0.2). Right ventricular systolic pressure (RVSP) did not change over time (36 mm Hg baseline, 37.5 mm Hg by 3 months, and 37 mm Hg by 1 year). One-year and 5-year survival were 93% and 73%, respectively. Postimplantation TR was an independent risk factor for late death (P < 0.05). CONCLUSION: Cardiac device implantation was associated with a small but significant increase in the prevalence of moderate and severe TR, both acutely and chronically after implantation. The increase in TR was similar with both ICD and PPM placement, which was not related to the number of leads implanted and not associated with a significant increase in RVSP. Postimplantation TR was associated with a higher risk of mortality.
Assuntos
Desfibriladores Implantáveis/estatística & dados numéricos , Cardiopatias/mortalidade , Cardiopatias/prevenção & controle , Marca-Passo Artificial/estatística & dados numéricos , Insuficiência da Valva Tricúspide/mortalidade , Desfibriladores Implantáveis/efeitos adversos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Marca-Passo Artificial/efeitos adversos , Medição de Risco , Distribuição por Sexo , Taxa de Sobrevida , Insuficiência da Valva Tricúspide/etiologiaAssuntos
Desfibriladores Implantáveis/efeitos adversos , Traumatismos Cardíacos/complicações , Síndrome do QT Longo/terapia , Pericárdio/lesões , Pneumotórax/etiologia , Adulto , Feminino , Traumatismos Cardíacos/diagnóstico , Humanos , Pneumotórax/diagnóstico , Radiografia Torácica , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: The risk of ventricular arrhythmias (VAs) after cardiac resynchronization therapy (CRT) has been associated with ischemic disease/scar, sex, and possibly left ventricular mass (LVM). OBJECTIVE: The purpose of this study was to evaluate sex differences and baseline/postimplant change in LVM on VA risk after CRT implantation in patients with nonischemic cardiomyopathy and left bundle branch block. METHODS: In patients meeting the criteria, baseline and follow-up echocardiographic images were obtained for LVM assessment. VA events were reported from device diagnostics and therapies. VA risk was stratified by receiver operating characteristic (Youden index cutoff point) for baseline LVM and baseline/postimplant change in LVM, and baseline patient characteristics by using a multivariable Cox regression model. RESULTS: One hundred eighteen patients (71 female [60.2%]; mean age 60.5 ± 11.3 years; left ventricular ejection fraction 19.2% ± 7.0%; QRS duration 165.6 ± 20 ms; LVM 313.9 ± 108.8 g) were enrolled and followed up for a median of 90 months (interquartile range 44-158 months). Thirty-five patients (29.6%) received appropriate shocks or antitachycardia pacing at a median of 73.5 months (interquartile range 25-130 months) postimplantation. Males had a higher VA incidence (male 18 of 47 [38.3%] vs female 17 of 71 [23.9%]; P = .02). Baseline LVM > 308.9 g separated patients with higher VA risk (P = .001). Less than a 20% decrease in LVM increased VA risk (P < .001). Baseline LVM was the only baseline characteristic predicting VA events in the Cox regression model (hazard ratio 1.01; 95% confidence interval 1.001-1.009; log-rank, P = .003). Sex differences in VA risk were eliminated by the baseline LVM parameters. CONCLUSION: VA risk after CRT in nonischemic cardiomyopathy was associated with baseline LV > 308.9 g and a decrease in LVM ≤ 20%, without sex differences.
RESUMO
BACKGROUND: Vascular access-site complications are the most frequent complications of percutaneous catheter ablation (CA) of ventricular arrhythmias (VAs). Whether arterial/venous vascular closure devices (VCDs) prevent vascular complications is unknown. OBJECTIVE: We investigated the benefit of VCDs in patients undergoing CA of VAs. METHODS: Consecutive CA of VAs were included (2018-2022). Vascular accesses were obtained with ultrasound guidance. At the discretion of the operator, arterial and/or venous VCDs were used. Cases were divided into 3 groups: no use of VCDs for any of the arterial/venous accesses (manual compression - MC), use of VCDs for some but not the all of the accesses (Partial-VCDs), use of VCDs for all of the accesses (Complete-VCDs). Vascular complications were defined minor if they didn't require intervention or major if they required intervention. RESULTS: A total of 1,016 procedures were performed in 872 patients (62±13 years, BMI 30±6 kg/m2, 27% female) during the study period. Femoral arterial access was obtained in 887 procedures (875 single access - 7.4±1.5 Fr size, 12 two accesses - 7.3±3 Fr and 6.9±1.8 Fr). Femoral venous access was obtained in 1,014 procedures (unilateral in 17%, bilateral in 83%, mean N. 2.6±0.7, 8.4±1.3 Fr). Hemostasis was achieved with MC in 192 (19%) procedures, Partial-VCD in 275 (27%), and Complete-VCD in 549 (54%). A vascular complication occurred in 52 (5.1%) procedures, including a minor hematoma in 3.9% and/or a major complication in 1.7%. The rate of vascular complications was 6.8% (5.2% minor and 1.6% major) in the MC group, 7.6% (5.1% minor and 3.3% major) in the Partial-VCD group, and 3.3% (2.9% minor and 0.9% major, P=0.014 for comparison) in the Complete-VCD group. At multivariable analysis, Complete-VCD remained independently associated with lower risk of vascular complications (odds ratio 0.69, 95% confidence interval 0.48 to 0.96, P=0.036). CONCLUSIONS: In patients undergoing CA of VAs, Complete-VCD is associated with lower rates of vascular-related complications compared to MC or Partial-VCD.
RESUMO
BACKGROUND: Following pulmonary vein isolation (PVI) for the treatment of paroxysmal atrial fibrillation (AF), spontaneous dissociated firing (DiFi) from the isolated veins may be observed. Little is known about the significance and prognostic implications of this phenomenon. We sought to determine the relationship between DiFi and ablation outcomes. METHODS: The study population consisted of 156 paroxysmal AF patients who underwent first time PVI and were found to have spontaneous DiFi from the pulmonary veins (PVs). Their outcomes were compared to a population of 156 propensity-matched controls from our prospectively maintained AF ablation data registry. RESULTS: DiFi was most frequently observed from the right superior PV and occurred in 89 patients (57.1%). After 24 months of follow-up, patients with DiFi had better success rates compared to those with silent veins after isolation (88.5% vs 75%, P = 0.002). The overall distribution of types of recurrent arrhythmia was similar between DiFi patients and their matched controls (P = NS). During repeat ablations, DiFi patients were less likely to have PV conduction recovery (60% vs 93.3%, P = 0.02). Importantly, none of the veins with DiFi during index procedures was found to have conduction recovery. CONCLUSION: In patients with paroxysmal AF undergoing ablation, DiFi from the PVs after their isolation was associated with improved ablation outcomes. It is possible that DiFi is an indicator of successful durable isolation of the PVs. The findings suggest that confirmation of exit block may be warranted to improve AF ablation outcomes.
Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Mapeamento Potencial de Superfície Corporal/estatística & dados numéricos , Ablação por Cateter/estatística & dados numéricos , Sistema de Condução Cardíaco/cirurgia , Veias Pulmonares/cirurgia , Fibrilação Atrial/epidemiologia , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Prevalência , Prognóstico , Fatores de Risco , Resultado do TratamentoRESUMO
Junctional tachycardia (JT) is typically considered to have an automatic mechanism originating from the distal atrioventricular node. When there is 1:1 retrograde conduction via the fast pathway, JT would resemble the typical form of atrioventricular nodal re-entrant tachycardia (AVNRT). Atrial pacing maneuvers have been proposed to exclude AVNRT and suggest a diagnosis of JT. However, after excluding AVNRT, one should consider the possibility of an infra-atrial narrow QRS re-entrant tachycardia, which can exhibit features that resemble AVNRT as well as JT. Pacing maneuvers and mapping techniques should be performed to assess for infra-atrial re-entrant tachycardia before concluding that JT is the mechanism of a narrow QRS tachycardia. Distinguishing JT from typical AVNRT or infra-atrial re-entrant tachycardia has notable implications regarding the approach to ablation of the tachycardia. Ultimately, a contemporary review of the evidence on JT raises some questions as to the mechanism and source of what has traditionally been considered JT.
Assuntos
Fibrilação Atrial , Taquicardia por Reentrada no Nó Atrioventricular , Taquicardia Ectópica de Junção , Taquicardia Supraventricular , Humanos , Técnicas Eletrofisiológicas Cardíacas/métodos , Taquicardia Ectópica de Junção/diagnóstico , Nó Atrioventricular , Fascículo Atrioventricular , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico , Taquicardia por Reentrada no Nó Atrioventricular/cirurgiaRESUMO
BACKGROUND: Atrial fibrillation (AF) risk increases with age. We aim to assess the efficacy and safety of catheter ablation in the older population. METHODS: All patients undergoing AF ablation (2013-2021) at our institution were enrolled in a prospectively maintained registry. The primary endpoint was AF recurrence. Patients were divided into 3 groups: non-elderly (< 65 years), elderly (65-75 years), and very elderly (> 75 years). Patient surveys at baseline and during follow-up were used to calculate quality of life (QoL) metrics: the AF severity score as well as the AF burden. RESULTS: A total of 7020 patients were included (42% non-elderly, 42% elderly, and 16% very elderly). Periprocedural major complications were low (< 1.5%) and similar in all groups besides pericardial effusion which was more frequent with older age and similar between the elderly and very elderly. At 3 years, AF recurrence for persistent AF (PersAF) was highest in the very elderly group (48%), followed by the elderly group (42%), and was the lowest in the non-elderly group (36%). In paroxysmal AF (PAF), there was no difference in AF recurrence between the elderly and non-elderly, while the very elderly remained associated with a significantly increased risk. Multivariable Cox analysis confirmed these findings (PersAF; elderly: HR = 1.23, P = 0.003; very elderly: HR = 1.44, P < 0.001) (PAF; elderly: HR = 1.04, P = 0.62; very elderly: HR = 1.30, P = 0.01). Catheter ablation resulted in a significant improvement in quality of life, irrespective of age group. CONCLUSION: Catheter ablation in elderly and very elderly patients is safe, efficacious, and associated with QoL benefits. Overall, major complications were minimal and did not differ significantly between age groups, with the exception of pericardial effusions which were higher in the elderly and very elderly compared to non-elderly adults. Very elderly patients had a higher rate of AF recurrence when compared with elderly or non-elderly patients. Nevertheless, ablation resulted in a remarkable improvement in QoL and a reduction of AF burden and AF symptoms with a similar magnitude, irrespective of age.