Feasibility of Transatrial Access for Epicardial Ablation: Evaluation of 2 Different Techniques in Swine.

BACKGROUND: The subxiphoid pericardial access is technically difficult and has a considerable rate of complications, thus transatrial access may be an alternative. OBJECTIVES: This study sought to assess the feasibility and safety of this strategy regarding periprocedural period and after 1-week follow-up. METHODS: The investigators performed epicardial mapping through transatrial puncture in 20 swine. Animals were divided into group A, in which aspiration of the sheath was performed to maintain negative pressure after the withdraw of the catheters, and group B, in which a device (Konar-MF VSD Occluder) was delivered to occlude the right atrial appendage perforation. Bleeding was investigated immediately and 1 week after. RESULTS: Access was safe in 19 of 20 animals (95%) with small amount of bleeding (6.4 ± 6 mL). In group A (n = 10), 1 animal presented hemopericardium right after the puncture. In the other 9, epicardial ablation was performed and 60.0 ± 28.0 mL of blood was aspirated without events. After 1 week, fibrin-hemorrhagic pericarditis was identified in 3 animals. In group B (n = 10), reaching the epicardial surface was possible in all animals. An adequate position of the prosthesis was obtained in 90% (9 of 10). One death occurred in the immediate postoperative period, secondary to pneumothorax. After 1 week, postmortem analysis showed absence of pericardial bleeding and a normal-appearing pericardium in the 8 animals with adequate prosthesis position. CONCLUSIONS: Transatrial access allows epicardial mapping and ablation. Sheath removal after negative pressure contributes to achieving acute bleeding control but does not prevent its occurrence. The use of the device prevents bleeding and hemorrhagic pericarditis.

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

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

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

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

Carotid Sinus Massage in Syncope Evaluation: A Nonspecific and Dubious Diagnostic Method.

BACKGROUND: Carotid sinus hypersensitivity (CSH) is a frequent finding in the evaluation of syncope. However, its significance in the clinical setting is still dubious. A new criterion was proposed by Solari et al. with a symptomatic systolic blood pressure (SBP) cut-off value of ≤ 85 mmHg to refine the vasodepressor (VD) response diagnosis. OBJECTIVE: To determine and compare the response to carotid sinus massage (CSM) in patients with and without syncope according to standard and proposed criteria. METHODS: CSM was performed in 99 patients with and 66 patients without syncope. CSH was defined as cardioinhibitory (CI) for asystole ≥ 3 seconds, or as VD for SBP decrease ≥ 50 mmHg. RESULTS: No differences in the hemodynamic responses were observed during CSM between the groups, with 24.2% and 25.8% CI, and 8.1% and 13.6% VD in the symptomatic and asymptomatic groups, respectively (p = 0.466). A p value < 0.050 was considered statistically significant. During the maneuvers, 45 (45.45%) and 34 (51.5%) patients in the symptomatic and asymptomatic groups achieved SBP below ≤ 85 mmHg. Symptoms were reported especially in those patients in whom CSM caused a SBP decrease to below 90 mmHg and/or asystole > 2.5 seconds, regardless of the pattern of response or the presence of previous syncope. CONCLUSION: The response to CSM in patients with and without syncope was similar; therefore, CSH may be an unspecific condition. Clinical correlation and other methods of evaluation, such as long-lasting ECG monitoring, may be necessary to confirm CSH as the cause of syncope.

Carotid Sinus Massage in Syncope Evaluation: A Nonspecific and Dubious Diagnostic Method / Massagem do Seio Carotídeo na Avaliação da Síncope: Um Método Diagnóstico Inespecífico e Duvidoso

Abstract Background: Carotid sinus hypersensitivity (CSH) is a frequent finding in the evaluation of syncope. However, its significance in the clinical setting is still dubious. A new criterion was proposed by Solari et al. with a symptomatic systolic blood pressure (SBP) cut-off value of ≤ 85 mmHg to refine the vasodepressor (VD) response diagnosis. Objective: To determine and compare the response to carotid sinus massage (CSM) in patients with and without syncope according to standard and proposed criteria. Methods: CSM was performed in 99 patients with and 66 patients without syncope. CSH was defined as cardioinhibitory (CI) for asystole ≥ 3 seconds, or as VD for SBP decrease ≥ 50 mmHg. Results: No differences in the hemodynamic responses were observed during CSM between the groups, with 24.2% and 25.8% CI, and 8.1% and 13.6% VD in the symptomatic and asymptomatic groups, respectively (p = 0.466). A p value < 0.050 was considered statistically significant. During the maneuvers, 45 (45.45%) and 34 (51.5%) patients in the symptomatic and asymptomatic groups achieved SBP below ≤ 85 mmHg. Symptoms were reported especially in those patients in whom CSM caused a SBP decrease to below 90 mmHg and/or asystole > 2.5 seconds, regardless of the pattern of response or the presence of previous syncope. Conclusion: The response to CSM in patients with and without syncope was similar; therefore, CSH may be an unspecific condition. Clinical correlation and other methods of evaluation, such as long-lasting ECG monitoring, may be necessary to confirm CSH as the cause of syncope.

Resumo Fundamento: A hipersensibilidade do seio carotídeo (HSC) é um achado frequente na avaliação da síncope. Entretanto, o valor da resposta positiva é ainda incerto no contexto clínico. Novo critério diagnóstico para tentar refinar a resposta vasodepressora (VD) foi proposto por Solari et al. com determinação da queda sintomática da pressão arterial sistólica (PAS) a níveis ≤ 85 mmHg como ponto de corte. Objetivo: Determinar e comparar a resposta à massagem do seio carotídeo (MSC) em pacientes com e sem síncope de acordo com os critérios vigentes e propostos. Métodos: A MSC foi realizada em 99 pacientes com síncope e 66 pacientes sem síncope. A HSC foi definida como cardioinibitória (CI), se assistolia ≥ 3 segundos, ou VD, se queda da PAS ≥ 50 mmHg. Resultados: Não foram observadas diferenças na resposta hemodinâmica entre os grupos durante a MSC, com 24,2% e 25,8% de resposta CI, e 8,1% e 13,6% de resposta VD nos grupos sintomático e assintomático, respectivamente (p = 0,466). Considerou-se p < 0,05 estatisticamente significativo. Durante as manobras, 45 (45,45%) e 34 (51,5%) pacientes nos grupos sintomático e assintomático atingiram PAS ≤ 85 mmHg. Sintomas foram relatados principalmente por pacientes em que a MSC reduziu a PAS para menos de 90 mmHg e/ou causou assistolia > 2,5 segundos, independentemente do padrão da resposta ou história de síncope prévia. Conclusão: As respostas à MSC em pacientes com e sem síncope foram semelhantes. Portanto, a HSC pode ser uma condição inespecífica. A correlação clínica mais precisa e outros métodos para avaliação, como monitoramento por ECG de longa duração, podem ser necessários para confirmação da HSC como causa da síncope.

Radiofrequency catheter ablation of premature ventricular contractions originating in the right ventricular outflow tract.

OBJECTIVES: To evaluate if radiofrequency catheter ablation is an effective procedure for the treatment of right ventricular outflow tract premature ventricular contractions (RVOT-PVC) and ascertain if it results in an improvement of symptoms. METHODS: A prospective study with 30 consecutive patients (mean age 40 +/- 13 years, 25 females), with no apparent structural cardiopathy, with very frequent (mean density of 1,263 +/- 593/h) RVOT-PVC, symptomatic for more than one year (mean = 74 months) and resistant to antiarrhythmic drugs (3 +/- 1.7, including beta-blockers), who underwent radiofrequency catheter ablation. RESULTS: After the first procedure, there were 23 initial successful cases (76.6%) and 7 initial failures (23.4%). Four patients experienced relapses, two of whom did not undergo the second procedure. The second procedure was carried out in 9 patients (7 initial failures and 2 relapses), and there was success in 5 additional patients, one of them by epicardial access. The final success rate was 80% (24/30), and there were no major complications. After a mean follow-up of 14 +/- 6 months, in the successful group there was a reduction greater than 90% in density of premature ventricular contractions (PVC) (24/24; p<0.0001) and a resulting absence of symptoms in the majority of patients (23/24; p<0.001). CONCLUSION: Radiofrequency catheter ablation is a safe and effective treatment for patients with persistent and symptomatic PVC with RVOT morphology.

Ablation of typical atrial flutter: a prospective randomized study of cooled-tip versus 8-mm-tip catheters.

OBJECTIVES: Both ablation catheters with closed irrigated system and 8mm tip-catheters have been shown to be more effective for typical atrial flutter radiofrequency (RF) ablation when compared to conventional 4 mm tip catheter. Considering the differences in complexity and costs of both systems, a prospective study was designed to compare the efficacy and safety of cooled-tip and 8mm-tip catheters for atrial flutter ablation. METHODS: Fifty-two consecutive patients underwent RF ablation of cavotricupsid isthmus (CTI) for the treatment of typical atrial flutter, using catheter with closed irrigation system (n=26) or 8 mm-tip catheter (n=26). The RF pulses were applied point-by-point for 60 seconds, with power limited at 50 w for the irrigated catheter and by temperature control (60 degrees/70 w) for the 8 mm catheter. RESULTS: The CTI block was successfully performed in 98.1%. Four patients in the irrigated group needed to switch to the other group. There was no significant difference with regard to ablation parameters, such as total time of RF ablation (591.1+/-309.0 s vs 486.2+/-250.8 s), total procedure duration (86.4+/-23.6 vs 78.1+/-22.5 min) and time of fluoroscopy (17.0+/-6.7 vs 15.4+/-4.6 min). During follow-up of 10.6 months in average, one patient in the irrigated group had recurrence of typical atrial flutter. CONCLUSION: Efficacy and safety of CTI ablation was comparable between both techniques (irrigated catheter and 8 mm-tip catheter). The complexity of irrigated catheter makes it less competitive.

Ablação com radiofreqüência de extra-sístoles da via de saída do ventrículo direito / Radiofrequency catheter ablation of premature ventricular contractions originating in the right ventricular outflow tract

OBJETIVOS: Avaliar se a ablação com radiofreqüência é um procedimento eficiente para o tratamento das extra-sístoles da via de saída do ventrículo direito (EVSVD), e se resulta em melhora dos sintomas. MÉTODOS: Estudo prospectivo, com 30 pacientes consecutivos (idade média de 40±13 anos, 25 do sexo feminino), sem cardiopatia estrutural aparente, com EVSVD, muito freqüentes (densidade média de 1.263±593/h), sintomáticos por mais de 1 ano (média =74 meses) e refratários aos fármacos antiarrítmicos (3±1,7, incluindo os beta-bloqueadores), que foram submetidos à ablação com radiofreqüência. RESULTADOS: Após o primeiro procedimento, houve 23 sucessos iniciais (76,6 por cento) e 7 iniciais insucessos (23,4 por cento). Quatro pacientes tiveram recorrências, sendo que dois desses não se submeteram ao segundo procedimento. O segundo procedimento foi realizado em 9 pacientes (7 insucessos iniciais e 2 recorrências), e o sucesso ocorreu em 5 pacientes adicionais, sendo 1 caso por acesso epicárdico. A taxa de sucesso final foi de 80 por cento (24/30), e nenhuma complicação maior ocorreu. Após um seguimento médio de 14±6 meses, no grupo de sucesso final houve uma redução de mais de 90 por cento na densidade das extra-sístoles(24/24; p<0,0001) e resultante ausência de sintomas na maioria dos pacientes (23/24; p<0,001). CONCLUSÃO: A ablação com radiofreqüência é um tratamento seguro e eficaz para os pacientes com extra-sístoles persistentes e sintomáticas com morfologia do trato de saída do ventrículo direito.

OBJECTIVES: To evaluate if radiofrequency catheter ablation is an effective procedure for the treatment of right ventricular outflow tract premature ventricular contractions (RVOT-PVC) and ascertain if it results in an improvement of symptoms. METHODS: A prospective study with 30 consecutive patients (mean age 40 ± 13 years, 25 females), with no apparent structural cardiopathy, with very frequent (mean density of 1,263 ± 593/h) RVOT-PVC, symptomatic for more than one year (mean = 74 months) and resistant to antiarrhythmic drugs (3 ± 1.7, including beta-blockers), who underwent radiofrequency catheter ablation. RESULTS: After the first procedure, there were 23 initial successful cases (76.6 percent) and 7 initial failures (23.4 percent). Four patients experienced relapses, two of whom did not undergo the second procedure. The second procedure was carried out in 9 patients (7 initial failures and 2 relapses), and there was success in 5 additional patients, one of them by epicardial access. The final success rate was 80 percent (24/30), and there were no major complications. After a mean follow-up of 14 ± 6 months, in the successful group there was a reduction greater than 90 percent in density of premature ventricular contractions (PVC) (24/24; p<0.0001) and a resulting absence of symptoms in the majority of patients (23/24; p<0.001). CONCLUSION: Radiofrequency catheter ablation is a safe and effective treatment for patients with persistent and symptomatic PVC with RVOT morphology.

Ablação do flutter atrial típico: estudo prospectivo e randomizado do cateter irrigado fechado versus cateter com eletrodo distal de 8 mm / Ablation of typical atrial flutter: a prospective randomized study of cooled-tip versus 8-mm-tip catheters

OBJETIVOS: Trabalho prospectivo, randomizado para comparar a eficácia e a segurança do cateter irrigado em relação ao cateter com eletrodo distal de 8 mm para ablação com radiofreqüência (RF) do flutter atrial. MÉTODOS: Em 52 pacientes consecutivos referidos para tratamento do flutter atrial típico, a ablação do istmo cavotricuspídeo (Ist-CT) foi realizada com cateter de irrigação fechada (n=26) ou com cateter de eletrodo distal de 8 mm (n=26). Os pulsos de RF foram aplicados ponto a ponto por 60 segundos com potência limitada a 50 w com o cateter irrigado e por controle de temperatura (60°C, 70 w) com cateter de 8 mm. O critério de fim do procedimento foi a obtenção de bloqueio bidirecional do Ist-CT. RESULTADOS: O bloqueio Ist-CT foi obtido em 98,1 por cento dos pacientes. O "crossover" ocorreu em quatro pacientes do grupo com cateter irrigado. Não se encontrou diferença estatística significante em relação aos parâmetros da ablação, tais como tempo total de aplicação de RF (591,1±309,0s vs 486,2±250,8s), duração do procedimento (86,4 ± 23,6 vs 78,1±22,5min) e tempo de fluoroscopia (17,0±6,7 vs 15,4±4,6min) entre os dois grupos. Durante seguimento médio de 10,6 meses, um paciente do grupo irrigado apresentou recorrência do flutter atrial típico. CONCLUSÃO: A ablação do Ist-CT resultou ser efetiva e segura para o controle do flutter atrial com ambas as técnicas empregadas (cateter com eletrodo distal de 8 mm e cateter irrigado). A complexidade técnica do cateter irrigado proporciona menor competitividade.

OBJECTIVES: Both ablation catheters with closed irrigated system and 8mm tip-catheters have been shown to be more effective for typical atrial flutter radiofrequency (RF) ablation when compared to conventional 4 mm tip catheter. Considering the differences in complexity and costs of both systems, a prospective study was designed to compare the efficacy and safety of cooled-tip and 8mm-tip catheters for atrial flutter ablation. METHODS: Fifty-two consecutive patients underwent RF ablation of cavotricupsid isthmus (CTI) for the treatment of typical atrial flutter, using catheter with closed irrigation system (n=26) or 8 mm-tip catheter (n=26). The RF pulses were applied point-by-point for 60 seconds, with power limited at 50 w for the irrigated catheter and by temperature control (60°C / 70 w) for the 8mm catheter. RESULTS: The CTI block was successfully performed in 98.1 percent. Four patients in the irrigated group needed to switch to the other group. There was no significant difference with regard to ablation parameters, such as total time of RF ablation (591.1±309.0s vs 486.2±250.8s), total procedure duration (86.4±23.6 vs 78.1±22.5min) and time of fluoroscopy (17.0±6.7 vs 15.4±4.6min). During follow-up of 10.6 months in average, one patient in the irrigated group had recurrence of typical atrial flutter. CONCLUSION: Efficacy and safety of CTI ablation was comparable between both techniques (irrigated catheter and 8mm-tip catheter). The complexity of irrigated catheter makes it less competitive.

Arritmias e genética / Arrhythmias and genetics

Os recentes avanços na área de genética em arritmias têm possibilitado a descoberta de novas síndromes clínicas em pacientes sem cardiopatia estrutural aparente. Uma das principais causas tem sido o desequilíbrio das correntes iônicas gerado a partir de defeitos genéticos, polimorfismos, intervenções terapêuticas ou anormalidades estruturais, que podem ocasionar vários fenótipos arritmogênicos, como arritmias cardíacas, síncope e morte súbita. Os estudos genéticos estão na sua curva de aprendizado e a lista de arritmias cardíacas e seus aspectos genéticos ainda está longe de ser concluída. Discutiremos neste capítulo as principais doenças do ritmo cardíaco que, até o momento, apresentam implicações com aspectos genéticos