Mechanical and electrical uncoupling: the role of cardiac magnetic resonance imaging in arrhythmogenic cardiomyopathy. Proof of concept.

OBJECTIVES: Arrhythmogenic cardiomyopathy (ACM) is a complex cardiac disorder associated with ventricular arrhythmias. Understanding the relationship between mechanical uncoupling and cardiac structural changes in ACM patients is crucial for improved risk stratification and management. METHODS: In this study, we enrolled 25 ACM patients (median age 34 years, 72% men) based on the 2019 Modified Task Force and Padua criteria. Patients were categorized by the presence or absence of clinically relevant ventricular tachycardia (crVT), necessitating emergency interventions. Right ventricular-arterial coupling (VAC) was assessed using echocardiography. Low-rank regression splines were employed to model left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) in relation to VAC. RESULTS: Positive associations were observed between VAC and LVEF (ρ = 0.472, p = 0.023), RVEF (ρ = 0.522, p = 0.038), and right ventricular (RV) indexed stroke volume (ρ = 0.79, p < 0.001). Patients with crVT exhibited correlations with RV shortening, reduced RVEF (39.6 vs. 32.2%, p = 0.025), increased left ventricular (LV) mass (38.99 vs. 45.55, p = 0.045), and LV end-diastolic volume (LVEDV) (56.99 vs. 68.15 mL/m2, p = 0.045). Positive associations for VAC were noted with LVEDV (p = 0.039) and LV mass (p = 0.039), while negative correlations were observed with RVEF by CMR (p = 0.023) and RV shortening by echocardiography (p = 0.026). CONCLUSIONS: Our findings underscore the significance of right VAC in ACM, demonstrating correlations with RV and LVEF, RV stroke volume, and clinically relevant arrhythmias. Insights into RVEF, LV mass, and end-diastolic volume provide valuable contributions to the understanding of ACM pathophysiology and may inform risk assessment strategies.

OBJETIVOS: La miocardiopatía arritmogénica (MCA) es un trastorno cardíaco complejo asociado con arritmias ventriculares (AV). Comprender la relación entre el desacoplamiento mecánico y los cambios estructurales cardíacos en pacientes con MCA es crucial para una estratificación de riesgos y una gestión mejorada. MÉTODOS: En este estudio, reclutamos a 25 pacientes con MCA (edad media 34 años, 72% hombres) basándonos en los criterios del Task Force 2019 y los criterios de Padua. Los pacientes se clasificaron según la presencia o ausencia de taquicardia ventricular clínicamente relevante (crVT), que requería intervenciones de emergencia. Se evaluó el acoplamiento ventricular derecho-arterial (VAC) mediante ecocardiografía. Se utilizaron low-rank regression splines para modelar la fracción de eyección del ventrículo izquierdo (FEVI) y la fracción de eyección del ventrículo derecho (FEVD) en relación con el VAC. RESULTADOS: Se observaron asociaciones positivas entre el VAC y la FEVI (ρ = 0.472, p = 0.023), la FEVD (ρ = 0.522, p = 0.038) y el volumen de eyección indexado del ventrículo derecho (ρ = 0.79, p < 0.001). Los pacientes con crVT mostraron correlaciones con acortamiento del ventrículo derecho, disminución de la FEVD (39.6 vs. 32.2%, p = 0.025), aumento de la masa ventricular izquierda (38.99 vs. 45.55, p = 0.045) y volumen diastólico final del ventrículo izquierdo (VDVI) (56.99 vs. 68.15 mL/m2, p = 0.045). Se observaron asociaciones positivas para el VAC con el VDVI (p = 0.039) y la masa ventricular izquierda (p = 0.039), mientras que se observaron correlaciones negativas con la FEVD por RMC (p = 0.023) y el acortamiento del ventrículo derecho por ecocardiografía (p = 0.026). CONCLUSIONES: Nuestros hallazgos subrayan la importancia del VAC derecho en la MCA, demostrando correlaciones con la FEVD y FEVI, el volumen de eyección del ventrículo derecho y arritmias clínicamente relevantes. Las percepciones sobre la FEVD, la masa ventricular izquierda y el volumen diastólico final proporcionan contribuciones valiosas para comprender la fisiopatología de la MCA y pueden informar estrategias de evaluación de riesgos.

Evaluation of patients with implantable cardioverter-defibrillator in a Latin American tertiary center.

INTRODUCTION: Despite advancements in implantable cardioverter-defibrillator (ICD) technology, sudden cardiac death (SCD) remains a persistent public health concern. Chagas disease (ChD), prevalent in Brazil, is associated with increased ventricular tachycardia (VT) and ventricular fibrillation (VF) events and SCD compared to other cardiomyopathies. METHODS: This retrospective observational study included patients who received ICDs between October 2007 and December 2018. The study aims to assess whether mortality and VT/VF events decreased in patients who received ICDs during different time periods (2007-2010, 2011-2014, and 2015-2018). Additionally, it seeks to compare the prognosis of ChD patients with non-ChD patients. Time periods were chosen based on the establishment of the Arrhythmia Service in 2011. The primary outcome was overall mortality, assessed across the entire sample and the three periods. Secondary outcomes included VT/VF events and the combined outcome of death or VT/VF. RESULTS: Of the 885 patients included, 31% had ChD. Among them, 28% died, 14% had VT/VF events, and 37% experienced death and/or VT/VF. Analysis revealed that period 3 (2015-2018) was associated with better death-free survival (p = .007). ChD was the only variable associated with a higher rate of VT/VF events (p < .001) and the combined outcome (p = .009). CONCLUSION: Mortality and combined outcome rates decreased gradually for ICD patients during the periods 2011-2014 and 2015-2018 compared to the initial period (2007-2010). ChD was associated with higher VT/VF events in ICD patients, only in the first two periods.

[Electrocardiographic interval as a predictor of life-threatening arrhythmias in dilated cardiomyopathy patients]. / Intervalo electrocardiográfico como predictor de arritmias graves en pacientes con miocardiopatía dilatada.

Background: The Tpe interval (Tp-e) in the surface electrocardiogram represents ventricular repolarization, a key phase in the pathogenesis of severe ventricular arrhythmias. However, there are few studies evaluating changes in this electrocardiographic interval as a risk factor for serious arrhythmias in patients with dilated cardiomyopathy. Objective: To determine whether the Tp-e interval prolongation predicts the presence of life-threatening arrhythmias in patients with dilated cardiomyopathy (DCM) with implantable cardioverter-defibrillator (ICD). Material and methods: Analytical, cross-sectional study in patients with DCM with ICDs. The Tp-e interval was measured in the V2 electrocardiographic lead and correlated with the incidence of life-threatening arrhythmias identified by the ICD. Results: 53 patients were recruited, 10 (18.8%) presented life-threatening arrhythmias. Prolongation of Tp-e interval was related to an increase in the incidence of ventricular tachycardia/fibrillation tachycardia (VT/FT) with a mean of 93 ± 20.5 ms (p = 0.003), using ROC curves to determine the thereshold of 90 ms for increased risk of VT/VF with sensitivity of 70% and specificity of 84%, with an area under the curve of 0.798. Conclusion: The prolongation of the ITp-e interval greater than 90 ms in a population with dilated cardiomyopathy predicts the presence of arrhythmic episodes, such as VT and/or VT/FT.

Introducción: el intervalo Tpe (ITp-e) en el electrocardiograma de superficie representa la repolarización ventricular, fase clave en la patogénesis de arritmias ventriculares graves. Sin embargo, existen pocos estudios que evalúen la alteración de este intervalo electrocardiográfico como factor de riesgo de arritmias graves en pacientes con miocardiopatía dilatada. Objetivo: determinar si la prolongación del ITp-e predice la presencia de arritmias potencialmente mortales en pacientes con miocardiopatía dilatada (MCD) portadores de desfibrilador automático implantable (DAI). Material y métodos: estudio, transversal analítico en pacientes con MCD portadores de DAI. Se midió el ITp-e en la derivación electrocardiográfica V2 y se correlacionó con la incidencia de arritmias potencialmente letales identificadas por el DAI. Resultados: se incluyeron 53 pacientes, 10 (18.8%) presentaron arritmias potencialmente mortales. La prolongación del ITp-e se relacionó con aumento de incidencia de taquicardia ventricular/fibrilación ventricular (TV/FV) con media de 93 ± 20.5 ms (p = 0.003), por lo que se determinó mediante curvas ROC el punto de corte de 90 ms para el aumento de riesgo de TV/FV con sensibilidad de 70% y especificidad de 84%, con área bajo la curva de 0.798. Conclusión: la prolongación del intervalo ITp-e > 90 ms en población con miocardiopatía dilatada predice la presencia de episodios arrítmicos como TV o FV.

Taquicardia ventricular polimórfica tipo torsadess de pointes secundaria a estimulación por marcapasos / Polymorphic ventricular taquicardia "torsades de pointes" associated to abnormal pacemaker stimulation

La taquicardia ventricular polimórfica se origina en los ventrículos, cuyos complejos QRS son de morfología, amplitud y dirección variable, con frecuencias que oscilan entre 200 y 250 lpm, pudiendo ser autolimitadas o degenerar en una fibrilación ventricular. La TdP es un tipo de taquicardia ventricular polimórfica caracterizada por complejos con un eje eléctrico que gira alrededor de la línea isoeléctrica y que está asociada a QT largo. Se presenta el caso de una paciente portadora de marcapaso que presenta episodios de taquicardia ventricular polimórfica, con una morfología típica de TdP, sin documentación de QT prolongado previo ni actual, generada por la estimulación ventricular sobre onda T, de forma accidental por desplazamiento del electrodo auricular a Ventrículo Derecho (VD).

Polymorphic ventricular tachycardia is a tachycardia originating in the ventricles, where the QRS complexes have variable morphology, amplitude, and direction, with frequencies ranging between 200 and 250 bpm; it may be self-limited or degenerate into ventricular fibrillation. Torsades de Pointes (TdP) is a type of polymorphic ventricular tachycardia characterized by complexes with an electrical axis that rotates around the isoelectric line and that is associated with long QT interval. We present the case of a patient with a pacemaker who presents episodes of polymorphic ventricular tachycardia, with a typical morphology of TdP, without documentation of previous or current prolonged QT, generated by ventricular stimulation on the T wave, accidentally due to displacement of the atrial electrode to the Right Ventricle (RV).

Arrhythmic Recurrence and Outcomes in Patients Hospitalized With First Episode of Electrical Storm.

Electrical storm (ES) is a life-threatening condition that may lead to recurrent arrhythmias, need for ventricular mechanical support, and death. The study aimed to assess the burden of arrhythmia recurrence and in-hospital outcomes of patients admitted for ES in a large urban hospital. We performed a retrospective analysis of patients admitted with ventricular arrhythmias from January 2018 to June 2021 and identified 61 patients with ES, defined as 3 or more episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) within 24 hours. We reviewed the in-hospital outcomes and compared outcomes between patients who had no recurrence of VT/VF after the first 24 hours (34 [56%]), those with recurrence of 1 or 2 episodes of VT/VF within a 24-hour period (15 [24%]), and patients with 3 or more recurrent VT/VF events consistent with recurrent ES after the first 24 hours (12 [20%]). Patients with recurrent ES had significantly higher in-hospital mortality as compared with those with recurrent VT/VF not meeting criteria for ES or no recurrences of VT/VF (3 [25%] vs 0 [0%] vs 0 [0%]; p = 0.002). Moreover, patients with recurrent ES also had higher rates of the combined end points of ventricular mechanical support and death (7 [58%] vs 1 [6%] vs 1 [3%], p <0.001), invasive mechanical ventilation and death (10 [83%] vs 2 [13%] vs 2 [6%], p <0.001), catheter ablation or death (12 [100%] vs 7 [47%] vs 12 [35%], p <0.001) and heart transplantation and death (3 [25%] vs 2 [13%] vs 0 [0%], p = 0.018). In conclusion, patients admitted with ES have a high risk of in-hospital recurrence, associated with extremely poor outcomes.

Frequency of Electrocardiographic Alterations and Pericardial Effusion in Patients With Uncomplicated Malaria.

Studies have proposed that malaria may lead to electrocardiographic (ECG) changes and pericardial inflammation. We aimed to investigate the frequency of ECG alterations, determined by ECG and Holter monitoring, and pericardial effusion in patients with malaria infection. We performed a prospective observational study of adult patients with uncomplicated malaria in Amazonas, Brazil. Peripheral blood smears, ECG, and bedside echocardiography were conducted before antimalarial treatment and repeated at follow-up after completed treatment. We evaluated the diagnostic value of PR-segment depression, PR-segment elevation, and Spodick's sign for detecting pericardial effusion. A subset of patients underwent Holter monitoring at baseline. Among 98 cases of uncomplicated malaria (55% men; mean age 40 years; median parasite density 1,774/µl), 75 had Plasmodium vivax, 22 Plasmodium falciparum, and 1 had mixed infection. At baseline, 17% (n = 17) had PR-segment depression, 12% (n = 12) PR-segment elevation, 3% (n = 2) Spodick's sign, and the prevalence of pericardial effusion was 9% (n = 9). ECG alterations had sensitivities of 22% to 89% and specificities of 88% to 100% for detecting pericardial effusion at baseline. PR-segment depression had the best accuracy (sensitivity 89%, specificity 90%). Of the 25 patients, 4 patients who did not have pericardial effusion, displayed nonsustained ventricular tachycardia, determined by Holter monitoring (median duration 43 hours). Follow-up examination data were obtained for 71 patients (median 31 days), for whom PR-segment depression, elevation, and pericardial effusion had reduced significantly (p <0.05). In conclusion, our findings suggest that ECG alterations may be useful to detect pericardial effusion in malaria and that these findings decrease after completed antimalarial treatment.

A rare coronary anomaly as a possible cause of ventricular tachycardia / Una anomalía coronaria poco común como posible causa de taquicardia ventricular

We present the case of a 77-year-old man who came to the emergency room after a syncopal episode in the context of sustained monomorphic ventricular tachycardia for which electrical cardioversion was performed. In order to determine the etiology of the ventricular arrhythmic event, a study of the coronary anatomy was carried out using invasive coronary angiography, observing coronary arteries without significant lesions, although, as a chance finding, a coronary anomaly was described, with absence of the main coronary artery, with independent exit of circumflex (Cx) and anterior descending (AD) arteries of the right coronary sinus, originating the AD and right coronary artery from the same coronary ostium. These findings were later confirmed by computed tomography with 3D reconstruction. In addition, an interarterial path of AD (between aorta and pulmonary artery) and an intramuscular path of AD were observed, as well as a retro-aortic path of Cx. Given these findings, an implantable cardioverter defibrillator was implanted as secondary prevention. Good subsequent evolution with home discharge without incident. We present this case to help better understand these disorders, since they currently constitute a diagnostic challenge, since in many cases it is a chance finding in complementary tests or even in autopsies. It is also a relatively frequent cause of cardiorespiratory arrest in young patients. Of the many anatomical variables that make up the group of coronary anomalies, there is little bibliographic information on this anomaly presented, without finding images similar to those reported in this case.

Se presenta el caso de un varón de 77 años que acude a urgencias tras un episodio sincopal en el contexto de una taquicardia ventricular monomorfa sostenida, por lo que se realizó cardioversión eléctrica. Para filiar la etiología del evento arrítmico ventricular se realizó un estudio de la anatomía coronaria mediante coronariografía invasiva, en el que se objetivaron las arterias coronarias sin lesiones significativas, pero como hallazgo casual se describió una anomalía coronaria, con ausencia de tronco coronario y salida independiente de las arterias circunfleja (Cx) y descendente anterior (DA) del seno coronario derecho, originándose la DA y la coronaria derecha del mismo ostium coronario. Dichos hallazgos se confirmaron mediante tomografía computarizada con reconstrucción tridimensional. Además, se objetivó un trayecto interarterial de la DA (entre las arterias aorta y pulmonar) y un trayecto intramuscular de la DA, así como un trayecto retroaórtico de la Cx. Debido a estos hallazgos, se procedió al implante de un desfibrilador automático implantable como prevención secundaria. El paciente tuvo una buena evolución posterior y fue dado de alta a su domicilio sin incidencias. Se presenta el caso para ayudar a comprender mejor estos trastornos, dado que actualmente constituyen un reto diagnóstico, ya que en muchas ocasiones se trata de un hallazgo casual en pruebas complementarias o incluso en autopsias. Además, es una causa relativamente frecuente de parada cardiorrespiratoria en pacientes jóvenes. De las muchas variables anatómicas que constituyen las anomalías coronarias, existe poca literatura sobre esta anomalía presentada y no hay imágenes similares a las de este caso.

Arritmias cardíacas em pacientes com COVID-19 / Cardiac arrhythmias in patients with COVID-19

Resumo Fundamento: A doença pelo novo coronavírus (COVID-19) está associada a manifestações clínicas cardiovasculares, incluindo a ocorrência de arritmias cardíacas. Objetivos: Avaliar a incidência de arritmias cardíacas (taquiarritmia atrial, bradiarritmia e taquicardia ventricular sustentada) e de parada cardiorrespiratória (PCR) em uma coorte de pacientes internados com COVID-19 em hospital universitário terciário. Métodos: Estudo de coorte retrospectivo realizado por meio de revisão dos registros de prontuário médico. Para comparação entre os grupos, foi considerado como estatisticamente significativo valor de P < 0,05. Resultados: Foram incluídos 241 pacientes consecutivos com diagnóstico de COVID-19 (idade média, 57,8 ± 15,0 anos; 51,5% homens; 80,5% de raça branca) e 35,3% com necessidade de ventilação mecânica invasiva (VM). A mortalidade geral foi de 26,6%, sendo de 58,8% entre aqueles em VM. Arritmias cardíacas ocorreram em 8,7% dos pacientes, sendo a mais comum taquiarritmia atrial (76,2%). Pacientes com arritmias apresentaram maior mortalidade, 52,4% versus 24,1% (p=0,005). Em análise multivariada, apenas a presença de insuficiência cardíaca foi associada a maior risco de arritmias ( hazard ratio , 11,9; IC 95%: 3,6-39,5; p<0,001). Durante a internação, 3,3% dos pacientes foram atendidos em PCR, com predomínio de ritmos não chocáveis. Todos os atendidos em PCR evoluíram com óbito durante a internação. Conclusão: A incidência de arritmias cardíacas em pacientes internados com COVID-19 em hospital terciário brasileiro foi de 8,7%, sendo a mais comum taquiarritmias atrial. A presença de insuficiência cardíaca foi associada a maior risco de arritmias. Pacientes com COVID-19 atendidos em PCR apresentam elevada mortalidade.

Abstract Background: The coronavirus disease 2019 (COVID-19) is associated with cardiovascular clinical manifestations, including cardiac arrhythmias. Objective: To assess the incidence of cardiac arrhythmias (atrial tachyarrhythmia, bradyarrhythmia, and sustained ventricular tachycardia) and cardiac arrest (CA) in a cohort of patients hospitalized with COVID-19 in a tertiary university-affiliated hospital. Methods: Cohort study with retrospective analysis of electronic medical records. For comparison between groups, a value of p <0.05 was considered statistically significant Results: We included 241 consecutive patients diagnosed with COVID-19 (mean age, 57.8 ± 15.0 years; 51.5% men; 80.5% white), 35.3% of whom received invasive mechanical ventilation (MV). The overall mortality was 26.6%, being 58.8% among those on MV. Cardiac arrhythmias were identified in 8.7% of the patients, the most common being atrial tachyarrhythmia (76.2%). Patients with arrhythmias had higher mortality (52.4% versus 24.1%, p = 0.005). On multivariate analysis, only the presence of heart failure (HF) was associated with a higher risk of arrhythmias (hazard ratio, 11.9; 95% CI: 3.6-39.5; p <0.001). During hospitalization, 3.3% of the patients experienced CA, with a predominance of non-shockable rhythms. All patients experiencing CA died during hospitalization. Conclusions: The incidence of cardiac arrhythmias in patients admitted with COVID-19 to a Brazilian tertiary hospital was 8.7%, and atrial tachyarrhythmia was the most common. Presence of HF was associated with an increased risk of arrhythmias. Patients with COVID-19 experiencing CA have high mortality.

Cardiac Arrhythmias in Patients with COVID-19. / Arritmias Cardíacas em Pacientes com COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) is associated with cardiovascular clinical manifestations, including cardiac arrhythmias. OBJECTIVE: To assess the incidence of cardiac arrhythmias (atrial tachyarrhythmia, bradyarrhythmia, and sustained ventricular tachycardia) and cardiac arrest (CA) in a cohort of patients hospitalized with COVID-19 in a tertiary university-affiliated hospital. METHODS: Cohort study with retrospective analysis of electronic medical records. For comparison between groups, a value of p <0.05 was considered statistically significant. RESULTS: We included 241 consecutive patients diagnosed with COVID-19 (mean age, 57.8 ± 15.0 years; 51.5% men; 80.5% white), 35.3% of whom received invasive mechanical ventilation (MV). The overall mortality was 26.6%, being 58.8% among those on MV. Cardiac arrhythmias were identified in 8.7% of the patients, the most common being atrial tachyarrhythmia (76.2%). Patients with arrhythmias had higher mortality (52.4% versus 24.1%, p = 0.005). On multivariate analysis, only the presence of heart failure (HF) was associated with a higher risk of arrhythmias (hazard ratio, 11.9; 95% CI: 3.6-39.5; p <0.001). During hospitalization, 3.3% of the patients experienced CA, with a predominance of non-shockable rhythms. All patients experiencing CA died during hospitalization. CONCLUSIONS: The incidence of cardiac arrhythmias in patients admitted with COVID-19 to a Brazilian tertiary hospital was 8.7%, and atrial tachyarrhythmia was the most common. Presence of HF was associated with an increased risk of arrhythmias. Patients with COVID-19 experiencing CA have high mortality.

FUNDAMENTO: A doença pelo novo coronavírus (COVID-19) está associada a manifestações clínicas cardiovasculares, incluindo a ocorrência de arritmias cardíacas. OBJETIVOS: Avaliar a incidência de arritmias cardíacas (taquiarritmia atrial, bradiarritmia e taquicardia ventricular sustentada) e de parada cardiorrespiratória (PCR) em uma coorte de pacientes internados com COVID-19 em hospital universitário terciário. MÉTODOS: Estudo de coorte retrospectivo realizado por meio de revisão dos registros de prontuário médico. Para comparação entre os grupos, foi considerado como estatisticamente significativo valor de P < 0,05. RESULTADOS: Foram incluídos 241 pacientes consecutivos com diagnóstico de COVID-19 (idade média, 57,8 ± 15,0 anos; 51,5% homens; 80,5% de raça branca) e 35,3% com necessidade de ventilação mecânica invasiva (VM). A mortalidade geral foi de 26,6%, sendo de 58,8% entre aqueles em VM. Arritmias cardíacas ocorreram em 8,7% dos pacientes, sendo a mais comum taquiarritmia atrial (76,2%). Pacientes com arritmias apresentaram maior mortalidade, 52,4% versus 24,1% (p=0,005). Em análise multivariada, apenas a presença de insuficiência cardíaca foi associada a maior risco de arritmias ( hazard ratio , 11,9; IC 95%: 3,6-39,5; p<0,001). Durante a internação, 3,3% dos pacientes foram atendidos em PCR, com predomínio de ritmos não chocáveis. Todos os atendidos em PCR evoluíram com óbito durante a internação. CONCLUSÃO: A incidência de arritmias cardíacas em pacientes internados com COVID-19 em hospital terciário brasileiro foi de 8,7%, sendo a mais comum taquiarritmias atrial. A presença de insuficiência cardíaca foi associada a maior risco de arritmias. Pacientes com COVID-19 atendidos em PCR apresentam elevada mortalidade.

Síndrome de Brugada asociado a pericarditis aguda / Brugada syndrome associated to acute pericarditis

Resumen Comunicamos el caso de un hombre de 56 años que ingresó por pericarditis aguda febril, probablemente de causa viral, que durante su evolución presentó una fibrilación auricular paroxística y taquicardia ventricular polimorfa recurrente. El análisis de la historia clínica y serie electrocardiográfica permitió el diagnóstico retrospectivo asociado de un síndrome de Brugada. Hubo buena respuesta inicial al tratamiento antiinflamatorio asociado a colchicina y se implantó un desfibrilador automático intracavitario para prevención de muerte súbita. Se discuten aspectos clínicos del síndrome de Brugada, la importancia de la fiebre y de la pericarditis como cuadro clínico asociado.

Abstract A 56-year-old patient was admitted for acute febrile pericarditis, probably viral, who presented with paroxysmal atrial fibrillation and recurrent polymorphic ventricular tachycardia during his clinical course. Analysis of the clinical and electrocardiographic findings allowed the retrospective diagnosis of Brugada syndrome in the context of pericarditis. An initial response to anti-inflammatory treatment associated with colchicine was good. An internal cardioverter defibrillator was implanted to prevent sudden death. Clinical aspects of the Brugada syndrome, the importance of fever and pericarditis as an associated clinical condition are discussed.

Associations between Cardiac Magnetic Resonance T1 Mapping Parameters and Ventricular Arrhythmia in Patients with Chagas Disease.

Chronic Chagas disease can progress to myocardial involvement with intense fibrosis, which may predispose patients to sudden cardiac death through ventricular arrhythmia. The associations of myocardial fibrosis detected by cardiac magnetic resonance (CMR) parameters with non-sustained ventricular tachycardia (NSVT) were evaluated. This cross-sectional study included patients in early stages of Chagas disease (n = 47) and a control group (n = 15). Patients underwent cardiac evaluation, including CMR examination. Myocardial fibrosis assessment by CMR with measurement of late gadolinium enhancement (LGE), native T1, and extracellular volume (ECV) was performed. There was an increase in myocardial fibrosis CMR parameters and ventricular arrhythmias among different stages of Chagas disease, combined with a decrease in the left ventricular ejection fraction (LVEF) by CMR and also in the right ventricular systolic function by S' wave on tissue Doppler. Fibrosis mass and ECV were associated with the Rassi score, ventricular extrasystole, and E/e' ratio in a logistic regression model adjusted for age and gender. The ECV maintained an association with the presence of NSVT, even after adjustments for fibrosis mass and LVEF assessed by CMR. The receiver-operating characteristic area under the curve for global ECV (0.85; 95% CI: 0.71-0.99) and NSVT was greater than that for fibrosis mass (0.75; 95% CI: 0.54-0.96), although this difference was not statistically significant. Extracellular volume could be an early marker of increased risk of ventricular arrhythmia in Chagas disease, presenting an independent association with NSVT in the initial stages of chronic Chagas cardiomyopathy, even after adjustment for fibrosis mass and LVEF.

Efficacy and safety of combined endocardial/epicardial catheter ablation for ventricular tachycardia in Chagas disease: A randomized controlled study.

BACKGROUND: Epicardial mapping and ablation are frequently necessary to eliminate ventricular tachycardia (VT) in patients with Chagas disease. Nonetheless, there are no randomized controlled trials demonstrating the role of this strategy. OBJECTIVE: We conducted this randomized controlled trial to evaluate the efficacy and safety of combined epicardial ablation in patients with Chagas disease. METHODS: We randomized patients with Chagas disease and VT in a 1:1 fashion to either the endocardial (endo) mapping and ablation group or the combined endocardial/epicardial (endo/epi) mapping and ablation group. The efficacy end points were measured by VT inducibility and all-ventricular arrhythmia recurrence. Safety was assessed by the rate of periprocedural complications. RESULTS: Thirty patients were enrolled, and most were male. The median age was 67 (Q1: 58; Q3: 70) years in the endo group and 58 (Q1: 43; Q3: 66) years in the endo/epi group. The left ventricular ejection fraction was 33.0% ± 9.5% and 35.2% ± 11.5%, respectively P = .13. Acute success (non-reinducibility of clinical VT) was obtained in 13 patients (86%) in the endo/epi group and in 6 patients (40%) in the endo-only group (P = .021). There were 12 patients with VT recurrence (80%) in the endo-only group and 6 patients (40%) in the endo/epi group (P = .02) (by intention-to-treat analysis). Epicardial ablation was ultimately performed in 9 patients (60%) in the endo-only group because of an absence of endocardial scar or maintenance of VT inducibility. There was no difference in complications between the groups. CONCLUSION: Combining endo/epi VT catheter ablation in patients with Chagas disease significantly increases short- and long-term freedom from all-ventricular arrhythmias. Epicardial access did not increase periprocedural complication rates.

Ventricular arrhythmias in the Chagas disease are not random phenomena: Long-term monitoring in Chagas arrhythmias.

BACKGROUND: Variability of ventricular arrhythmias among days in patients with Chagas disease is not detected by 24 hours of Holter monitoring. OBJECTIVE: To analyze whether ventricular arrhythmias are a random phenomenon or have a reproducible behavior in patients with Chagas cardiomyopathy. METHOD: Holter monitoring was recorded in 16 subjects with a mean age of 52 ± 8 years. They were clinically stable and had ventricular couplets, isolated premature ventricular contractions (PVCs), and nonsustained ventricular tachycardia (NSVT). The recordings occurred for 7 days. Hurst exponent (HE) evaluated randomness and predictability index (PI) and repeated analysis of variance (ANOVA) assessed reproducibility. RESULTS: The HE was significantly greater than 0.5 in all 16 patients, which confirms the nonrandomness of arrhythmias in this Chagas sample. The PI for ventricular couplets and isolated PVCs was, on average, 38% and 54%, respectively. ANOVA with repeated measurement showed significant differences in the daily frequency of ventricular couplets (n = 15, P ≤ .05), isolated PVC (n = 12, P ≤ .05), and NSVT (n = 7, P ≤ .05). CONCLUSION: Ventricular arrhythmias in Chagas cardiomyopathy are not random. Dissimilarities in arrhythmias frequency make unlikely that 24 hours of Holter recording can capture this variability.

[Clinical features and complications of Takotsubo syndrome in a peruvian social security referral center]. / Características clínicas y complicaciones del síndrome de Takotsubo en un centro de referencia de la seguridad social peruana.

In order to describe the clinical features and complications of Takotsubo syndrome, a case series study was conducted with patients admitted with this pathology to the National Cardiovascular Institute-INCOR in Lima-Peru between January 2013 and December 2018. Twenty-six patients (26) were included, with an average age of 69 years and female predominance (96.2%); additionally, a trigger was identified in 23 cases (88.5%). In the electrocardiogram, 61.5% had ST segment elevation; and, in the evolution, 92.3% showed negative T waves and 38.5% a QTc interval >500 ms. In-hospital complications were cardiogenic shock (11.5%), atrial fibrillation (7.7%) and ventricular tachycardia (7.7%). In this series, Takotsubo syndrome predominated in postmenopausal women, usually triggered by a stressor, with a low complication rate and no in-hospital mortality.

Con el objetivo de describir las características clínicas y complicaciones del síndrome de Takotsubo, se realizó un estudio de serie de casos de pacientes que ingresaron con esta patología al Instituto Nacional Cardiovascular-INCOR en Lima-Perú, entre enero de 2013 a diciembre de 2018. Se incluyeron 26 pacientes, con una edad promedio de 69 años y predominio del sexo femenino (96,2%), además un desencadenante se identificó en 23 casos (88,5%). En el electrocardiograma, el 61,5% tuvo supradesnivel del segmento ST; y en la evolución el 92,3% mostró ondas T negativas y el 38,5% un intervalo QTc >500 ms. Las complicaciones intrahospitalarias fueron choque cardiogénico (11,5%), fibrilación auricular (7,7%) y taquicardia ventricular (7,7%). En esta serie, el síndrome de Takotsubo predominó en mujeres posmenopáusicas, generalmente desencadenado por un factor estresante, con una baja tasa de complicaciones y ausencia de mortalidad intrahospitalaria.

Comparison of the amount and patterns of late enhancement in Chagas disease according to the presence and type of ventricular tachycardia.

BACKGROUND: Ventricular tachycardia (VT) is one of the main predictors of mortality in Chagas cardiomyopathy (CC). Although the substrate of sustained and nonsustained-VT (NS-VT) seems to be the same, little is known about the distribution of late enhancement (LE). Our aim was to compare the clinical findings and the amount and patterns of LE in Chagas disease according to the presence and type of VT. METHODS AND RESULTS: Magnetic resonance imaging was performed in 54 Chagas seropositive patients: 8 indeterminate and 46 with CC of whom 15 were without VT, 13 with NS-VT, and 18 with sustained-VT (S-VT). There were 31 males (57%), mean age was 55.9 ± 12.2 years. LE was found in 87% of all patients and in 50%, 80%, and 100% of the indeterminate, without VT and VT groups, respectively. The percentage of LE increased progressively in the indeterminate, CC without VT, and CC with VT groups; without a significant difference between NS-VT and S-VT (0.93%, 15.2%, 23.2%, and 21.4%, respectively). The amount of LE increased with the functional class. LE in the basal and mid lateral wall was more frequent in VT, without difference between S-VT and NS-VT. The only predictor of VT was the percentage of LE, odds ratio (OR), 6.2; (95% confidence interval [CI], 3.7-28.4; P = .01) with a cutoff of Odds Ratio 17.1%. CONCLUSIONS: The amount of LE increases in relation to the clinical stage of the disease and its functional class in Chagas seropositive patients. The amount of LE was the main predictor of VT, without difference between S-VT and NS-VT.

Características clínicas y complicaciones del síndrome de Takotsubo en un centro de referencia de la seguridad social peruana / Clinical features and complications of Takotsubo syndrome in a peruvian social security referral center

RESUMEN Con el objetivo de describir las características clínicas y complicaciones del síndrome de Takotsubo, se realizó un estudio de serie de casos de pacientes que ingresaron con esta patología al Instituto Nacional Cardiovascular-INCOR en Lima-Perú, entre enero de 2013 a diciembre de 2018. Se incluyeron 26 pacientes, con una edad promedio de 69 años y predominio del sexo femenino (96,2%), además un desencadenante se identificó en 23 casos (88,5%). En el electrocardiograma, el 61,5% tuvo supradesnivel del segmento ST; y en la evolución el 92,3% mostró ondas T negativas y el 38,5% un intervalo QTc >500 ms. Las complicaciones intrahospitalarias fueron choque cardiogénico (11,5%), fibrilación auricular (7,7%) y taquicardia ventricular (7,7%). En esta serie, el síndrome de Takotsubo predominó en mujeres posmenopáusicas, generalmente desencadenado por un factor estresante, con una baja tasa de complicaciones y ausencia de mortalidad intrahospitalaria.

ABSTRACT In order to describe the clinical features and complications of Takotsubo syndrome, a case series study was conducted with patients admitted with this pathology to the National Cardiovascular Institute-INCOR in Lima-Peru between January 2013 and December 2018. Twenty-six patients (26) were included, with an average age of 69 years and female predominance (96.2%); additionally, a trigger was identified in 23 cases (88.5%). In the electrocardiogram, 61.5% had ST segment elevation; and, in the evolution, 92.3% showed negative T waves and 38.5% a QTc interval >500 ms. In-hospital complications were cardiogenic shock (11.5%), atrial fibrillation (7.7%) and ventricular tachycardia (7.7%). In this series, Takotsubo syndrome predominated in postmenopausal women, usually triggered by a stressor, with a low complication rate and no in-hospital mortality.