Brugada syndrome unmasked by left ventricle posteromedial papillary muscle ventricular tachycardia: Coincidence or consequence.

A 46-year-old man presented with left ventricle posteromedial papillary muscle ventricular tachycardia, presyncope, and a type-1 Brugada pattern on the post-electrical cardioversion electrocardiogram. There was a probability of a Brugada syndrome with the expression of its disease in the left ventricle; or a left monomorphic ventricular tachycardia as a part of Brugada phenocopy; or a Brugada syndrome with left monomorphic ventricular tachycardia as an epiphenomenon. Cardiac magnetic resonance, electrophysiological study, and ajmaline test were the key diagnostic tools employed.

Prognostic impact of atrial fibrillation and flutter temporal pattern on anticoagulation and return visits to the emergency department: A historic cohort of 1112 patients.

BACKGROUND: Emergency department (ED) visits due to atrial fibrillation and flutter (AFF) are common, and provide an opportunity to define stroke risk. The prognostic impact of AFF duration on return ED visits is unknown. We aimed to investigate both the prognostic impact of AFF classification on ED visits and the adherence to guideline recommendations on anticoagulation. METHODS: This single-center historic cohort of every patient treated for AFF in our ED during 2012. Follow-up data was obtained on May 2015 (median follow-up of 863 days). RESULTS: Among 1112 patients (495 Paroxysmal AF - parAF, 475 Persistent AF - persAF, and 142 flutter), those with parAF were less frequently under oral anticoagulation than persAF and flutter patients (15.8%, 39.4%, 40.1%, p < 0.01). Mean CHA2DS2-VASc scores of parAF were lower than persAF (2.2 vs. 3.12, p < 0.01), and did not differ from those with flutter. Return visits to the ED were highest among flutter patients and lowest among parAF (49.3% vs. 37.2%, p < 0.01). Heart failure, hypertension, female gender and atrial flutter were independent risk factors for repeated visits on multivariate regression. CONCLUSIONS: AFF duration provide prognostic information in the ED. ED return visits were common and particularly incident among flutter patients. Furthermore, stroke risk was high and anticoagulation rates were low across all groups. Patients with paroxysmal AF were less commonly anticoagulated even though their mean CHA2DS2-VASc scores were 2.2. These results reveal that guideline adherence is still lacking and should raise awareness to a stricter patient follow-up after ED visits.

Atrial flutter and embolic risk: The relationship between atrial flutter cycle length and left atrial appendage function.

BACKGROUND: The potential for thromboembolism in atrial flutter (AFL) is different from atrial fibrillation. AFL cycle length (AFL-CL) may be related to reduced left atrial appendage (LAA) function. Very rapid AFL-CL can lead to mechanical and electrophysiological disorders that contribute to lower LAA emptying velocity (LAEV). The aim of this study is to relate atrial flutter cycle length with LAEV and its role in thrombogenesis. METHODS: Cross-sectional study of patients with atrial flutter AFL who underwent transoesophageal echocardiography (TEE) before catheter ablation or electric cardioversion. AFL-CL in milliseconds was measured with a 12-lead EKG or in intracardiac records. RESULTS: We included 123 patients. There was correlation between AFL-CL and LAEV (r = 0.34; p = 0.003) in typical AFL. Cycle length, LA size and atypical flutter were predictors of low LAEV on multivariate analysis. An index multiplying atrial rate (bpm) during the arrhythmia versus left atrial size(mm) >11,728 was associated with spontaneous echogenic contrast and/or left atrial thrombus on TEE (C-statistic = 0.71; CI95%0.60-0.81). CONCLUSIONS: There was a significant relationship between the AFL-CL and LAEV. The LAEV was affected by the LA size, the type of atrial flutter and the AFL-CL. A new index, relating the atrial rate with the left atrial size, was able to identify a higher occurrence of spontaneous echogenic contrast and/or left atrial thrombus.

Routine Detection of Atrial Fibrillation/Flutter Predicts a Worse Outcome in a Cohort of Tetralogy of Fallot Patients During 23 Years of Follow-Up.

Atrial flutter/fibrillation (AFL/AF) is a late complication in adults with repaired tetralogy of Fallot (TOF). Its effects on long-term prognosis are not fully understood. We evaluate the impact of AFL/AF in adults with repaired TOF on global mortality and unplanned hospitalizations during follow-up, and the predictors for AFL/AF occurrence. The presence of AFL/FA was analysed in all exams performed during the last 10 years of outpatients follow up in a unicentric cohort of repaired TOF between 1980 and 2003. Two-hundred and six patients were included; at a mean follow-up of 21 ± 8.2 years, there were 5 deaths (19.2%) in the AFL/AF group and 2 (1.1%) in those without arrhythmia (p < 0.001). Patients with AFL/AF where older at the time of the surgical repair (p < 0.001) and had a higher rate of reinterventions (p = 0.003). No differences were observed between the groups regarding the use of a transannular patch, ventriculotomy and previous palliative shunt. QRS duration was longer in patients with AFL/AF (174 ± 33.4) when compared to those without arrhythmia (147 ± 39.6; p < 0.0001). Age at surgery, QRS duration, and tricuspid regurgitation ≥ moderate were independent risk predictors for AFL/AF. In the multivariate analysis, atrial flutter/fibrillation and QRS duration were predictors of death and hospitalization. AFL/AF is associated with an increased risk of death and hospitalization during the follow-up of patients with repaired TOF. Early detection of AFL/AF and their predictors is an essential step in the evaluation of such population.

Non-fluoroscopic catheter ablation: A randomized trial.

BACKGROUND: Catheter ablation provides curative treatment for tachyarrhythmias. Fluoroscopy, the method used for this, presents several risks. The electroanatomical mapping (MEA) presents a three-dimensional image without using X-rays, and may be adjunct to fluoroscopy. OBJECTIVES: We evaluated the possibility of performing catheter ablation with the exclusive use of electroanatomical mapping (MEA), dispensing with fluoroscopy. We compared the total time of procedure and success rates against the technique using fluoroscopy (RX) with emission of X-rays. METHODS: Randomized, unicentric, uni-blind study of patients referred for tachyarrhythmia ablation. RESULTS: Twelve patients were randomized to the XR group and 11 to the EAM group. The mean age was 48.5 (±12.6) vs 46.3 (±16.6) (P = ns). Success occurred in 11 patients (91.7%) in the RX group and 9 (81.8%) in the MEA group (P = 0.46). The procedure time in minutes was higher in the MEA group than in the RX group (79-47-125min vs 49-30-100min; P = 0.006). The mean fluoroscopy time was 11 ±â€¯9 min versus zero (RX vs MEA: P < 0.001). The mean radiofrequency applications were lower in the RX group against the MEA group (6 ±â€¯3.5 × 13.2 ±â€¯18.2 p < 0.019). There were no complications. CONCLUSION: MEA opened new therapeutic possibilities for patients with arrhythmias, reducing the risk of radiation. In this study, it was possible to demonstrate that it is feasible to perform ablation only with the use of MEA, with similar success with fluoroscopy, at the expense of a longer procedure time.

Coronary sinus cannulation predicts atrioventricular nodal reentry as mechanism of supraventricular tachycardia.

INTRODUCTION: Common clinical teaching, for invasive electrophysiology, is that if the first year fellow cannulates the coronary sinus (CS) in his first attempt, the arrhythmia is more likely to be atrioventricular nodal reentry tachycardia (AVNRT). This general perception has not yet been clinically tested. We evaluated this theory in prospective patients undergoing an electrophysiological study (EPS) for paroxysmal supraventricular tachycardia (PSVT). METHODS: Cohort study. CS ease of cannulation (CSCS) was graded as: 1) 1st year fellow cannulates in first attempt; 2) 1st year fellow needs more than one attempt or maneuver to cannulate the CS; 3) staff physician cannulates in first attempt after the fellow was unsuccessful; 4) staff physician requires more than one maneuver to cannulate the CS; 5) staff physician judges that the cannulation process was extremely difficult. RESULTS: Of the 1361 patients undergoing EPS in our institution, 165 were selected. Age was 49 ±â€¯15 years. AVNRT occurred in 77.6%, atrioventricular reentry tachycardia (AVRT) in 15.1% and atrial tachycardia (AT) in 7.3% of cases. The CSCS = 1 was more prevalent in AVNRT, 89% versus 68% AVRT and 58.3% of AT (P = 0.0005). Patients with CSCS = 1 have a higher chance of the PSVT being AVNRT (odds ratio: 4.41; 95CI: 1.84-10.56; P = 0.0009). CONCLUSION: The CSCS predicts the likelihood of the induced PSVT being AVNRT as compared to AVRT and AT. More studies are required to try to associate this finding to clinical patient characteristics to create a score for PSVT mechanism prediction.

Late Outcome and Predictors of Adverse Events Related to the Implantation of a Permanent Pacemaker in Patients with Isolated Congenital Atrioventricular Block.

Isolated congenital atrioventricular block (ICAVB) is a rare, and pacemaker implantation is the only effective treatment. We sought to identify the predictive factors of adverse events related to pacemaker implantation in ICAVB. This is a cohort study of patients diagnosed with ICAVB who underwent pacemaker implantation from 1980 to 2014 in a single center. During the studied period, a total of 647 patients underwent implantation of their first permanent cardiac pacemaker before 30 years of age. Of these, only 62 (9.5 %) were diagnosed with ICAVB. This condition was diagnosed in utero in 15 (24.2 %) cases, 5 (8.1 %) in the neonatal period, 32 (51.6 %) during childhood, and 10 (16.1 %) during adolescence and young adulthood. The presence of autoantibodies (anti-Ro/SSA) was observed in 41 % of mothers who underwent serological evaluation. Age at the time of the initial pacemaker implant was 9.8 ± 9 years. During a mean follow-up time of 15 years, 1 (1.7 %) death occurred due to infectious endocarditis. Complications related to pacemaker implant were reported in 24 patients (38.7 %). The number of complications was significantly higher in the group with an epimyocardial implantation site (HR 6; CI 2.45-14.95). Ventricular dysfunction occurred in 6 (11.7 %) patients; however, we were not able to identify any predictors of it. Our results showed a low mortality rate after permanent therapy. However, these patients exhibited high morbidity related to the pacemaker system, and the epimyocardial implant site was an independent predictor of complications. Predictors of left ventricular dysfunction were not found in the present study.

CHA2 DS2 VASc Score as a Predictor of Cardiovascular Events in Ambulatory Patients without Atrial Fibrillation.

BACKGROUND: New evidence suggests that the CHA(2)DS(2)VASc (congestive heart failure, hypertension [HTN], age, diabetes, stroke, vascular disease, and female gender) score may be a reliable tool to predict the risk of thromboembolic events in patients without documented atrial fibrillation (AF). METHODS: We performed a prospective cohort study of outpatients without AF or flutter, who were not using oral anticoagulation. Clinical characteristics were assessed and patients were stratified according to the CHA(2)DS(2)VASc score. We evaluated the incidence of major adverse cardiac outcomes and its relation to the CHA(2)DS(2)VASc score during the follow-up. RESULTS: Four hundred sixty-eight patients without AF were enrolled with a mean follow-up of 12 ± 6 months. Age was 64.9 ± 11.3 years. The prevalence of HTN was 88.4%, diabetes 37.6%, heart failure 26.3%, and vascular disease 61.7%. Overall, CHA(2)DS(2)VASc score was 3.4 ± 1.4. There were 15 major adverse cardiac outcomes during 12.2 months of follow-up (overall incidence of 3.2 per 100 person-years). We found significant differences in relation to gender, age, previous stroke, and follow-up length in patients with and without adverse outcomes. The CHA(2)DS(2)VASc score was higher in those with adverse outcomes (4.2 ± 1.7 vs 3.4 ± 1.4; P = 0.035). Patients with a CHA(2)DS(2)VASc ≥6 had a relative risk for adverse outcomes of 4.2 (95% confidence interval: 1.27-13.90). CONCLUSIONS: In our population, CHA(2)DS(2)VASc score predicts major adverse cardiac outcomes, including stroke and death, in a cohort of patients without AF.

Catheter ablation of typical right atrial flutter in a 20-day-old neonate with tachycardiomyopathy.

Background: Fetal echocardiography can diagnose neonatal atrial flutter, which can cause heart failure in newborns. Little is known about catheter ablation in this population. Methods: Case report that aimed to review a successful ablation in a 20-day-old patient with refractory atrial flutter. Results: This is the first report of a successful neonatal atrial flutter ablation without any early recurrence after the procedure. Conclusions: Atrial flutter ablation performed on newborns is a reliable and long-lasting treatment option.

Prognosis of programmed ventricular stimulation in adult patients with syncope of unexplained origin: A historical cohort.

Background: Programmed ventricular stimulation (PVS) during electrophysiological study (EPS), is a globally accepted tool for risk stratification of sudden cardiac death (SCD) in some specific clinical situations. The aim of this study was to evaluate the prognosis of ventricular arrhythmia induction in a cohort of patients with syncope of undetermined origin (SUO). Methods: This is a historical cohort study in a population of patients with SUO referred for EPS between the years 2008-2021. In this interval, 575 patients underwent the procedure. Results: Patients with induced ventricular arrhythmias had a higher occurrence of structural heart disease (36.7% vs. 76.5%), ischemic heart disease (28.2 vs. 57.1%), heart failure (15.5% vs. 34.4%), and lower left ventricular ejection fraction (59.16% vs. 47.51%), when compared to the outcome with a negative study. PVS triggered ventricular arrhythmias in 98 patients, 62 monomorphic and 36 polymorphic. During a median follow-up of 37.6 months, 100 deaths occurred. Only the induction of sustained ventricular arrhythmias showed a significant association with the primary outcome (all-cause mortality) with a p value <.001. After the performance of EPS, 142 patients underwent cardioverter-defibrillator (ICD) implantation. At study follow-up, 30 patients had therapies by the device. Only the induction of sustained monomorphic ventricular arrhythmia showed statistically significant association with appropriate therapies by the device (p = .012). Conclusion: In patients with SUO, the induction of sustained monomorphic ventricular arrhythmia after programmed ventricular pacing is related to a worse prognosis, with a higher incidence of mortality and appropriate therapies by the ICD.

The role of three-dimensional echocardiography in interventricular mass evaluation.

A young patient underwent a screening electrocardiogram (EKG) that suggested apical hypertrophic cardiomyopathy. Serial investigation with echocardiography showed a well-defined hyperechogenic mass involving the interventricular septal. To better define the lesion extension three-dimensional (3D) echocardiography was done and it demonstrated a mass invading the septal myocardium, involving the major part of the muscular portion. The findings were highly suggestive of a cardiac fibroma. A cardiac magetic resonance image (MRI) was also compatible with this diagnosis. In our case, 3D echo showed a high accuracy, proving to be a useful tool to determine the anatomy of the lesion, complementary to MRI, guiding best management strategy.

Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization. / Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação.

BACKGROUND: Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. OBJECTIVE: To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). METHODS: This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. RESULTS: The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). CONCLUSIONS: In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

FUNDAMENTO: O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. OBJETIVO: Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). MÉTODO: Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. RESULTADOS: A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). CONCLUSÃO: Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Electrophysiological study as a predictor of mortality in unexplained syncope.

Background: Electrophysiological study can help in the diagnosis of arrhythmic syncope. According to the electrophysiological study finding, the prognosis of patients with syncope is still a matter of study. Objective: The aim of this study was to assess the survival of patients undergoing electrophysiological study according to their findings and to identify clinical and electrophysiological independent predictors of all-cause mortality. Methods: A retrospective cohort study included patients with syncope who underwent electrophysiological study from 2009 to 2018. A Cox logistic regression analysis was performed to identify independent prognostic factors for all-cause mortality. Results: We included 383 patients in our study. During a mean follow-up of 59 months, 84 (21.9%) patients died. The split His group had the worst survival compared with the control group, followed by sustained ventricular tachycardia and HV interval ≥ 70 ms, respectively (p = .001; p < .001; p = .03). The supraventricular tachycardia group showed no differences compared with the control group (p = .87). In the multivariate analysis, independent predictors of all-cause mortality were Age (OR 1.06; 1.03-1.07; p < .001); congestive heart failure (OR 1.82; 1.05-3.15; p = .033); split His (OR 3.7; 1.27-10.80; p = .016); and sustained ventricular tachycardia (OR 1.84; 1.02-3.32; p = .04). Conclusion: Split His, sustained ventricular tachycardia, and HV interval ≥ 70 ms groups had worse survivals when compared to the control group. Age, congestive heart failure, split His, and sustained ventricular tachycardia were independent predictors for all-cause mortality.

Impact of the left common ostium following pulmonary vein isolation in AF: Systematic review and meta-analysis.

Purpose: Pulmonary vein isolation (PVI) through catheter ablation is the basis for the treatment of atrial fibrillation (AF). The left common ostium (LCO) is a high prevalence anatomical variation and has conflicting results in the effects on the prognosis following ablation. We undertook a systematic review and meta-analysis of studies that compared the arrhythmia recurrence rate after radiofrequency ablation or cryoablation balloon between patients with normal pattern pulmonary vein and patients with LCO. Methods and Results: Results were pooled using a fixed or random effect, at the discretion of heterogeneity (>25%), in addition, we associated subgroup analysis in these cases and when clinically indicated. Fourteen non-randomized studies totaling 3278 patients were included. In analyses using the two energies all patients: OR 1.01 (95% CI 0.84-1.23; P = .90, I 2 = 67%) and excluding patients with any type of persistent AF (PeAF) and those submitted to linear atrial lesion (LAL) OR 0.80 (95% CI 0.52-1.22; P = .30, I 2 = 71%). Using CRYO: all patients OR 1.34 (95% CI 1.03-1.74; P = .03, I 2 = 0%). Using RF: all patients-OR 0.55 (95% CI 0.32-0.95; P = .03, I 2 = 49%); excluding studies with long duration PeAF and the performance of LAL concomitant-OR 0.45 (95% CI 0.23-0.91; P = .03, I 2 = 44%). Conclusion: The results suggest a better prognosis in patients with LCO, submitted to PVI without additional LAL under RF energy in paroxysmal AF and short-duration PeAF. In patients undergoing CRYO, the presence of LCO suggests a worse prognosis.

Improved Flutter Ablation Outcomes Using a 10mm-tip Ablation Catheter.

INTRODUCTION: Radiofrequency(RF) ablation has become the first line of therapy for atrial flutter(AFL). Advances in catheter and mapping technologies have led to better understanding and different approaches for treating this arrhythmia. We describe the results of different approaches to ablate this arrhythmia. MATERIALS AND METHODS: A cohort of 198 patients with isthmus dependent AFL. The techniques used were: 10mm-tip catheter with power set to 100w, 8mm-tip catheter with power set to 60W and irrigated tip catheter. RESULTS: 212 procedures, including redos were done in 198 consecutive patients. We used irrigated tip catheters in 14 procedures, 8mm-tip in 55 procedures, and 10mm-tip in 143 procedures. Bidirectional block was achieved in 97.6% of cases with all techniques, with no difference among them. Procedure time was shorter in the 10mm-tip versus 8mm-tip(69.6±30.6min vs.105±43min) or irrigated tip(180±90min) (P<0.05). Fluoroscopy time was also shorter in the 10mm-tip versus 8mm-tip (24±18min vs. 37±23min) or irrigated tip (110±25min)(P<0.05). The cumulative incidence of failure during follow-up was 1.2%/year in the 10mm, 10.1%year in the 8mm and 6.9%year in the irrigated tip. The survival free of a new procedure was significantly higher among 10mm patients. CONCLUSIONS: In our series we found a high rate of acute success with the use of different techniques for AFL ablation. Procedure and fluoroscopic times were shorter with the use of 10mm-tip as compared with the others techniques. The long-term risk of recurrence was lower when we used the 10mm-tip catheter and the survival free of a second procedure was higher among patients treated with this catheter.

Update on Management of Postoperative Atrial Fibrillation After Cardiac Surgery.

Postoperative atrial fibrillation (POAF) after cardiac surgery remarkably remains the most prevalent event in perioperative cardiac surgery, having great clinical and economic implications. The purpose of this study is to present recommendations based on international evidence and adapted to our clinical practice for the perioperative management of POAF. This update is based on the latest current literature derived from articles and guidelines regarding atrial fibrillation.

Inter-observer variation of Syntax score among cardiac surgeons, clinical and interventional cardiologists.

BACKGROUND: Despite the complexity of SYNTAX score (SS), guidelines recommend this tool to help choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with left main of three-vessel coronary artery disease. The aim of this study was to compare the inter-observer variation in SS performed by clinical cardiologists (CC), interventional cardiologists (IC), and cardiac surgeons (CS). METHODS: Seven coronary angiographies from patients with left main and/or three-vessel disease chosen by a heart team were analyzed by 10 CC, 10 IC and 10 CS. SS was calculated via SYNTAX website. RESULTS: Kappa concordance was very low between CC and CS (k = 0.176), moderate between CS and IC (k = 0.563), and moderate between CC and IC (0.553). There was a statistically significant difference between CC, who classified more cases as low complexity (70%), and CS, who classified more cases as moderate complexity (80%) (p = 0.041). CONCLUSION: Concordance between SS analyzed by CC, CS and IC is low. The usefulness of SS in decision-making of revascularization strategy is undeniable and evidence supports its use. However, this study highlights the importance of well-trained professionals on calculating the SS. It could avoid misclassification of borderline cases.

Comparative Analysis between Transferred and Self-Referred STEMI Patients Undergoing Primary Angioplasty.

BACKGROUND: Studies have shown the benefits of rapid reperfusion therapy in acute myocardial infarction. However, there are still delays during transport of patients to primary angioplasty. OBJECTIVE: To evaluate whether there is a difference in total ischemic time between patients transferred from other hospitals compared to self-referred patients in our institution. METHODS: Historical cohort study including patients with acute myocardial infarction treated between April 2014 and September 2015. Patients were divided into transferred patients (group A) and self-referred patients (group B). Clinical characteristics of the patients were obtained from our electronic database and the transfer time was estimated based on the time the e-mail requesting patient's transference was received by the emergency department. RESULTS: The sample included 621 patients, 215 in group A and 406 in group B. Population characteristics were similar in both groups. Time from symptom onset to arrival at the emergency department was significantly longer in group A (385 minutes vs. 307 minutes for group B, p < 0.001) with a transfer delay of 147 minutes. There was a significant relationship between the travel distance and increased transport time (R = 0.55, p < 0.001). However, no difference in mortality was found between the groups. CONCLUSION: In patients transferred from other cities for treatment of infarction, transfer time was longer than that recommended, especially in longer travel distances.

Unscheduled Emergency Visits after Cardiac Devices Implantation: Comparison between Cardioverter Defibrillators and Cardiac Resynchronization Therapy Devices in less than one year of Follow Up.

BACKGROUND: The use of Cardiovascular Implantable Electronic Devices (CIED), such as the Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronization Therapy (CRT), is increasing. The number of leads may vary according to the device. Lead placement in the left ventricle increases surgical time and may be associated with greater morbidity after hospital discharge, an event that is often confused with the underlying disease severity. OBJECTIVE: To evaluate the rate of unscheduled emergency hospitalizations and death after implantable device surgery stratified by the type of device. METHODS: Prospective cohort study of 199 patients submitted to cardiac device implantation. The groups were stratified according to the type of device: ICD group (n = 124) and CRT group (n = 75). Probability estimates were analyzed by the Kaplan-Meier method according to the outcome. A value of p < 0.05 was considered significant in the statistical analyses. RESULTS: Most of the sample comprised male patients (71.9%), with a mean age of 61.1 ± 14.2. Left ventricular ejection fraction was similar between the groups (CRT 37.4 ± 18.1 vs. ICD 39.1 ± 17.0, p = 0.532). The rate of unscheduled visits to the emergency unit related to the device was 4.8% in the ICD group and 10.6% in the CRT group (p = 0.20). The probability of device-related survival of the variable "death" was different between the groups (p = 0.008). CONCLUSIONS: Patients after CRT implantation show a higher probability of mortality after surgery at a follow-up of less than 1 year. The rate of unscheduled hospital visits, related or not to the implant, does not differ between the groups.

Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação / Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization

Resumo Fundamento O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. Objetivo Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). Método Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. Resultados A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). Conclusão Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Abstract Background Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. Objective To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). Methods This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. Results The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). Conclusions In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.