RESUMEN
BACKGROUND: Pulmonary vein isolation (PVI) is the most effective therapy to achieve rhythm control in atrial fibrillation (AF). Peri-procedural imaging is used in many but not all centers. However, the impact of imaging on safety and efficacy of PVI is not clear. The Israeli Catheter Ablation Registry (ICAR) is a great opportunity to explore this issue in real-world practice. AIM: To describe the real-world utilization of peri-procedural imaging technologies in a large cohort of patients undergoing ablation for AF. METHODS: A prospective-multicenter cohort of AF patients who underwent PVI during the years 2019-2021. Peri-procedural imaging (CT, ICE, TEE) was utilized based on the center and operator discretion. The study endpoints were peri-procedural complications and AF recurrence at 12 months follow-up among patients with and without peri-procedural imaging. RESULTS: Between January 2019 and December 2021, a total of 921 patients underwent PVI. Peri-procedural imaging (at least 1 modality of CT, TEE, and or ICE) was utilized in 753 (81.8%) and no imaging among 168 (18.2%) patients. Cryoablation was the dominant energy used for PVI in both groups (92.3% of the non-imaging group, and 95.3% among imaging group), while RF was used in the rest of the patients. Fluoroscopy time was not different between the 2 groups; however, procedure duration was longer among the imaging group (90 min) compared to the non-imaging group (74.5 min, p = 0.006). By 12 months, the incidence of AF recurrence and repeated ablation were not different between the groups. Complications and re-hospitalization for cardiocerebrovascular reasons were not different among the 2 groups. Cox regression model demonstrated no association between preprocedural imaging and the risk of AF recurrence after ablation. CONCLUSION: This real-world multicenter prospective registry study demonstrated that the rate of complications and the rate of recurrence of AF during 1 year follow-up were not different among patients who had PVI either with or without peri-procedural imaging.
Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Sistema de Registros , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/etnología , Venas Pulmonares/cirugía , Masculino , Femenino , Israel/epidemiología , Persona de Mediana Edad , Anciano , Disparidades en Atención de Salud/etnologíaRESUMEN
BACKGROUND: Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED). OBJECTIVES: We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use. METHODS: This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral. RESULTS: In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43-2.45), p < 0.001), evening or night shifts (OR 1.31 (95% CI 1.11-1.55), p < 0.001; OR 1.68 (95% CI 1.32-2.15), p < 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26-0.37), p < 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46-0.67), p < 0.001), beta blockers (OR 0.63 (95% CI 0.52-0.76), p < 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48-0.69), p < 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years. CONCLUSIONS: The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.
RESUMEN
Background: Evidence regarding the mortality benefit of implantable cardioverter defibrillator (ICD) non-ischemic dilated cardiomyopathy (NIDCM) is inconsistent. The most recent randomized study, the DANISH trial, did not find improved outcomes with ICD. However, based on previous studies and meta-analyses, current guidelines still highly recommend ICD implantation in NIDCM patients. The introduction of novel medications for heart failure improved the clinical outcome dramatically. We aimed in this study to evaluate the effect of Angiotensin Receptor-Neprilysin Inhibitors (ARNi) and sodium-glucose transport protein 2 inhibitors (SGLT2i) on the mortality benefit of ICD in NIDCM. Methods: We used a previous metanalysis algorithm and added an updated comprehensive literature search in PubMed for randomized control trials that examined the mortality benefit of ICD in NIDCM vs. optimal medical treatment. The primary outcome included death from any cause. We did a meta-regression analysis to search for a single independent factor affecting mortality. Using previous data, we evaluated the theoretical effect of ICD implementation on patients treated with SGLT2 inhibitors and ARNi. Results: No new articles were added to the results of the previous meta-analysis. 2,622 patients with NIDCM from 5 cohort studies published between 2002 and 2016 were included in the analysis. 50% of them underwent ICD implantation for primary prevention of sudden cardiac death, and 50% did not. ICD was associated with a significantly decreased risk for death from any cause compared to control (OR = 0.79, 95%CI: 0.66-0.95, p = 0.01, I2 = 0%). The theoretical addition of ARNi and the SGLT2 inhibitor dapagliflozin did not change the significant mortality effect of ICD (OR = 0.82, 95%CI: 0.7-0.9, p = 0.001, I2 = 0%) and (OR = 0.82, 95%CI: 0.7-0.9, p = 0.001, I2 = 0%). A meta-regression revealed no association between death from any cause and left bundle branch block (LBBB), use of amiodarone, use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers, year initiated enrollment, and the year ended enrollment (R2 = 0.0). Conclusion: In patients with NIDCM, the addition of ARNi and SGLT2i did not affect the mortality advantages of ICD for primary prevention. PROSPERO registry number: https://www.crd.york.ac.uk/prospero/, identifier: CRD42023403210.
RESUMEN
Guidelines recommend patients undergoing a first pacemaker implant who have even mild left ventricular (LV) impairment should receive biventricular or conduction system pacing (CSP). There is no corresponding recommendation for patients who already have a pacemaker. We conducted a meta-analysis of randomized controlled trials (RCTs) and observational studies assessing device upgrades. The primary outcome was the echocardiographic change in LV ejection fraction (LVEF). Six RCTs (randomizing 161 patients) and 47 observational studies (2644 patients) assessing the efficacy of upgrade to biventricular pacing were eligible for analysis. Eight observational studies recruiting 217 patients of CSP upgrade were also eligible. Fourteen additional studies contributed data on complications (25 412 patients). Randomized controlled trials of biventricular pacing upgrade showed LVEF improvement of +8.4% from 35.5% and observational studies: +8.4% from 25.7%. Observational studies of left bundle branch area pacing upgrade showed +11.1% improvement from 39.0% and observational studies of His bundle pacing upgrade showed +12.7% improvement from 36.0%. New York Heart Association class decreased by -0.4, -0.8, -1.0, and -1.2, respectively. Randomized controlled trials of biventricular upgrade found improvement in Minnesota Heart Failure Score (-6.9 points) and peak oxygen uptake (+1.1 mL/kg/min). This was also seen in observational studies of biventricular upgrades (-19.67 points and +2.63 mL/kg/min, respectively). In studies of the biventricular upgrade, complication rates averaged 2% for pneumothorax, 1.4% for tamponade, and 3.7% for infection over 24 months of mean follow-up. Lead-related complications occurred in 3.3% of biventricular upgrades and 1.8% of CSP upgrades. Randomized controlled trials show significant physiological and symptomatic benefits of upgrading pacemakers to biventricular pacing. Observational studies show similar effects between biventricular pacing upgrade and CSP upgrade.
Asunto(s)
Terapia de Resincronización Cardíaca , Insuficiencia Cardíaca , Marcapaso Artificial , Disfunción Ventricular Izquierda , Humanos , Terapia de Resincronización Cardíaca/efectos adversos , Estimulación Cardíaca Artificial/efectos adversos , Trastorno del Sistema de Conducción Cardíaco/terapia , Sistema de Conducción Cardíaco , Función Ventricular Izquierda , Volumen Sistólico/fisiología , Resultado del Tratamiento , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/terapiaRESUMEN
Background: The use of cardiovascular implantable electronic device (CIED) is steadily increasing, and complications include venous occlusion and fractured leads. Transvenous lead extraction (TLE) can facilitate the re-implantation of new leads. Aims: This study aims to explore predictors and complications of non-infectious TLE. Methods: This study involves a retrospective analysis and comparison of characteristics, complications, and outcomes of patients with and without occluded veins (OVs) undergoing TLE at our center. Results: In total, eighty-eight patients underwent TLE for non-infectious reasons. Indications for TLE were lead malfunction (62; 70.5%) and need for CIED upgrade (22; 25%). Fourteen patients referred due to lead malfunction had an OV observed during venography. The OV group (36 patients) were significantly older (65.7 ± 14.1 vs. 53.8 ± 15.9, p = 0.001) and had more comorbidities. Ejection fraction (EF) was significantly lower for the OV group (27.5 vs. 57.5%, p = 0.001) and had a longer lead dwelling time (3,226 ± 2,324 vs. 2,191 ± 1,355 days, p = 0.012). Major complications were exclusive for the OV group (5.5% vs. none, p = 0.17), and most minor complications occurred in the OV group as well (33.3 vs. 4.1%, p < 0.001). Laser sheath and mechanical tools for TLE were frequently used for OV as compared to the non-occluded group (94.4 vs. 73.5%, respectively, p = 0.012). Procedure success was higher in the non-occluded group compared to the OV group (98 vs. 83.3%, respectively, p = 0.047). Despite these results, periprocedural mortality was similar between groups. Conclusion: Among the TLE for non-infectious reasons, vein occlusion appears as a major predictor of complex TLE tool use, complications, and procedural success. Venography should be considered prior to non-infectious TLE to identify high-risk patients.
RESUMEN
Epicardial access is becoming increasingly important for various cardiovascular interventions. Access to dry pericardial space can be challenging and is often associated with significant complications. A novel concealed-needle blunt-tip device is designed to capture the parietal pericardium layer and retract it into the distal end of the device, which houses a fixated concealed needle, in a bid to minimize the likelihood of lacerating the visceral layer of the pericardium. This prospective single-arm study evaluated the feasibility of use of this device in 11 human subjects with successful access attained in 91% (10 of 11) of cases without adverse events. (Pericardial Access With ViaOne Device; NCT05006157).
Asunto(s)
Pericardio , Estudios Clínicos como Asunto , Estudios de Factibilidad , Humanos , Pericardio/cirugía , Estudios ProspectivosRESUMEN
Following the Egyptian withdrawal in the mid-12th century BCE from their involvement in the Arabah copper production, and after an additional period of organization, the degree of copper efficiency and production at Timna and Faynan increased in the Early Iron Age (11th-9th centuries), rendering the region the largest and most advanced smelting centre in the Levant. The existing paradigm offered as an explanation for this technical and commercial success is based on extraneous influence, namely, the campaign of Pharaoh Sheshonq I near the end of the 10th century BCE that spurred a renewed Egyptian involvement in the Arabah copper industry. An alternative paradigm is suggested here, viewing the advances in Arabah copper technology and production as a linear development and the outcome of continuous and gradual indigenous improvements on the part of local craftsmen, with no external intervention. Behind these outstanding technical achievements stood excellent managerial personnel, supported by an innovative technical team. They employed two techniques for copper-production optimization that can be defined based on concepts taken from the world of modern industrial engineering: (i) "trial and error", in which the effect of each production variable was tested individually and separately, and (ii) "scaling-up", in which the size of some production elements (i.e., tuyère) was increased by using existing techniques which required minimum developmental costs and experimental risks.
Asunto(s)
Cobre/química , Tecnología/historia , Arqueología , Análisis por Conglomerados , Egipto , Historia Antigua , Humanos , Pueblos Indígenas/psicología , IndustriasRESUMEN
Background The cardiac ryanodine receptor type 2 (RyR2) is a large homotetramer, located in the sarcoplasmic reticulum (SR), which releases Ca2+ from the SR during systole. The molecular mechanism underlying Ca2+ sensing and gating of the RyR2 channel in health and disease is only partially elucidated. Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT1) is the most prevalent syndrome caused by RyR2 mutations. Methods and Results This study involves investigation of a family with 4 cases of ventricular fibrillation and sudden death and physiological tests in HEK 293 cells and normal mode analysis (NMA) computation. We found 4 clinically affected members who were homozygous for a novel RyR2 mutation, G3118R, whereas their heterozygous relatives are asymptomatic. G3118R is located in the periphery of the protein, far from the mutation hotspot regions. HEK293 cells harboring G3118R mutation inhibited Ca2+ release in response to increasing doses of caffeine, but decreased the termination threshold for store-overload-induced Ca2+ release, thus increasing the fractional Ca2+ release in response to increasing extracellular Ca2+. NMA showed that G3118 affects RyR2 tetramer in a dose-dependent manner, whereas in the model of homozygous mutant RyR2, the highest entropic values are assigned to the pore and the central regions of the protein. Conclusions RyR2 G3118R is related to ventricular fibrillation and sudden death in recessive mode of inheritance and has an effect of gain of function on the protein. Despite a peripheral location, it has an allosteric effect on the stability of central and pore regions in a dose-effect manner.
Asunto(s)
ADN/genética , Muerte Súbita Cardíaca/epidemiología , Ventrículos Cardíacos/fisiopatología , Mutación , Canal Liberador de Calcio Receptor de Rianodina/genética , Taquicardia Ventricular/genética , Función Ventricular/fisiología , Adolescente , Análisis Mutacional de ADN , Muerte Súbita Cardíaca/etiología , Ecocardiografía , Electrocardiografía Ambulatoria , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Heterocigoto , Humanos , Incidencia , Israel/epidemiología , Masculino , Canal Liberador de Calcio Receptor de Rianodina/metabolismo , Tasa de Supervivencia/tendencias , Taquicardia Ventricular/complicaciones , Taquicardia Ventricular/epidemiologíaRESUMEN
PURPOSE: This study sought to identify risk factors for permanent pacemaker implantation (PPMI) after Transcatheter aortic valve implantation (TAVI) and explain their trends over the last decade. TAVI is performed nowadays for severe aortic stenosis in more patients with lower surgical risk. While most TAVI complications have been reduced, PPMI remains common. METHODS: In this observational, retrospective cohort analysis, 338 TAVI patients treated between 2008 and 2017 were reviewed. Risk factors were compared between the early (2008-2013) and late years (2014-2017), and a multivariable logistic regression model was used. RESULTS: A decreasing trend in PPMI over time was observed (p for trend = 0.008), as was a lower rate of PPMI in the late period (19.3% vs. 31.7%, p = 0.009). Three variables were identified as independent risk factors for PPMI that also decreased significantly in the late period: valve implantation depth ≥ 8 mm (OR = 4.3, 95% CI 2.3-8.2, p < 0.001), use of self-expandable valves (OR = 2.8, 95% CI 1.4-5.5, p = 0.004), and patient risk assessed by EuroSCORE II (OR = 1.07, 95% CI 1.0-1.1, p = 0.034). Indications for PPMI were also shown to change over time, with an increase in the prevalence of complete AVB as the main indication for PPMI (p = 0.048), and a trend towards a decrease in LBBB alone (p = 0.061). CONCLUSIONS: The decrease in post-TAVI PPMI over the past decade is multifactorial and can be explained by (1) lower baseline patient surgical risk, (2) modified procedural variables including decreased implantation depth and increased use of balloon-expandable valves, and (3) refined indications for PPMI.
Asunto(s)
Estenosis de la Válvula Aórtica , Prótesis Valvulares Cardíacas , Marcapaso Artificial , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Humanos , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: The prognosis of patients with untreated cardiac implantable electronic device (CIED) infection is poor. Whether removal of all leads by a successful transvenous lead extraction (TLE) procedure changes the prognosis is unclear. OBJECTIVE: To identify predictors of mortality in patients with CIED infection despite successful TLE. METHODS: Retrospective single-center analysis of prospectively collected database from consecutive patients undergoing TLE at our center. Predictors for mortality were identified and a score predicting high mortality rate was calculated. RESULTS: A total of 371 consecutive patients underwent TLE, of whom 337 (90.8%) had complete hardware removal. Most were extracted due to infectious causes (81.3%). Approximately one-third (35%) died during a mean follow-up of 1056 ± 868 days. There was significantly higher mortality observed in the infectious group. Multivariate logistic regression models for infectious group only identified creatinine and albumin measurements as risk markers for 30 days mortality (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.19-2.38; P = .003 and OR, 0.4; 95% CI, 0.16-0.97; P = .039, respectively). A risk score was created based on cutoff values of creatinine ≥2md/dL (1 point) and albumin ≤3.5 g/dL (1 point). A value of 2 points predicted a 50% chance of 30-day mortality and a 75% chance of 1-year mortality (P < .0001 for both). CONCLUSIONS: Creatinine and albumin can be used as a combined risk score to successfully identify patients at risk of death despite undergoing a successful TLE procedure for infectious reasons. This score could help decision making when contemplating on conservative antibiotic treatment vs TLE.
Asunto(s)
Desfibriladores Implantables/efectos adversos , Remoción de Dispositivos , Marcapaso Artificial/efectos adversos , Falla de Prótesis , Infecciones Relacionadas con Prótesis/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Creatinina/sangre , Bases de Datos Factuales , Remoción de Dispositivos/efectos adversos , Remoción de Dispositivos/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Albúmina Sérica Humana/análisis , Factores de Tiempo , Resultado del TratamientoRESUMEN
Sudden cardiac death is one of the most important causes of death worldwide. Advancements in medical treatment, percutaneous interventions, and device therapy (ICD and CRTD) showed consistent reduction in mortality, mainly in survivors of SCD and in patients with ischemic cardiomyopathy and depressed left ventricular function. Patients with non-ischemic cardiomyopathies, mildly reduced LV function, and channelopathies have increased risk for SCD. Identifying the subgroup of these patients before they experience life-threatening or fatal events is essential to further improve outcomes. In this review, we aimed to summarize the current knowledge for risk stratification and primary prevention, to describe the gaps in evidence, and to discuss future directions for screening and treating patients at risk for SCD. PURPOSE OF REVIEW: The purpose of this review is to provide a comprehensive description of the etiologies of sudden cardiac death, risk stratification strategies, and to describe the current medical and interventional therapies. We aimed to discuss the current gaps in our knowledge of primary prevention of SCD and to review novel approaches and interventions. RECENT FINDINGS: The incidence of SCD has decreased in the last two decades due to improved pharmacological treatment and ICD implantation in SCD survivors and in patients with reduced left ventricular function and ischemic cardiomyopathy. The efficacy of ICD in patients with non-ischemic cardiomyopathy is challenged by new findings from the DANISH trial. Catheter ablation is new emerging strategy to prevent SCD in patients with scar relater or PVC-triggered ventricular arrhythmias. Despite the new treatments, SCD is still a major burden. ICD remains the cornerstone for patients with ischemic cardiomyopathy, whereas appropriate risk stratification of the patients with non-ischemic cardiomyopathy and channelopathies is needed to further improve outcomes. The future of ablation as the treatment and prevention of SCD remains to be studied.
Asunto(s)
Muerte Súbita Cardíaca/prevención & control , Muerte Súbita Cardíaca/etiología , Humanos , Prevención Primaria/tendencias , Medición de RiesgoRESUMEN
Mutations in the SCN5A gene, encoding the cardiac voltage-gated sodium channel NaV1.5, are associated with inherited cardiac arrhythmia and conduction disease. Ca2+-dependent mechanisms and the involvement of ß-subunit (NaVß) in NaV1.5 regulation are not fully understood. A patient with severe sinus-bradycardia and cardiac conduction-disease was genetically evaluated and compound heterozygosity in the SCN5A gene was found. Mutations were identified in the cytoplasmic DIII-IV linker (K1493del) and the C-terminus (A1924T) of NaV1.5, both are putative CaM-binding domains. These mutants were functionally studied in human embryonic kidney (HEK) cells and HL-1 cells using whole-cell patch clamp technique. Calmodulin (CaM) interaction and cell-surface expression of heterologously expressed NaV1.5 mutants were studied by pull-down and biotinylation assays. The mutation K1493del rendered NaV1.5 non-conductive. NaV1.5K1493del altered the gating properties of co-expressed functional NaV1.5, in a Ca2+ and NaVß1-dependent manner. NaV1.5A1924T impaired NaVß1-dependent gating regulation. Ca2+-dependent CaM-interaction with NaV1.5 was blunted in NaV1.5K1493del. Electrical charge substitution at position 1493 did not affect CaM-interaction and channel functionality. Arrhythmia and conduction-disease -associated mutations revealed Ca2+-dependent gating regulation of NaV1.5 channels. Our results highlight the role of NaV1.5 DIII-IV linker in the CaM-binding complex and channel function, and suggest that the Ca2+-sensing machinery of NaV1.5 involves NaVß1.
RESUMEN
AIMS: Lead perforation is a rare, well-known complication of cardiac implantable electronic device (CIED) implants, whose management is mostly not evidence-based. Main management strategies include conservative approach based on clinical and lead function follow-up vs. routine invasive lead revision approach. This study compared the complications of both strategies by composite endpoint, including recurrent perforation-related symptoms, recurrent pericardial effusion (PEf), lead dysfunction, and device infection during 12 month follow-up. METHODS AND RESULTS: Multicentre retrospective analysis, inquiring data from imaging studies, device interrogation, pericardiocentesis, and clinical charts of patients with suspected perforating leads between 2007 and 2014 in five hospitals. All cases were reviewed by electrophysiologist and defined as definite perforations by suggestive symptoms along with lead perforation on imaging, bloody PEf on pericardiocentesis shortly after implant, or right ventricular (RV) lead non-capture along with diaphragmatic stimulation upon bipolar pacing. Clinical outcomes associated with both management approaches were compared, with respect to the composite endpoint. The study included 48 definitive perforation cases: 22 managed conservatively and 26 via lead revision. Conservative management was associated with an increased composite endpoint compared with lead revision (8/22 vs. 1/26; P = 0.007). The dominant complication among the conservative cohort was appearance of cardiac tamponade during follow-up; 5/6 occurring in cases which presented with no or only mild PEf and were treated by antiplatelets/coagulants during or shortly after CIED implantation. CONCLUSION: A conservative management of CIED lead perforation is associated with increased complications compared with early lead revision. Lead revision may be the preferred management particularly in patients receiving antiplatelets/coagulants.
Asunto(s)
Dispositivos de Terapia de Resincronización Cardíaca/efectos adversos , Lesiones Cardíacas/etiología , Lesiones Cardíacas/terapia , Anciano , Taponamiento Cardíaco/etiología , Taponamiento Cardíaco/terapia , Remoción de Dispositivos , Femenino , Humanos , Masculino , Derrame Pericárdico/etiología , Derrame Pericárdico/terapia , Pericardiocentesis , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/terapia , Retratamiento , Estudios RetrospectivosRESUMEN
INTRODUCTION: Cardiac implantable electronic device (CIED) trans venous lead extraction (TLE) is technically challenging. Whether the use of a laser sheath reduces complications and improves outcomes is still in debate. We therefore aimed at comparing our experience with and without laser in a large referral center. METHODS: Information of all patients undergoing TLE was collected prospectively. We retrospectively compared procedural outcomes prior to the introduction of the laser sheath lead extraction technique to use of laser sheath. RESULTS: During the years 2007-2017, there were 850 attempted lead removals in 407 pts. Of them, 339 (83%) were extracted due to infection, device upgrade/lead malfunction in 42 (10%) cases, and other (7%). Complete removal (radiological success) of all leads was achieved in (88%). Partial removal was achieved in another 6% of the patients. Comparison of cases prior to and after laser technique introduction, showed that with laser, a significantly smaller proportion of cases required conversion to femoral approach [31/275 (6%) laser vs. 40/132 (15%) non-laser; p<0.001]. However, success rates of removal [259/275 (94%) vs. 124/132 (94%) respectively; p = 0.83] and total complication rates [35 (13%) vs. 19 (14%) respectively; p = 0.86] did not differ prior to and after laser use. In multivariate analysis, laser-assisted extraction was an independent predictor for no need for femoral extraction (OR = 0.39; 95% CI 0.23-0.69; p = 0.01). CONCLUSION: Introduction of laser lead removal resulted in decreased need to convert to femoral approach, albeit without improving success rates or preventing major complications.
Asunto(s)
Remoción de Dispositivos/métodos , Electrodos Implantados , Marcapaso Artificial , Anciano , Anciano de 80 o más Años , Remoción de Dispositivos/efectos adversos , Remoción de Dispositivos/instrumentación , Electrodos Implantados/efectos adversos , Falla de Equipo , Femenino , Vena Femoral , Humanos , Rayos Láser , Masculino , Persona de Mediana Edad , Marcapaso Artificial/efectos adversos , Estudios Prospectivos , Vena Subclavia/lesiones , Resultado del TratamientoRESUMEN
BACKGROUND: Catheter ablation (CA) is a well-established therapeutic option for patients with recurrent symptomatic atrial fibrillation (AF). Data on gender-related differences are limited with regard to baseline characteristics and long-term success rates of catheter ablation for AF. METHODS: We analyzed a cohort of 251 consecutive patients who underwent a first catheter ablation for AF in our institute during the period 2008 through 2015. All patients were followed by regular annual clinic visits, electrocardiograms, periodic 24-48 hour Holter monitoring, and loop recorders. The primary endpoint was first recurrence of AF during 1 year of follow-up. RESULTS: The cohort comprised 26% women (n=65), who were older (62.1 ± 9.6 vs. 54.4 ± 11.3 years, P < 0.01) and had a higher proportion of diabetes mellitus (23.1 vs. 5.4%, P < 0.001) than male patients. No other significant differences were evident. At 1 year follow-up, the cumulative survival free of AF was significantly higher in women compared with men (83% vs. 66%, respectively, log rank P value = 0.021). Subgroup analysis showed an interaction between female and small indexed left atrial diameter (LADi < 23 mm/m2). CONCLUSIONS: Our findings suggest that women experience a significantly lower rate of AF recurrence post-CA compared with men. This gender-related advantage appears to be restricted to women without significant left atrial enlargement. It further implies that left atrial enlargement has a stronger negative impact on post-CA AF recurrence in females than in males. Due to the relatively small sample number of females further research is warranted to validate our conclusions.
Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Atrios Cardíacos/cirugía , Adulto , Anciano , Antiarrítmicos/administración & dosificación , Fibrilación Atrial/mortalidad , Ablación por Catéter/efectos adversos , Electrocardiografía Ambulatoria/métodos , Femenino , Estudios de Seguimiento , Atrios Cardíacos/patología , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Sistema de Registros , Estudios Retrospectivos , Factores Sexuales , Resultado del TratamientoRESUMEN
BACKGROUND: Cardiac resynchronization therapy (CRT) is an effective treatment for heart failure (HF); however, a third of patients are non-responders. The development of quadripolar left ventricular (LV) lead was shown, mainly in single manufactures' registry, to improve LV remodeling and overall mortality. However, limited reports exist on the impact of quadripolar LV leads on HF hospitalization rates in real-life cohorts. We evaluated the clinical outcomes associated with quadripolar LV leads in a large nation-wide registry including all patients implanted with a cardiac resynchronization therapy with defibrillator (CRT-D). METHODS: Between July 2010 and October 2016, 2913 consecutive patients were implanted with a CRT-D and all were prospectively enrolled in the Israeli ICD Registry. Quadripolar LV leads were implanted in 973 (33.4%) patients during this period, and their clinical outcomes were compared to CRT-D recipients implanted with a bipolar LV lead. Primary endpoint was HF hospitalization rate. RESULTS: Quadripolar leads were implanted more in patients with non-ischemic cardiomyopathy and for primary prevention indication and less in post-infarction patients and for secondary prevention of sudden death. Longer QRS duration was observed with quadripolar leads (147 ± 23 vs 143 ± 25; p < 0.001). Outcome event rate for 100 patient years revealed no difference in HF hospitalization rates between bipolar and quadripolar LV leads. Quadripolar lead implant led to lower cardiac mortality, with no influence on overall mortality. Multivariate analysis revealed no significant differences in study endpoints between bipolar and quadripolar LV leads. CONCLUSION: In a large real-life registry, implantation of quadripolar LV leads in patients with CRT-D did not influence HF hospitalization rates.
Asunto(s)
Desfibriladores Implantables/estadística & datos numéricos , Insuficiencia Cardíaca/terapia , Mortalidad Hospitalaria/tendencias , Hospitalización/estadística & datos numéricos , Sistema de Registros , Anciano , Terapia de Resincronización Cardíaca/métodos , Terapia de Resincronización Cardíaca/mortalidad , Dispositivos de Terapia de Resincronización Cardíaca/estadística & datos numéricos , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Humanos , Israel , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Resultado del Tratamiento , Remodelación Ventricular/fisiologíaRESUMEN
PURPOSE: The aim of this study was to evaluate the effects of fish oils, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), on ventricular tachyarrhythmic episodes (VTEs) in implantable cardioverter defibrillator (ICD) recipients with ischemic cardiomyopathy. METHODS: One hundred five ICD recipients with ischemic cardiomyopathy received 3.6 g of EPA and DHA and placebo for 6 months, each at a random order, with a 4-month washout period between treatments. Eighty-seven patients completed the 16-month study protocol. The primary end point was any VTE (including sustained and non-sustained ventricular tachycardias at a rate of >150 bpm) as recorded by the ICDs. Secondary end points included device therapy (anti-tachycardia pacing (ATP) or shocks). RESULTS: During treatment with fish oils, there was a significant increase in EPA and DHA concentrations in red blood cells (RBCs) and subcutaneous fat tissue. Among 87 patients who completed the study protocol, the mean number of VTEs was significantly lower during treatment with fish oil (1.7) vs. placebo (5.6; p = 0.035). Appropriate device therapy for VTE occurred in 18 (21%) patients. Fish oil therapy was associated with a trend toward fewer VTEs terminated with ATP (2.8 ± 13.7 vs. 0.5 ± 2.1, respectively; p = 0.077). VTE terminated by ICD shocks, however, was rare, and rates were similar between both groups (0.11 ± 0.6 vs. 0.10 ± 0.4, p = not significant, respectively). CONCLUSIONS: Our data suggest that fish oil therapy may be associated with a reduction in the frequency of VTE in ICD recipients with ischemic cardiomyopathy.
Asunto(s)
Desfibriladores Implantables , Suplementos Dietéticos , Ácidos Grasos Omega-3/administración & dosificación , Isquemia Miocárdica/tratamiento farmacológico , Taquicardia Ventricular/tratamiento farmacológico , Anciano , Terapia Combinada , Estudios Cruzados , Ácidos Docosahexaenoicos/administración & dosificación , Método Doble Ciego , Ácido Eicosapentaenoico/administración & dosificación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/terapia , Estudios Prospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Taquicardia Ventricular/complicaciones , Taquicardia Ventricular/diagnóstico por imagen , Taquicardia Ventricular/terapia , Resultado del Tratamiento , Remodelación Ventricular/fisiologíaRESUMEN
High precision is necessary during percutaneous transcatheter heart valve implantation. The precision of the implantation has been established by increasing the heart rate (usually to 200 beats per minute) to the point of significantly reduced cardiac output and thus minimizing valve movement. Routinely, this tachycardia is induced by rapid pacing. Here we report a case of failure to pace during valve-in-valve (VIV) Edwards Sapien XT implantation in the tricuspid valve position. Transient cardiac arrest was induced by intravenous adenosine injection enabling accurate valve implantation.
RESUMEN
Potassium levels are often abnormal in patients with heart failure (HF) and have a detrimental effect on clinical outcome. We evaluated potassium levels in a real-world cohort of patients with HF and its effect on mortality. All patients with a diagnosis of HF at a health maintenance organization were evaluated and followed for cardiac-related hospitalizations and death. The cohort consisted of 6,073 patients with HF. Mean potassium levels were 4.57 ± 0.53 mmol/L. Most patients (68%) had potassium levels in the normal range (4.0 to 5.0 mmol/L). High-normal potassium levels (5.0 to 5.5) were present in 17% of the patients, low potassium levels (<4.0) in 11%, and hyperkalemia (K ≥5.5) in 4%. Mean follow-up was 576 days. The overall mortality rate during this period was 14%. Survival rate by Kaplan-Meier analysis demonstrated that hypokalemia (K ≤3.5) was associated with the lowest survival rate. Survival was highest in patients with high-normal potassium levels. Cox regression analysis after adjustment for significant predictors including co-morbidities and standard HF drug therapies demonstrated that high-normal potassium levels were independently associated with reduced mortality compared with normal reference levels (hazard ratio 0.78, 95 confidence interval [CI] 0.64 to 0.95, p = 0.01). Subgroup analysis showed improved outcome with high-normal potassium levels in patients with reduced renal function, spironolactone, and loop diuretic therapy. In conclusion, potassium levels in the high-normal range appear to be safe and are associated with an improved outcome in patients with HF.